Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department—Convenience or necessity?

Michael Willis; Efrem Colonetti; Ali Bakir; Yousef Jamal Alame; Megan Annetts; Deren T Aygin; Amina Daou; Sultan Farooq; Nicholas A Fine; Gozde Firat; Benjamin Goozee; Anuj Neelesh Gupta; Charlotte Hubbett; Nicole Shun Yee Loi; Laura Maciejec-Biskup; Merline Gabriela Muthukumar; Jason Pott; Benjamin M Bloom; Maria Lorenza Muiesan; Tim Harris

doi:10.1371/journal.pone.0305276

. 2024 Jun 14;19(6):e0305276. doi: 10.1371/journal.pone.0305276

Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department—Convenience or necessity?

Michael Willis ^1,^*, Efrem Colonetti ², Ali Bakir ³, Yousef Jamal Alame ⁴, Megan Annetts ⁵, Deren T Aygin ⁶, Amina Daou ⁷, Sultan Farooq ⁸, Nicholas A Fine ¹, Gozde Firat ⁹, Benjamin Goozee ¹⁰, Anuj Neelesh Gupta ¹¹, Charlotte Hubbett ¹, Nicole Shun Yee Loi ¹², Laura Maciejec-Biskup ¹³, Merline Gabriela Muthukumar ¹⁴, Jason Pott ¹, Benjamin M Bloom ¹, Maria Lorenza Muiesan ², Tim Harris ^1,^*

Editor: Robert Jeenchen Chen¹⁵

¹Barts Health NHS Trust, London, England

²Department of Clinical and Experimental Sciences University of Brescia, Brescia, Italy

³The Ivers Practice, Iver, England

⁴Hampshire Hospital NHS Foundation Trust, Hampshire, England

⁵Monash Children’s Hospital, Melbourne, Australia

⁶Mid and South Essex NHS Foundation Trust, Chelmsford, England

⁷Guy’s and St Thomas’ NHS Foundation Trust, London, England

⁸Whittington Health NHS Trust, London, England

⁹The Royal Free London NHS Foundation Trust, London, England

¹⁰St John of God Subiaco Hospital, Perth, Australia

¹¹Dorset County Hospital NHS Foundation Trust, Dorchester, United Kingdom

¹²The Prince Charles Hospital, Brisbane, Australia

¹³Royal North Shore Hospital, Sydney, Australia

¹⁴Lewisham and Greenwich NHS Foundation Trust, London, England

¹⁵Stanford University School of Medicine, UNITED STATES

Competing Interests: The authors have declared that no competing interests exist.

^✉

* E-mail: m.willis@doctors.org.uk (MW); t.harris@qmul.ac.uk (TH)

Roles

Michael Willis: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Visualization, Writing – original draft, Writing – review & editing

Efrem Colonetti: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Visualization, Writing – review & editing

Ali Bakir: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – review & editing

Yousef Jamal Alame: Conceptualization, Investigation, Methodology, Writing – review & editing

Megan Annetts: Conceptualization, Investigation, Methodology, Writing – review & editing

Deren T Aygin: Conceptualization, Investigation, Methodology, Writing – review & editing

Amina Daou: Conceptualization, Investigation, Methodology, Writing – review & editing

Sultan Farooq: Conceptualization, Investigation, Methodology, Writing – review & editing

Nicholas A Fine: Conceptualization, Investigation, Methodology, Writing – review & editing

Gozde Firat: Conceptualization, Investigation, Methodology, Writing – review & editing

Benjamin Goozee: Conceptualization, Investigation, Methodology, Writing – review & editing

Anuj Neelesh Gupta: Conceptualization, Investigation, Methodology, Writing – review & editing

Charlotte Hubbett: Conceptualization, Investigation, Methodology, Writing – review & editing

Nicole Shun Yee Loi: Conceptualization, Investigation, Methodology, Writing – review & editing

Laura Maciejec-Biskup: Conceptualization, Investigation, Methodology, Writing – review & editing

Merline Gabriela Muthukumar: Conceptualization, Investigation, Methodology, Writing – review & editing

Jason Pott: Conceptualization, Methodology, Writing – review & editing

Benjamin M Bloom: Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Writing – review & editing

Maria Lorenza Muiesan: Conceptualization, Methodology, Supervision, Writing – review & editing

Tim Harris: Conceptualization, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

Robert Jeenchen Chen: Editor

PMCID: PMC11178163 PMID: 38875242

Abstract

Background

Peripheral Intravenous Cannulas (PIVCs) are frequently utilised in the Emergency Department (ED) for delivery of medication and phlebotomy. They are associated with complications and have an associated cost to departmental resources. A growing body of international research suggests many of the PIVCs inserted in the ED are unnecessary.

Methods

The objective of this study was to determine the rates of PIVC insertion and use. This was a prospective observational study conducted in one UK ED and one Italian ED. Adult ED patients with non-immediate triage categories were included over a period of three weeks in the UK ED in August 2016 and two weeks in the Italian ED in March and August 2017. Episodes of PIVC insertion and data on PIVC utilisation in adults were recorded. PIVC use was classified as necessary, unnecessary or unused. The proportion of unnecessary and unused PIVCs was calculated. PIVCs were defined as unnecessary if they were either used for phlebotomy only, or solely for IV fluids in patients that could have potentially been hydrated orally (determined against a priori defined criteria). PIVC classified as unused were not used for any purpose.

