Table of Contents
Nursing practice in the emergency department requires increased commitment to evidence-based practice. DIA constitutes one of the most important challenges for nurses to deliver efficient and timely care. Clinical Practice Guidelines for DIA enable to get a clear vision, which options and in what cases can improve the DIA. Meant for the patients with the IV access, the CPGs argue enhanced vascular cannulation with the help of warming, intraosseous and ultrasound-guided access, subcutaneous rehydration therapy, and alternative options. These interventions are found to have different quality of evidence, and, accordingly, the level of recommendation for the treatment of patients with DIA. Still, the CPGs serve another valuable educational and informational source of nursing excellence in emergency care.
Scope and Purpose
Difficult intravenous access is supposed to be the life-threatening issue for critically ill patients in the emergency department. Consequently, the objective of the guideline was to offer alternative options in case of Difficult Intravenous Access that will fit the needs of patients with specific health history. Taking into account the variations of the current conditions of clinical decision making in the case of DIA, the objective of established CPGs appears to be appropriate. The purpose of the CPGs is directed towards the improvements in emergency service, while implementing the evidence base for the enhanced nursing practice. It manifests the search of the most rapid and the least painful ways to improve IV access (ANA).
The guideline is designated towards a comparison of alternative options for improving venous access in case of DIA, in response to their efficacy and comfort to the patient. Warming, intraosseous, ultrasound-guided and subcutaneous rehydration therapy or infrared methods are included in the assessment, as most common and available ones in the ED. The statement turns out to be congruent with the latest peer-reviewed scientific reports (Fields, Piela, Au, & Ku, 2014; Moore, 2014; Upadya & Goel, 2014). The included interventions are predisposed by the specific club of stakeholders and recipients.
The guidelines concern the health care staff of emergency departments and nurse students to be instructed and aware of all the possible solutions for efficient vascular access in case of DIA. Hence, the guidelines primarily concern practice nurses, physicians and technicians. Critically ill and unstable patients constitute the suggested group to receive more efficient and less painful medical procedure of vascular access. In particular, patients with obesity, hypovolemia, IVdrug abuse, and vasculopathy have the highest risk of difficult intravenous (IV) access (ANA, 2011). Still, while the development group considers the guidelines to be rather optional than the direct instructions of nurse behavior in case of DIA, the guidelines concern first of all nurse professionals, as potential learners. Consequently, representatives in the field of emergency care formed the team for the establishment of the CPGs.
The guidelines were developed by the ENA’s Emergency Nursing Resources Development Committee (ENA, 2011). The committee is represented by the full range of nurse professionals in the field. They are certified emergency and pediatric emergency nurses, mobile intensive care nurses, advanced practice registered nurses, clinical nurse specialists, nurse practitioners and nurse researchers. The broad variety of professions contributes to the broad coverage and understanding of the problems involved in the process of guideline’s development. In order to incorporate views and preferences of the target populations, the number of observational and cohort studies and controlled clinical trials were analyzed. The analysis is manifested in the rigorous systematic procedure.
Rigor of Development
In order to analyze evidence-based recommendations, the systematic review of recent studies were detected and critically studied. ENA’s guidelines for the Development of Clinical Practice Guidelines, as the framework for search, were taken into account. PubMed, GoogleScholar, CINAHL, Cochrane - British Medical Journal, Agency for Healthcare Research and Quality (AHRQ) and the National Guideline Clearing house covered the field of search (ENA, 2011).
Results of research evidences were achieved within the set of terms “difficult intravenous access,” “tools intravenous access,” “heat,” “nitroglycerin,” “tourniquet,” “ultrasound,” “light,” “illumination,” “subcutaneous rehydration therapy,” and “hypodermoclysis” (ENA, 2011). The documents were critically assessed, whether they are congruent with the scientific requirements and ENA’s Guidelines for the Development of Clinical Practice Guidelines. More recent studies by Fields et al. (2014) imply to the similar criteria of search for the evidence-based information.
