Intraosseous access: a simulation analysis

Abstract

Introduction: The priority in critical patients is to find a vascular access. The most used access is the peripheral venous access, but when its placement goes wrong or is difficult, the literature recommends implementing intraosseous (IO) access as a valid alternative. The IO access is a rapid, reliable and a relatively safe method. Despite the recommendations, IO access is rarely used when indicated. The objective of this study was to evaluate the critical points of the IO procedure, positioning time, percentage of success at first attempt in simulation and, in according to obtained outcomes, checking of the procedure inclusion within university programs. Material and methods: A sample of 84 people was recruited; among them 44 were students attending the third year of the Degree Course in Nursing of the University of Turin (site of Asti) and 40 nurses from intensive care unit and emergency ward of Cardinal Massaia Hospital of Asti. A short lesson about IO access took place, followed by a practical demonstration. Subsequently, the IO access insertion performance and difficulty perceived were evaluated. Statistical analysis was performed by means of inferential and descriptive bivariate analysis. Results: The average value of the performance “IO access insertion” was 12.2±1.22 (average of the assigned points by the sample). The average difficulty perceived was 1.65±0.42, and mainly found in “selection of the correct point of insertion” with a value of 2.64±0.87, “needle placement” with a medium value of 2.35±1.02 and “medication” with a value of 2.0±0.94. Average execution time of IO access and needle placement were 73.3 and 36.1 seconds, respectively. Finally, the success rate at the first attempt was 72.6%. Discussion: The IO access execution time, for the complete procedure and for the needle placement only, was below the 3 minutes. Among nurses and students, data of the success of the procedure show significant results, but the difference between subgroups is still lower than expected considering the results of the statistical analysis about procedure success, execution time and error percentage. Most critical issues were found in the retrieval of area of insertion, whereas the most difficulty perceived was on reference point selection, correct needle placement and medication. The procedure may become subject of teaching in the University. Conclusion: The study evaluates the possibility of the IO access use, by underlining how is necessary a training about it. The principal reason of ‘non-use’ of this device is the disinformation of healthcare professionals. The results seem to underline the importance of a possible integration of IO access technique in the programs of Degree Nursing Course and post-base course. This may improve nursing in emergency situations and therefore, patient outcomes. When healthcare staff training is possible, periodical refresh is particularly recommended in order to maintain the acquired skills.