SummaryPeripheral venous access is frequently required in the hospital environment. This can occasionally be diYcult to obtain. We have reviewed the pertinent literature and propose a structured algorithmic approach to reduce patient discomfort and to minimise the time involved in securing venous access.Keywords: peripheral venous access; ultrasound; transillumination; venous cannulationThe placement of peripheral intravenous lines forms a significant part of the workload of junior medical 1 2 and, increasingly, nursing staV 3-6 in a hospital environment. However, peripheral venous line placement can be diYcult, especially at the extremes of age or if the patient is obese, dark skinned, an intravenous drug abuser, is hypotensive or has multiple injuries limiting the number of limbs available for use.Central venous line placement is not to be undertaken lightly as a substitute for diYcult peripheral venous access. The procedures involved usually require a high level of operator skill, as well as conferring a risk of morbidity and mortality.7-9 Central venous lines can, in any case, be inserted via peripheral veins if required. 11We therefore decided to review methods of obtaining peripheral venous access, with emphasis on diYcult situations. We believe that proper selection of site and optimal technique will minimise the need for repeated attempts at venous access. We have devised an algorithmic approach to help in this situation.We carried out a Medline search for the years from 1980 to 1998 using the keywords 'peripheral venous access' and 'venous cannulation'. We chose 35 articles for the purposes of the review. This includes a 1975 reference obtained by cross-referencing the articles initially generated. We also manually searched current textbooks on anaesthetics, intensive care, emergency medicine, phlebotomy and acute paediatrics. All the articles chosen were in the English language. Methods of improving venous prominence and/or locating peripheral veinsIn general, the upper limb is the preferred site for placing an intravenous cannula. This is because of the increased incidence of thrombophlebitis and thrombosis with lower limb infusions, 12 13 as well as the need to often immobilise the patient if a drip is sited in the lower limb. The non-dominant upper limb is preferred as an initial option.An attempt should initially be made to locate visible veins with the limb dependent, that is, below the level of the heart. A visible vein should also be easily compressible in order to qualify for use. The vein should be palpated by the operator's index finger to determine the relative size of the vessel and the direction in which it runs. A firm to hard non-compressible vein is indicative of thrombosis and not suitable for further eVorts at venous access.If the peripheral veins are not prominent and need to be made more prominent, gentle slapping of the skin overlying the vein may make it more prominent. The mechanism by which this occurs is unclear. This slapping must not be too firm as pain may cause reflex vasoc...
We studied the prevalence of polypharmacy in attenders aged 75 years and over to an emergency department (ED) in North London over a period of 1 month. We identified 467 patients in this age group. Analysis of medications being prescribed revealed at least 82 patients on medication with the potential for adverse interaction. There is a need for ED-initiated strategies to identify interactions and for pathways to allow for medication review.
BackgroundThe re-engineering of emergency department (ED) processes in the UK since 2002 has produced significant reductions in waiting times.AimsWe aim to describe the generic themes contributory to this improvement in performance, which has led to progress not yet replicated elsewhere in the English-speaking world.MethodsWe reviewed the Emergency Services Collaborative (ESC) set up by the National Health Service (NHS) Modernisation Agency as well as our own departmental performance in order to identify key themes for discussion. In addition, we reviewed relevant information from the UK Department of Health website. We used the 4-h target of patient passage through the ED as our primary outcome measure.ResultsEarly results from the ESC showed improvements, which have been sustained and enhanced since inception. We use our hospital performance figures to demonstrate a pattern of progressive improvement in performance, with 99.1% of all new attenders in 2007–2008 being seen, treated and discharged or admitted within 4 h of presentation to the ED.ConclusionsThe whole systems approach to re-engineering emergency care has led to universal improvements in patient throughput in EDs in the UK. Several of the concepts found to be useful in the NHS are worthy of consideration and adoption by other health care systems. Long waits in the ED are a thing of the past in the UK.
The use of a blind finger sweep to clear the upper airway can cause subsequent problems when used in paediatric practice. This case report adds support to recommendations that this procedure should not be used, while simultaneously describing a complication the authors have not come across in the published literature.
The United Kingdom is facing up to the effects of an ageing society, with steadily increasing longevity. This is inevitably going to lead to an increase in health care costs in the short term. The number of nonagenarians and centenarians is rising as a result of widespread improvements in health care. The impact of attendances by this group of patients in the emergency department is leading to an increasing prevalence of complex medical illness, with potentially increased costs of care that may be incompletely reimbursed. We have attempted to quantify the extent of the problem in our department, and make some recommendations for the future.
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