Accordingly, the evidence table for the analyzed publications was developed, including scaling of the evidence results and critical analysis of the content. In particular, the quality assessment meant detecting flaws and inconsistencies in results. The level of evidence concerned the analysis of research, design type, and its reliability. All the issues enable the selected evidence-based documents to be taken for suggestions for possible medical interventions. Moreover, the strength of the CPG manifests in the variety of analyzed options, some of which are not well-known and novice. For instance, the stakeholders addressed “infrared light, trans illumination, and a Vein Entry Indicator Dev” as the alternative options for improving DIA (ANA, 2011).
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However, the limitations concern the restricted volume of data achieved from the available sources. The evidence information was collected mostly from pediatric cases, while the literature regarding adult patients is not sufficient to make conclusions about factors of DIA and its influence on the rapid and efficient cannulation. The systematic review by Heinrichs, Fritze, Vandermeer, Klassen, and Curtis (2013) also shows that positive results from using one of the interventions are noticed among pediatric children but are mostly insignificant. The strengths and limitations are also reinforced by benefits and risks considered in developing CPG.
The development team declares that recommendations are not imperatives for the course of treatment. If used without taking into account specific cases of treatment with individual preferences and clinical conditions, recommendations may lead to harm. At the same time, with the help of CPG physicians, nurses, and the department technicians will possess the broader range of alternative options that can help with rapid and safe vascular access. Besides, the provided information seems to be trustworthy due to the critical analysis and assessment of recommendations in response to the quality. The latter predisposed distinguishing the level of recommendations. Moreover, external review of CPG was included.
The CPGs were reviewed by experts of Institute for Emergency Nursing Research (IENR) Advisory Council before the publishing in 2011 that reinforced the achieved recommendations. ENA members realize that CPG reflects the advances and possibilities of application for the given period under investigation. Consequently, the CPG can be updated without notice in response to new findings and clinic surveys (ENA, 2011). The updates can be generated, taking into account the clear presentation of recommendations and their strengths.
Clarity and Presentation
The five main interventions, earlier mentioned, are considered to be applicable in the emergency nursing practice. The outline of CPG offers the list of these interventions together with the required environment, technologies, and risks for their application. The factors of age and clinical environment are included in the recommendations. However, the recommendation table does not provide details for patients with a different set of disorders and complications. The most detailed information is available for warming IO and ultrasound-guided vascular access that are found to be represented in the recent studies (Fields et al., 2014; Heinrichs et al., 2013; Moore, 2014).
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Applicability and Editorial Independence
CPGs refer solely to educational and informational fields of application. Consequently, the options provided cannot serve as the direct instructions for emergency nurse behavior in the ED. At the same time, all the above mentioned interventions are assessed toward their applicability in the ED. In particular, CPGs outline specific parameters for each of the options that shape dissemination. They are educational considerations, operator techniques, and time and success rate as critical features that are identified in recent studies (James Cheung, Rosenberg, & Vaillancourt, 2014; Moore, 2014). Patients’ individual needs in the given case are considered to be the primary guides for decision-making. In the light, the CPGs connect the nursing practice with the most advanced research. The monitoring of the CPGs’ dissemination is provided by ENA.
ENA’s team represents the interests of the target population, which means that the presented document is the most objective and meaningful. Due to the critical analysis of available evidence-based studies involved, while developing the CPGs, the view of the funding body is minimized in the content of guideline. In addition, the document offers, reliable advice source out of previous generalized nursing practice that diminishes the conflicts of interests (ENA, 2011).
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In the long run, the CPG for DIA provides the evidence-based suggestions for improving vascular access in the form of the list of possible interventions and recommendations to the application. Given the qualitative evaluation of the recent studies in the field and scaling the recommendations, the CPG does imply to the preference, while involving specific interventions like IO and ultrasound guided access, SQ therapy and warming, and alternative devices for improving DIA. However, the level of their involvement is different in the peculiarities of which are also addressed. Hence, the advanced practice nurse may benefit from the information provided in the CPG guideline in everyday emergency practice. The recommendations of CPG appear to be crucial in the decision-making process for timely care of patients with DIA.
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