Results

A total of 1,618 patients were included amongst which 977 PIVCs were inserted. Of the 977 PIVCs, 413 (42%) were necessary, 536 (55%) were unnecessary, and 28 (3%) were unused. Of the unnecessary PIVCs, 473 (48%) were used solely for phlebotomy and 63 (6%) were used for IV fluids in patients that could drink.

Conclusions

More than half of PIVCs placed in the ED were unnecessary in this study. This suggests that clinical decision making about the benefits and risks of PIVC insertion is not being performed on an individual basis.

Introduction

Over one billion peripheral intravenous cannulas (PIVCs) are inserted worldwide each year [1], with an estimated 60% of hospitalised patients receiving PIVCs over the course of their admission [2]. PIVCs are frequently inserted in the Emergency Department (ED) for blood sample collection and are most commonly used for the delivery of IV fluid [3, 4]. Previous studies have not assessed if IV fluid delivery followed best practice and/or was required for the clinical situation. Insertion of PIVCs may alter clinician’s prescribing behaviour potentially influencing the prescribing of IV fluids where oral hydration could be used [3]. Data suggests many ED patients can be hydrated orally and supplementary IV fluids are not always required [5, 6]. Identifying the incidence of unnecessary IV fluid delivery could assist in guiding policy concerning the insertion of and appropriate usage of PIVCs.

Previous studies have shown rates of unused or unnecessary ED PIVCs ranging from 9% to 83% [3–11]. However, most of these studies used retrospective case-note reviews to determine the insertion rate and usage of PIVCs.

PIVCs carry an associated cost and risk, most notably for catheter-associated infection and Staphylococcus aureus bacteraemia, with an estimated 10,028 annual cases in the US [12] and other studies in inpatients on medical, surgical and ICUs (Intensive Care Units) suggest a rate of between 0.03% to 0.1% [7, 13]. This risk of catheter-associated infection has been reported to be significantly greater when inserted in the ED compared to inpatient wards (odds ratio [OR] 6.0, p<0.001) [12]. Other risks associated with the procedure include pain, phlebitis, occlusion and medication extravasation [14, 15]. The cost associated with inserting PIVCs in two Australian studies ranges from AUD$16.40 to 22.79 (USD$11.84–16.45, GBP£8.87–12.32 at time of publication) [11, 16]. There is also an significant environmental impact from non-recyclable plastic packaging and materials required to insert and dress an unnecessary/unused PIVC.

We therefore performed a prospective observational study to determine the rates of PIVC insertion and describe their use in the ED in two hospitals; one in the UK ED and one in Italy. Secondly, we sought to assess the proportion of patients receiving IV fluid who could have potentially been hydrated orally against a priori defined criteria.

Methods

Study setting and design

This study took place in the EDs of two urban, tertiary centres; centre A in UK and centre B in Italy. Centre A is a major trauma centre, teaching hospital and stroke centre seeing over 135,000 patients per year in the ED. Centre B is also a trauma centre and teaching hospital seeing over 80,000 patient per year in the ED. In centre A, data were collected prospectively by observed PIVC utilisation in patients over 3 weeks. Data was collected between 0800–2200 for 21 consecutive days in August 2016. In centre B data was prospectively collected in random 6-hour blocks between 0800–2000 in two 7-day periods in March and August 2017. The times for data collection were determined by researcher availability.

The study was reviewed by the research and audit departments for each institution and assessed via the institutional research assessment system, both of which delegated the study as not requiring written informed consent. There were no interventions, no patient identifying data was collected, no deviation from usual care occurred and no direct contact between the study team and patients.

Selection of participants

The inclusion criteria was all adult patients >18 years who were triaged to a non-resuscitation area of the ED and were discharged/admitted prior to the end of the data collection period. Patients were excluded if a PIVC had been inserted before ED arrival, if transferred to resuscitation areas, if presenting with minor injuries or if patients were still in the ED at the end of the study team’s data collection period (as it was not possible to prospectively determine PIVC use).

Methods of measurement

We a priori defined ‘unnecessary’ PIVCs as PIVCS utilised for phlebotomy only or used for IV fluids administration where none of the a priori criteria for IV fluids were met and no other IV treatment was given. “Unused” PIVCs were those never utilised for phlebotomy, nor IV fluid/medication delivery. We have combined these both of these definitions as “unused and unnecessary” PIVCs. Necessary PIVCs were defined as used for IV medications or IV fluids meeting the a priori defined criteria for IV fluid administration as below.

The data collection team received training concerning the study objectives, definitions, and an electronic tablet with an online database for collecting data. Data concerning PIVC insertion and utilisation were prospectively recorded from patient arrival until discharge from the ED through direct observation, prospective ED record review and/or clarification with the patient’s clinician. Data collected included: arrival date and time, biological sex, age, arrival mode, PIVC insertion location, PIVC gauge, grade of staff inserting the PIVC, PIVC usage (plus date and time for each use), a priori assessment of indication for intravenous fluid treatment and ED discharge time. All data were anonymised at the point of data entry.

