Literature Review for Intraosseous Line Policy Revision
I was given the opportunity to revise an existing policy by suggestion of my clinical nurse specialist (CNS) as we had recent practice changes with the use of intraosseous (IO) lines. My initial thought was to make a few quick changes, update the references and be done with it. However, as I began to read the policy and the research began to think more deeply about the implications of such a policy change and that if I was going to revised it, I wanted it done right, with the best possible outcomes for the patients we serve.
The current policy and understanding was that patients should only have IOs placed if they are in active cardiopulmonary arrest. I thought that this can leave many critically ill patients requiring resuscitation without a means to receive needed fluids, medications, or blood. Through vast research, some of which I will review here explains that IO is a very effective and efficient means to obtaining vascular access in critically ill patients where intravenous (IV) catheters would be difficult or almost impossible to place.
Phillips et al, describes, “an emergent patient situation is defined as a sudden unforeseen event that demands immediate action without which the patient is in danger of increasing morbidity or mortality. A nonemergent patient situation refers to the potential of an eventual increase in patient morbidity or mortality if action is not taken.” 1 The current policy had stated that IOs should only be used in “emergent” patients; however, many patients can potentially become emergent if immediate action is not taken to prevent deterioration. Through their review of research they concluded that,
“Intraosseous vascular access should be considered as an alternative to peripheral or central intravenous access in a variety of health care settings, including intensive care units, high acuity/progressive care units, general medical units, preprocedure surgical settings where lack of vascular access can delay surgery, and chronic care and long-term care settings, when an increase in patient morbidity or mortality is possible.” They went on to advise, “Organizational policies, procedures, and protocols that establish the responsibility of insertion, maintenance, and removal of intra-osseous access devices should be developed.” In my revision I explain that IOs are intended for “for patients in extremis or those in, or imminently in danger of, cardiopulmonary arrest when rapid vascular access cannot be obtained.” I believe this is in line with current research and best practice for optimal patient outcomes.
Schalk et al contend that “establishing vascular access is a crucial step in the treatment critically ill patients.” 2 They also report that “the EZ-IO® proved as a feasible, effective, and readily available vascular access device.” This policy is an important aspect of emergency and critical care and is most likely underutilized. I believe confusion in the policy has lead to fewer uses in “questionable” situations where IV access was unobtainable and patient condition could deteriorate. My revisions have given a broader but also more concise definition of patients that are candidates for IO line placement.
A big hurdle I ran into was getting my revisions approved by the Resuscitation Committee, their fear was voiced that if the terminology was changed, and IOs could be placed without an active “code” or cardiopulmonary arrest, the use of IOs would dramatically increase. Voigt et al state that

“Intraosseous (IO) vascular access is a viable primary alternative in patients requiring emergent vascular access in the hospital emergency department (ED) (eg, resuscitation, shock/septic shock) but is underutilized.” 3 They go on to explain, “Underutilization exists respite recommendations for IO access use from a number of important medical associations peripherally involved in the ED such as the
American Academy of Pediatrics.” It is important to use these devices as it may be difficult to obtain access in critical patients, like those with “cardiopulmonary arrest, shock, sepsis, burns, major trauma, and status epilipticus.” We will always have the option of attempting to place a central venous catheter
(CVC) but these take time to prepare and have added risks. When compared to difficult IV versus CVC versus IO, “the IO alternative was significantly faster,” and had greater than 90% success rate in first attempt in many studies. The study concluded by stating further need for teaching and support for IO use within hospitals and that “IO access be the priority as an alternative, definitions be developed on what point IO access should be attempted and on what types of patients, that continuing education and in-servicing programs be developed for further reminding of training, the physician ED specialty societies develop clinical guidelines for its use (as none exists), and ED nursing be designated product champions
(user and supporter) for IO access in the ED.” I feel that my revisions reflect these recommendations and are a great starting point to fully utilize the IO for the best patient outcomes.
The other option I previously mentioned for another alternative to IV access is that of the CVC.
Leidel et al conducted and observational study of IO use versus CVC use in the ED when peripheral veins could not be accessed. Their research showed that both were viable options but CVC require physician trained to place, generally takes longer than IO and CVC can “require the interruption of CPR in the majority of cases and may be associated with risks for the patient, especially in the emergency setting.” 4
The majority of placements they recorded were proximal humerus for IO and subclavian for CVC. They concluded that IOs were more successful on first attempts and took considerably less time to place.
Finally, I read a systematic review by Weiser et al that discussed current practice and advancements in IO lines. They report the US Army Tactical Combat Casualty Care currently recommends “using IO infusion in any resuscitation scenario in which IV access is unobtainable.” 5 I realize that we are in combat zones, but much of our technology and practices have originated from treatments developed or modified by the military. The military is now recommending preferred site access to IO in the proximal humerus due to the proximity to the heart and central circulation.
Depending on injuries or accessibility I changed the policy to reflect this and to have the secondary site of the distal tibia. This study also reported superior success with the EZ-IO battery powered model which we currently use.
I read completely through the existing policy multiple times and made many revisions each time.
I was confident with what I thought was an acceptable replacement and I forwarded to all the appropriate stakeholders for review. After approximately two months of email correspondence and continued changes based on stakeholder suggestions, I was able to present it to the Professional
Practice Policy and Procedure Committee (PPPPC) and it was passed with a few minor corrections. With review of the current literature I am sure that the policy reflects best practice and improvement in the current policy. I did have to make one change in the policy that was not reflected in the literature review which was that ED Techs would no longer be able to place IOs as per their medical director. By

the research and current practice this was not supported as emergency medical technicians routinely place these devises, and have show much success in studies. As this is a hospital based policy it was required that this policy reflect the current practice within the hospital. Overall, I believe the policy I have presented and has since passed reflects a truly evidence based resource supported by the literature review and references within the policy.
References
1.
Phillips, L., Proehl, J., Brown. L., Miller, J., Campbell, T., Youngberg., (2010). Recommendations for the Use of Intraosseous Vascular Access for Emergent and Nonemergent Situations in
Various Health Care Settings. Journal of Infusion Nursing, 33, 346-351. (LOE 8)
2.
Schalk, R., Schweigkofler, U., Lotz, G., Zacharowski, K., Latasch, L., & Byhahn, C. (2011). Efficacy of the EZ-IO® needle driver for out-of-hospital intraosseous access-a preliminary, observational, multicenter study. Scand J Trauma Resusc Emerg Med, 19, 65. (LOE 4)
3.
Voigt, J., Waltzman, M., & Lottenberg, L. (2012). Intraosseous vascular access for in-hospital emergency use: a systematic clinical review of the literature and analysis. Pediatric emergency
care, 28(2), 185-199. (LOE5)
4.
Leidel, B. A., Kirchhoff, C., Bogner, V., Braunstein, V., Biberthaler, P., & Kanz, K. G. (2012).
Comparison of intraosseous versus central venous vascular access in adults under resuscitation in the emergency department with inaccessible peripheral veins. Resuscitation, 83(1), 40-45.
(LOE 2)
5.
Weiser, G., Hoffmann, Y., Galbraith, R., & Shavit, I. (2012). Current advances in intraosseous infusion–a systematic review. Resuscitation, 83(1), 20-26. (LOE 1)