The study team assessed the indication for administering IV fluids against a set of a priori defined clinical indications based on National Institute for Health and Care Excellence (NICE, UK) guidance for intravenous therapy in adults [17]: emesis/nausea, IV fluid required to give medications/blood products/contrast media, fluid resuscitation required to improve oxygen delivery and organ perfusion, correction of electrolyte abnormalities, and/or the patient being held nil by mouth (for a proposed procedure or as GCS < 15 or swallowing impairment/awaiting swallowing assessment). Where there was no clear indication for prescribing IV fluids this was classified as ‘unnecessary’.

Primary data analysis

All data is presented using frequency and percentages. The results were analysed using Microsoft Excel.

Results

Baseline demographic data is presented in Table 1. Data were collected on 1618 patients, of which 977 had a PIVC inserted. Of the 977 PIVCs, 413 (42%) were necessary, 536 (55%) were unnecessary, and 28 (3%) were unused. Of the unnecessary PIVCs, 473 (48%) were used solely for phlebotomy and 63 (6%) were used for administration of IV fluids in patients that could drink. (Fig 1, Table 2). 130 (13%) PIVCs were utilised for IV fluids only, of which 63 (6%) did not meet the a priori criteria for IV fluid administration and were therefore classified as ‘unnecessary’.

Table 1. Demographic data on patients receiving a PIVC.

	Centre A	Centre B
Average age	49	63
Gender
Male	48%	54%
Female	52%	46%
PIVC gauge
14G/Orange	1%	0.25%
16G/Grey	2%
17G/White		9.5%
18G/Green	14%	67%
20G/Pink	68%	22%
22G/Blue	12%	0.25%
24G/Yellow	1%
26G/Violet	1%
Staff grade inserting PIVC
Doctor	4%	1%
Emergency Department Assistants	33%
Medical student	<1%
Nurse	62%	98%
Other	<1%	0.75%

Open in a new tab

Demographics included insertion site, gauge and grade of staff inserting the PIVC. Emergency Department Assistants (EDAs) are trained technicians aiding in phlebotomy, observations, and ECGs. Percentages may not add to 100 given rounding.

Fig 1 — Peripheral intravenous catheters inserted and determined to be unused and unnecessary. Data combined from centre A (UK) and centre B (Italy).

Table 2. Summary of PIVC use for patients presenting to centre A and B with combined data.

	Combined	Centre A	Centre B
PIVCs inserted (% of total patients)	977 (60%)	578 (50%)	399 (87%)
Blood sampling	874 (89%)	492 (85%)	382 (96%)
IV fluids	268 (27%)	215 (37%)	53 (13%)
Analgesia	130 (13%)	41 (7%)	89 (22%)
Non-analgesic medication	245 (25%)	177 (31%)	68 (17%)
Radiological contrast	12 (1%)	5 (1%)	7 (2%)
Blood transfusions	4 (0%)	2 (0%)	2 (1%)
Necessary PIVCs	413 (42%)	255 (44%)	158 (40%)
Unnecessary PIVCs
No a priori criteria met for IV fluid delivery	63 (6%)	48 (8%)	15 (4%)
Phlebotomy only	473 (48%)	248 (43%)	225 (56%)
Unused PIVCs	28 (3%)	27 (5%)	1 (<1%)
Unused and unnecessary	564 (58%)	323 (56%)	241 (60%)

Open in a new tab

We defined ‘unnecessary’ PIVCs as PIVCS utilised for phlebotomy only or used for IV fluids administration where none of the a priori criteria were met and no other treatment was given. Unused PIVCs were those never utilised for IV fluids/medications or phlebotomy. Necessary PIVCs were defined as used for IV medications or IV fluids meeting the a priori defined criteria for IV fluid administration.

Percentages reflect proportion of total cannulas where otherwise specified. Percentages may sum to more than 100 due to individual PIVCs being used for multiple therapies.

Discussion

This is one of the largest international prospective studies on PIVC use published to date. Data were collected on 1,618 patients with 977 (60%) having a PIVC placed. 564 (58%) of the PIVCs were classified as unnecessary, or unused. We defined PIVC placement as ‘unnecessary’ where PIVCs were utilised for phlebotomy only (473 (48%)), or for IV fluids administration where no a priori criteria were met and no other IV medication was given (63 (6%)). The number of unused PIVCs in the study was 28 (3%).

Centre B had a slightly older demographic with both centres having similar male:female ratios. Centre A had a higher number of PIVCs inserted, while for both sites the majority of PIVC insertion was by a nurse, EDA, and < 5% by physicians. Centre B inserted larger PIVCs on average. Both centres had similarly (high) numbers of unnecessary and unused PIVCs of 56% and 60% respectively, rates midway between previous studies, where PIVC utilisation rates between 35–72% [3, 6, 8–10, 18]. However, most of these studies are retrospective case note reviews. Fry et al. [4] reported a significantly lower rate than reported in this study with 9% of PIVCs classified by the authors as unnecessary and unused [4]. This was a retrospective study and the authors cited poor documentation of PIVC insertion site, size and use. The authors also did not account for inappropriate IV fluid usage which may have increased the number of PIVCs identified as unnecessary. Applying the criteria for unnecessary cannulation used in this study, 23% of PIVCs would be classified as unnecessary—with 30% PIVCs being used solely for phlebotomy. Limm et al. [3] reported an ED PIVC insertion rate of 15% with 50% unused up to 72 hours post-insertion in the ED. In a prospective study, Abbas et al. reported 86/106 (81%) patients admitted from the ED as having PIVCs placed, with 42 (49%) unused for the duration of the PIVC with 66% remaining in situ for >72 hours [19]. This small study collected data over 2 weeks describing similar data to the work reported in this journal.

PIVC insertion may alter clinician behaviour to prescribe IV fluids where patients could hydrate orally or where there is no therapeutic indication for IV fluids. To investigate this a priori criteria were defined for IV fluid delivery. The National Institute for Health and Care Excellence (NICE, UK) recommends patients not requiring fluid resuscitation (after initial assessment) receive a trial of oral or enteral fluid hydration before commencing IV fluids [17]. IV fluids are frequently prescribed for conditions where there is evidence against their efficacy, such as renal colic [20] and alcohol intoxication [21]. In this study IV fluids were administered for 130 (13%) of patients. In 48% of these patients, the a priori criteria defining clear patient benefit for IV fluid therapy were not met. This may reflect poor knowledge of national guidelines, lack of available oral hydration within the EDs and/or clinician belief in a therapeutic benefit for IV fluids. A recent large, prospective, before and after study demonstrated a PIVC usage rate of 70.5% pre-intervention and 83% post-intervention [11]. The authors defined a PIVC as unused if it was not utilised for IV fluids, medications or blood products within 24 hours and similarly did not distinguish those IV fluids with clear patient benefit, which may have further increased their defined “unused” PIVCs. Gentges et al. in a retrospective patient chart review reported a PIVC insertion rate in the ED of 55% and a significantly lower rate of unused PIVCs at 16% [5]. There was no definition for “unnecessary” IV fluid administration and the authors suggested that oral rehydration protocols were not well known; potentially increasing the rate of unnecessary IV fluid prescribing. Guihard et al. [22] reported 43% of PIVCs as unnecessary, with the administration of IV medications where an equally effective oral medication was available, most commonly analgesia (77% of cases) [22].

We report only on the use of PIVCs in the ED, some PIVCs not used in the ED may have been used on admitted patients. Guihard et al. [22] prospectively monitored all PIVCs inserted in the ED for 1 week and followed those admitted to medical wards. They counted ‘inappropriate’ PIVCs using similar a priori criteria as the study presented here and reported 43% of PIVCs to be unused or unnecessary. Lederle et al. [9] prospectively monitored 484 inpatients with PIVCs over a 6-week period and reported 33% had >2 consecutive days with no PIVC use and no reason for maintaining IV access. Data suggests that the longer a PIVC remains in situ the greater the risk of thrombophlebitis, infection and bacteraemia [1]. A recent prospective cohort study reported a significant increase in the incidence of bacteraemia following the introduction of a clinically indicated PIVC replacement strategy, which led to longer indwelling times [23]. Inserting PIVCs based on clinical need at the time they are required may reduce the total time for in situ cannula placement and associated risks.

Eleven (<1%) patients in centre A required transfer to the resuscitation area consequent upon clinical deterioration and in 7 of these patients the PIVC was unused until transfer. In a letter Lewindon highlighted the benefits of prophylactically placing PIVCs in the ED, where practitioners may be more familiar with the procedure, arguing PIVC placement may potentially prevent adverse outcomes if patients were to deteriorate and the difficulties surrounding urgent cannulation [24]. Other authors have stressed there may be a culture of convenience, and more junior members of staff view PIVC placement as part of the admissions process [25].

PIVC placement is regarded as painful by many patients, warranting analgesia [26, 27]. It has been shown to be more expensive [24] and take more time than phlebotomy alone [10] and utilises more resources and single-use plastics. In the study reported here 874 (89%) PIVCs were used for blood sampling; including 473 (48%) used only for phlebotomy with no IV medication or IV fluid delivery. Phlebotomy would be a less expensive and less painful alternative to PIVC insertion.

Limitations and recommendations for future work

There are several limitations to the study. Data was collected in two large tertiary inner-city EDs and the findings may not be generalisable to other countries or non-tertiary units with differing levels of trainee medical staff. We did not include patients triaged to resuscitation areas where a higher clinical risk suggests PIVC placement is more likely to be required. The study population did not include children or adolescents (<18 years) where different clinical behaviour may be observed based on both clinician and patient expectations [8].

Assessing the appropriateness of IV fluids is difficult to objectify with different clinicians offering different perspectives. There is data to suggest that clinicians do prescribe IV fluids for patients with no clear clinical benefit [20, 21]. There are no published guidelines for prescribing intravenous fluids across the wide spectrum of ED patients. The criteria to define IV fluid as ‘unnecessary’ used in this study are unvalidated and were developed for this study.

Our study was limited by data collection team availability and did not assess patients attending between 2200 and 0800 at centre A, and before/after the 6-hour random blocks at centre B. This convenience sample may not be a true reflection of patients presenting at other times. We excluded patients’ data from analysis if they were not discharged or admitted to the hospital by the end of a data collection period, as a result data on 501 patients were excluded. (Fig 1).

Conclusion

This study provides further evidence that a high proportion of PIVCs placed in the ED are not used to deliver therapy. 977/1618 (60%) of study patients had a PIVC inserted with 564 (58%) identified as unnecessary or unused. In 130 (13%) patients, the PIVCs were used only for IV fluids (with or without blood samples) with 63 (6%) not meeting a priori criteria for IV fluid therapy, where oral as opposed to IV fluids could have been prescribed. 473 (48%) PIVCs were used for blood draw only. ED patients are by their nature undifferentiated and at risk of clinical deterioration and may require urgent, unexpected administration of IV medication which may explain clinicians having a low threshold to place PIVCs. In the study reported here, <1% of patients required transfer to the resuscitation area for urgent treatment. Reducing the rate of PIVC placement may reduce costs, complications, patients’ pain and the rate of unnecessary prescriptions of IV fluids and medications.

Supporting information

S1 File

(DOCX)

pone.0305276.s001.docx^{(65.5KB, docx)}

Data Availability

All relevant data are within the manuscript and its Supporting information files.

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0305276.r001

Decision Letter 0

Ochuwa Adiketu Babah

2 Jul 2023

PONE-D-23-09905Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department – convenience or necessity?PLOS ONE

Dear Dr. Willis,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Dear Author,

Your manuscript titled "Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department – convenience or necessity?" has gone through editorial review. In order meet journal requirements, the following minor corrections need to be made.

1. Data availability - Please state where (that is, in what database) or from whom the data analyzed for this study can be retrieved.

2. Insert a title for figure 1.

3. References - You used et al after listing only one author for most of your citations. With Vancouvre referencing the norm is to list six authors putting et al. Please review the references according.

Once all changes have been made reviewers will be invited.

Thank you.

Please submit your revised manuscript by Aug 16 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Ochuwa Adiketu Babah, FWACS, FMCOG

Academic Editor

PLOS ONE

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PLoS One. 2024 Jun 14;19(6):e0305276. doi: 10.1371/journal.pone.0305276.r002

Author response to Decision Letter 0

21 Jul 2023

We thank you for your consideration and review of the original research article entitled “Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department – convenience or necessity?”

Please see below a response to the minor corrections requested:

1. Data availability - Please state where (that is, in what database) or from whom the data analyzed for this study can be retrieved.

Response: the data can be requested from myself (Dr Michael Willis), in a Microsoft Excel format.

2. Insert a title for figure 1.

Response: A title is present on lines 142 and 143 for figure 1. Please let me know if this needs to be rectified/in a different formatting.

Response: this has been rectified in the references section

Thank you once again for your time in considering this work.

Attachment

Submitted filename: Response to reviewers.docx

pone.0305276.s002.docx^{(16.9KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0305276.r003

Decision Letter 1

Amit Bahl

20 Dec 2023

PONE-D-23-09905R1Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department – convenience or necessity?PLOS ONE

Dear Dr. Willis,

Please submit your revised manuscript by Feb 03 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Amit Bahl, MD

Academic Editor

PLOS ONE

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thanks to the authors for submitting this article that looks at PIVC used in the ED setting. This is a useful topic given the risks associated with PIVC and the environmental impact. I have a few queries for the authors to clarify areas in the article

Introduction

Suggest re-structuring the introduction- 4th paragraph can be integrated with the first, then follow with risks associated with PIVC and then discuss unused/unnecessary PIVC. Authors could also consider discussing the environmental impact of the inappropriate use of PIVC

Line 63: where were the other studies conducted?

Lines 63-65- the sentence related to OR is not quite clear: are you saying that the risk of catheter associated infections is 6 times greater when inserted in the ED compared to inpatient wards? What is the p value? I’m not sure what the OR of 2.3 is referring to

Please also include where this study was conducted and if it was a large or small study eg. Are these results from a single centre ED in X country?

What is the rational for focusing only on the use of PIVC for IV fluids? What about unnecessary use related to medication? Or generally on the appropriate use of PIVC?

The first part of the aim isn’t quite clear- are you assessing the prevalence of PIVC use in the ED or are you describing the indications for PIVC use in the ED?

Methods

Need to specifically say that the study site were ED centers

Suggest providing a brief description of the ED sites- size, volume of patients, staffing, training, types of patients

Selection of participants might be better presented as inclusion and exclusion criteria. Unlikely that all patients would have been followed given the design used. Rather the inclusion criteria would have been adult patients, presenting to the ED with X conditions during the data collection periods and who were ?discharged from the ED by the end of the data collection period?

Why were patients with minor injuries excluded?

Was a data collection sheet used? If so, could you provide it?

Was the date of PIVC insertion recorded?

Were the indications for PIVC used recorded? This isn't actually stated in the methods. Were pre-determined categories used?

Were the diagnoses/likely diagnoses for the included patients recorded?

What was the length of stay for the included patients?

IV medications is listed as one of the indications for giving IV fluids- Have you classified IV medication as IV fluids? Please clarify

Authors state that patients were included if in a non-resus area and excluded if transferred to a resus area- fluid resuscitation is listed as one of the indications for IV fluids- seems to clash with the inclusion/exclusion criteria- authors please clarify

How did the team determine the indications for the administration of fluids? Did they ask the clinicians managing the patient or check the patient notes? (noted that data was collected using patient observations, records and clinicians but it would be good to specifically say how the indications for use were determined)

Definitions of unnecessary and necessary use of PIVC should be presented earlier

Results

Definitions for the categories should be presented in the methods not the results – the ‘unused and necessary’ category was not previously mentioned or defined

Would ‘unused’ PIVC also be considered ‘unnecessary’?

Table 2- were these categories pre-determined? It is not uncommon in an ED setting to place an IV in the event the patient will be admitted or deteriorates- was that indication included in the data collection?

Discussion- this could be more concise, The numerous subheadings are not necessary for this study. Focus on what you found and possible explanations for the findings. The ‘just in case’ category was not noted as in indication in the current study- is it that there were no ‘just in case’ scenarios or was this not collected?

The study was conducted in two countries- someone discussion around similarities/differences would be useful.

Reviewer #2: This paper requires edits prior to publication. Firstly, it is not the largest study to examine the utilisation of PIVC within the ED setting: Hawkins T et al. Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study. Acad Emerg Med. 2018 Jan;25(1):26-32. Secondly, an explanation as to why the two sites were chosen as comparison or similar sites is required. More detail into the methods as to why differing time frames, sampling methods and data collection processes were used is needed to strengthen the study. The differences are a significant risk to the methods and need to be explained. Additional explanation as to the data analysis methods used would be of benefit including reworking the tables as in the current format the results are unclear.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

PLoS One. 2024 Jun 14;19(6):e0305276. doi: 10.1371/journal.pone.0305276.r004

Author response to Decision Letter 1

14 Jan 2024

Please see the full responses to reviewers in the letter titled "Response to reviewers". We have also copied those responses below:

Reviewer #1

Introduction

• Suggest re-structuring the introduction- 4th paragraph can be integrated with the first, then follow with risks associated with PIVC and then discuss unused/unnecessary PIVC.

o With thanks. We have restructured the paragraph as suggested

• Authors could also consider discussing the environmental impact of the inappropriate use of PIVC

o We could not find studies comparing simple phlebotomy vs PIVC insertion and the environmental impact of this. Therefore we have added a line (76-78) to reflect this important point.

• Line 63: where were the other studies conducted?

o Webster et al. 2019 is a Cochrane review which included 7 trials. 6 were single centre, and one was a multi-centre trial. One trial was based in India, one in the UK, and the rest in Australia. 6 were based in acute inpatient settings, and one in a community hospital setting. Maki et al. 2016 included 20 prospective studies in their systematic review observing blood stream infection from PIVCs. 7 studies were based on medical inpatient wards, 7 on surgical wards, 2 in ITU and 4 in haematology/oncology wards. We have added a line (70-71) to reflect this.

• Lines 63-65- the sentence related to OR is not quite clear: are you saying that the risk of catheter associated infections is 6 times greater when inserted in the ED compared to inpatient wards? What is the p value? I’m not sure what the OR of 2.3 is referring to. Please also include where this study was conducted and if it was a large or small study eg. Are these results from a single centre ED in X country?

o The study Trinhh et al. 2011 was a single tertiary centre hospital in the US. It was a retrospective case note review over a 3 year period. The authors identified a total of 544 staphylococcus aureus bacteraemias, of which 24 were identified to be caused by the PIVC through clinical signs (phlebitis around the site) and positive tip cultures of the device. 16 of the PIVC-related S. aureus bacteremias (67%), the PIVC was placed in the emergency department, 4 (17%) were placed in an inpatient unit, 2 (8%) were placed by emergency medical services prior to admission, and 2 (8%) were placed at outside hospitals. The risk is 6 times greater for cannulas inserted in the ED (OR 6.03, p< 0.001) compared with those inserted as an inpatient (0.17, p<0.001). Note the previous reported OR of 0.23 was a mistake. The total were compared with the total PIVCs observed prospectively over a one day period (317 total PIVCs in situ with 79 inserted in A&E and 170 inserted on the ward). Note the confidence intervals are reported incorrectly for the OR of PIVCs inserted in the emergency department, with a typo at the upper bound. We could not find a revision submitted by the authors. The Fischer’s exact test is <0.001 for both. I have included the table from the paper for reference.

o We have updated the introduction to reflect these points in lines 72-73

• What is the rational for focusing only on the use of PIVC for IV fluids? What about unnecessary use related to medication? Or generally on the appropriate use of PIVC?

o There is previous evidence to show IV fluids were being utilised for inappropriate indications in the emergency department, examples include in renal colic and alcohol intoxication where IV fluids are frequently prescribed despite data showing no changes in outcomes. They are also the most common intervention given via a PIVC secondary to usage for phlebotomy. We felt it was more appropriate to focus on inappropriate IV fluid usage as we could formulate a priori indications related to known Trust guidelines. Given the heterogeneity and number of different medications given in a tertiary ED we felt it would be difficult to introduce a priori indications for this category. It is also hard to define appropriate vs inappropriate medications around delivering these as IV or PO. We could use guidelines but there are many good reasons the treating team may have deviated from these which were not apparent to the researchers. Furthermore the main data collectors were medical students in their 3rd-4th year of study, who would not be able to clinically determine every medication’s indication and if this was suitably given without a priori indications.

• The first part of the aim isn’t quite clear- are you assessing the prevalence of PIVC use in the ED or are you describing the indications for PIVC use in the ED?

o The first aim is to describe both the prevalence and their usage. This has been clarified in lines 80-81. The secondary aim was to assess the indications for IV fluid usage, and categorise PIVCs in to used, unused, and unnecessary.

Methods

• Need to specifically say that the study site were ED centers

o This is described in the introduction in lines 80-81, we have also added a clarification point in line 87 in the methods.

• Suggest providing a brief description of the ED sites- size, volume of patients, staffing, training, types of patients

o We have updated the methodology to reflect this in lines 87-90

• Selection of participants might be better presented as inclusion and exclusion criteria. Unlikely that all patients would have been followed given the design used. Rather the inclusion criteria would have been adult patients, presenting to the ED with X conditions during the data collection periods and who were ?discharged from the ED by the end of the data collection period?

o This has been clarified in lines 102-106.

• Why were patients with minor injuries excluded?

o The treatment of patients in minor injuries typically did not involve inserting a PIVC. If patients required IV medications or fluid, they were usually transferred into majors and would have been captured by our inclusion criteria with a PIVC generally inserted in majors.

• Was a data collection sheet used? If so, could you provide it?

o Data was collected using an electronic tablet on an online spreadsheet. The categories recorded are included in lines 116-117.

• Was the date of PIVC insertion recorded?

o Yes, this is detailed in lines 119-123. The date and time of PIVC insertion, and date and time of patient discharge was recorded.

• Were the indications for PIVC used recorded? This isn't actually stated in the methods. Were pre-determined categories used?

o The only indications were the a priori indications which are listed in lines 125-129. We did not otherwise record PIVC indications.

• Were the diagnoses/likely diagnoses for the included patients recorded?

o No, only the a priori indications for IV fluid usage.

• What was the length of stay for the included patients?

o We have not included this in our analysis, however it would have been a maximum of 14 hours in Centre A or 6 hours in Centre B (if patients stayed longer they would have been excluded as part of our study recruitment exclusions)

• IV medications is listed as one of the indications for giving IV fluids- Have you classified IV medication as IV fluids? Please clarify

o Some IV medications/contrast/blood products require an IV “push” of fluid. This was included in the a priori exclusions as the IV fluid is needed as part of administering medications. We have clarified this point in the methodology lines 126-127.

• Authors state that patients were included if in a non-resus area and excluded if transferred to a resus area- fluid resuscitation is listed as one of the indications for IV fluids- seems to clash with the inclusion/exclusion criteria- authors please clarify

o Some patients in the “majors” area were given IV fluid resuscitation if the resus area was full, or were not critically unwell enough to warrant transfer as decided by a senior clinician. This point captured those patients.

• How did the team determine the indications for the administration of fluids? Did they ask the clinicians managing the patient or check the patient notes? (noted that data was collected using patient observations, records and clinicians but it would be good to specifically say how the indications for use were determined)

o As noted in lines 117-119 “Data concerning PIVC insertion and utilisation were prospectively recorded from patient arrival until discharge from the ED through direct observation, prospective ED record review and/or clarification with the patient’s clinician”

o The specific indications are as described in the “a priori” indication list.

• Definitions of unnecessary and necessary use of PIVC should be presented earlier

o This has been moved to earlier in the methodology section

Results

• Definitions for the categories should be presented in the methods not the results – the ‘unused and necessary’ category was not previously mentioned or defined

o Definitions are listed in the methodology and we have included a definition for “unused” PIVCs, and we have felt that repeating the definitions in the results table provides clarity to those who may not read the full paper.

• Would ‘unused’ PIVC also be considered ‘unnecessary’?

o Yes, but we wanted to distinguish those unnecessary PIVCs that were utilised inappropriately for IV fluid administration, therefore we have used both unused and unnecessary

• Table 2- were these categories pre-determined? It is not uncommon in an ED setting to place an IV in the event the patient will be admitted or deteriorates- was that indication included in the data collection?

o We acknowledge the argument for ‘just in case PIVCs’. However predicting clinical risk of deterioration is challenging and risks many PIVCs being placed per use and may be regarded as wasteful. We have noted patients who had a PIVC inserted, and who subsequently deteriorated requiring admission to a resuscitation area as very low (see discussion). We did not recruit patients in the resuscitation area who are at higher risk in part for this reason. Liberal placement of PIVCs may also promote inappropriate use of IV fluids. In addition PIVCs take longer to insert, and have a higher environmental impact. There was otherwise no indication in the data collection for “just in case”

Discussion

• This could be more concise, The numerous subheadings are not necessary for this study. Focus on what you found and possible explanations for the findings. The ‘just in case’ category was not noted as in indication in the current study- is it that there were no ‘just in case’ scenarios or was this not collected?

o We have rewritten the discussion to be more concise, removed sections that do not explicitly relate to our results, and removed the subheadings. We would appreciate the reviewers’ opinion on removing the subheadings, as we feel this has now reduced some of the structure and clarity in the discussion.

o The “just in case” category was not included as an indication (see above answer). We have demonstrated that 11 patients with a PIVC were transferred to resus, and utilised this information to inform further discussion around the need for “just in case” PIVCs

• The study was conducted in two countries- someone discussion around similarities/differences would be useful.

o We discuss the similarities in the methodology section, but have chosen not to analyse the population differences between the two centres as this study was not powered or designed to be a comparison between two different hospitals. We have added lines in the discussion around some of the differences (159-163)

Reviewer #2:

• This paper requires edits prior to publication. Firstly, it is not the largest study to examine the utilisation of PIVC within the ED setting: Hawkins T et al. Peripheral Intravenous Cannula Insertion and Use in the Emergency Department: An Intervention Study. Acad Emerg Med. 2018 Jan;25(1):26-32.

o This is the largest international prospective study to date. It was not single centre, and we wanted to reflect this. However we can understand this line may be misleading, and so we have edited this in lines 153-154

• Secondly, an explanation as to why the two sites were chosen as comparison or similar sites is required. More detail into the methods as to why differing time frames, sampling methods and data collection processes were used is needed to strengthen the study. The differences are a significant risk to the methods and need to be explained.

o These are well made points. The data collection primarily reflected the availability of the research team. The study was not funded and all researchers completed training and data collection in their own time which was limited by their own work and study. The two sites were chosen as there were established academic links between them and existing research infrastructure, so making roll out of the study more likely to succeed. There is explanation in the limitations (lines 236-237) that describe the reasons for the differing time frames and sampling methods were used – due to data collector availability. We are happy to be advised if the reviewer suggests additional or alternative wording.

o We have added a section around the main differences in the hospitals in the discussion.

• Additional explanation as to the data analysis methods used would be of benefit including reworking the tables as in the current format the results are unclear.

o Thank you. We have reformatted the tables to provide more clarity with the results and more consistency with matching definitions.

Attachment

Submitted filename: Response to reviewers.docx

pone.0305276.s003.docx^{(118.9KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0305276.r005

Decision Letter 2

Robert Jeenchen Chen

26 Mar 2024

PONE-D-23-09905R2Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department – convenience or necessity?PLOS ONE

Dear Dr. Willis,

Please revise.

Please submit your revised manuscript by May 10 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Robert Jeenchen Chen, MD, MPH

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #1: Thanks for addressing the comments.

The only minor comment is if the authors could include how the criteria for administration of IVF was determined. Is it based on existing guidance or was it developed by the authors/expert team for the study.

Reviewer #2: Thank you for your edits to date. I would suggest the following minor edits prior to publication- Line 71- please expand ITU to explain the term. Line 159- should be 'centre' not 'centres'. Line 175- your results conflict with this study, in which the authors accept PIVC utilisation for IV fluids as an acceptable reason for PIVC insertion. I suggest you link this to your paragraph (line 191) which explains this further. In the current format it does not flow (ie move the paragraph involving lines 179-189 down further to line 207).

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

**********

PLoS One. 2024 Jun 14;19(6):e0305276. doi: 10.1371/journal.pone.0305276.r006

Author response to Decision Letter 2

1 May 2024

1 May 2024

Dear Dr Chen,

We thank you and the reviewers for the considered comments and review of the original research article entitled “Prospective observational study of peripheral intravenous cannula utilisation and frequency of intravenous fluid delivery in the emergency department – convenience or necessity?”

Please see below our responses to the reviewers comments, please note the line references in our responses are for the document entitled “Manuscript”:

Reviewer #1

• Thanks for addressing the comments. The only minor comment is if the authors could include how the criteria for administration of IVF was determined. Is it based on existing guidance or was it developed by the authors/expert team for the study

o These criteria were based on existing NICE (National Institute for Health and Clinical Excellence) guidance on indications for IV fluid in adults, we have clarified and referenced this in lines 127-127.

Reviewer #2

• Thank you for your edits to date. I would suggest the following minor edits prior to publication- Line 71- please expand ITU to explain the term.

o We have adjusted “ITU” to “ICU” Intensive Care Unit as this is a more internationally recognised term in line 71

• Line 159- should be 'centre' not 'centres'.

o This has been edited.

• Line 175- your results conflict with this study, in which the authors accept PIVC utilisation for IV fluids as an acceptable reason for PIVC insertion. I suggest you link this to your paragraph (line 191) which explains this further.

o We have moved this section on Hawkins et al. 2017 to lines 188-192, linking the distinction our work has made to identifying IV fluid treatment with a priori criteria.

• In the current format it does not flow (ie move the paragraph involving lines 179-189 down further to line 207).

o We agree and have moved the paragraph at your suggestion.

Thank you once again for your time in considering this work.

Yours sincerely,

Dr Michael Willis

BSc, MBBS, MRCPCH

Attachment

Submitted filename: Response to reviewers.docx

pone.0305276.s004.docx^{(22.1KB, docx)}