Barriers to utilization of intraosseous vascular access in pediatric emergencies
Article information
Administering lifesaving fluids and medications during pediatric emergency resuscitation inevitably requires rapid vascular access. Traditional intravenous access often requires multiple attempts; therefore, securing vascular access can be time-consuming [1]. Particularly in pediatric patients, anatomical variations, excess subcutaneous fat, and small and mobile veins, together with a child’s fearfulness, often exacerbate the difficulty and prolong the process, which can further jeopardize the patient’s clinical outcomes [2,3]. In situations where quick vascular access needs to be secured and/or both central and intravenous access cannot be achieved promptly, intraosseous (IO) vascular access comes into play [4,5]. IO vascular access is an increasingly common procedure for quickly establishing vascular access in most pediatric emergency settings [6]. Familiarity with both indications and contraindications for IO access (Fig. 1) [7] is crucial for providers of emergency medical services (EMS) [6,8].
Detailed indications and contraindications of intraosseous access in pediatric patients. a)Life-threatening emergencies involving conditions such as shock, severe sepsis, cardiopulmonary arrest, and status epilepticus. b)Aspirated bone marrow from intraosseous access is more suitable and preferred for inoculation of blood culture, bedside glucometer, pH, hemoglobin, and lactate testing.
Intraosseous (IO) success rates have been documented to be higher than those of traditional methods, with very minimal complication rates. One study finds that IO access was successful in 86% of pediatric patients, with a median time to successful IO placement of 8 minutes [9]. Moreover, a recent study by Ting et al. [10] reports IO success rates of 96.7% in young children in a prehospital setting. Another prospective study conducted in Germany finds an overall IO success rate of 98.3%, with a first attempt success rate of 81.9% [11]. Additionally, 63.6% of patients have been shown to be successfully punctured within the first 3 minutes from the time of indication [11]. In a 5-year review of prehospital IO needle placement, success rates were higher in children under 3 years (85%) than in older children or adults (50%). The main causes of failure were errors in the identification of landmarks, attempting IO access when contraindications existed, and the bending of needles after being placed incorrectly [12]. Improved tools and techniques, such as better needle design and new devices, have helped overcome drawbacks related to bone penetration, facilitating easier and faster access.
Despite the higher success rates reported in a wide variety of clinical settings, IO access is not widely utilized in emergencies that require quick vascular access [13]. Recent studies report barriers to fully utilizing IO access, primarily in adult emergency situations. However, there is limited synergistic information on the factors contributing to the underutilization of the IO approach in pediatric emergency patients. This section focuses on unravelling the factors that hinder IO access usage.
LACK OF OVERALL UNDERSTANDING OF IO INDICATIONS AND USEFULNESS
A proper understanding of the purpose, indications, and benefits of IO access is essential for healthcare providers, as well as members of the public. Some patients and/or patients’ relatives are known to have refused IO access procedures. In a national web-based survey conducted in China, 1,233 emergency medical providers (38.9%) reported rejection by individual patients and/or their relatives when attempting to perform IO access [14]. To help mitigate such behavior, it has been proposed that education aimed at raising awareness about the lifesaving benefits of IO access, particularly in emergency situations, is of vital significance [15]. Additionally, emphasis should be placed on the indications and contraindications of IO access, so that patients may always make the safest decision based on comprehensive information [16].
The use of IO access in pediatric emergencies has been endorsed by the American Heart Association, the American College of Emergency Physicians, the American Academy of Pediatrics, and many other reputable international organizations [17]. Improper risk-benefit analysis has led to the misconception that IO access is a very risky procedure that can do more harm than good. Such impressions have significantly discouraged IO access utilization. Awareness of the benefits of IO access needs to be strengthened, especially among EMS providers [18].
SUBOPTIMAL LEVEL OF KNOWLEDGE AND EXPERIENCE REGARDING IO ACCESS
IO access should always be performed by trained, qualified, and competent professionals to ensure the safest outcomes for patients [19]. Even in situations where EMS providers may possess sufficient information regarding IO access, skills and experience may be lacking. Pfister et al. [20] emphasized the importance of enhancing structured, standardized training in IO puncture among EMS providers. Standardized training has been found to improve success rates more than relying solely on a trainee’s previous experiences and occupation. On the other hand, Lo and Reynolds [21] reported that nothing is more helpful for reducing reluctance to use IO access during emergencies among trainee pediatricians than previous real-life experiences of IO needle insertion. Indeed, knowledge and attitude towards IO access utilization have been reported to increase following proper IO-focused training [22]. Studies further encourage regular workshops focused on IO access to contribute to practitioners’ overall readiness to undertake this vital approach [23]. Moreover, rescuers are required to learn safe techniques for establishing IO access [24]. In one study, telesimulation was found to be an effective novel approach in teaching procedural skills, including IO insertion techniques [25]. Following the telesimulation teaching session, there were significant improvements in physician knowledge, self-reported confidence, and comfort levels in inserting the IO needle [25]. Another survey in a prospective observational study reports high satisfaction rates and improved operability of the IO procedure among EMS providers after intensive training [26]. For IO vascular access to become a standard of care in clinical practice, education and training should be incorporated into core competency curricula [27]. Introduction of the Just in Time Training curriculum has been found to significantly improve the comfort level of trainees in performing IO needle insertion [28]. In addition, recent advancements have made it possible to develop cost-effective three-dimensional (3D) printed adult proximal IO tibia task trainers (simulators) as a practical tool for IO techniques. It has been reported that simulation-based training using such 3D-printed trainers is effective in fulfilling IO training objectives [29–31].
PSYCHOLOGICAL BARRIERS
Provision of EMS is often associated with psychological challenges such as stress and anxiety [32]. Providers of EMS often experience frustration when attempting to establish vascular access in critically ill patients, especially in children. Fear of failure and the potential to cause significant pain to patients often make EMS providers reluctant to place an IO needle [33]. For instance, Szarpak et al. [34] highlighted how psychological factors influence the underutilization of IO access. In their study, 48% of participants reported that psychological barriers accounted for their decision to avoid the procedure, with fear being the most frequently reported barrier. Other factors included a lack of confidence in achieving IO access and stress while performing the procedure. However, confidence in performing IO access increases with the number of learning modalities to which a trainee has been exposed. That is, participants who reported previous hands-on workshops were less likely to have psychological concerns when inserting an IO device [35].
LACK OF PROPER IO ACCESS-FOCUSED PROTOCOLS AND GUIDELINES
It is important for all EMS agencies to have the appropriate equipment, staff, protocols, and guidelines to ensure high-quality care of children [36]. Given the usefulness of IO techniques, IO-related protocols and guidelines are crucial in supporting clinical decision-making. Therefore, they should be developed, made available, and highly integrated into our daily emergency medical practices [37]. Several international organizations, including the American Heart Association, have established protocols and guidelines for emergency situations that have proven to be useful. However, the lack of specific national organizational guidelines regarding IO access in pediatric patients presents a significant challenge. Local guidelines are highly recommended to ensure that emergency medical teams can perform this procedure safely, effectively, and with full confidence [38].
AVAILABILITY, AFFORDABILITY, AND USER-FRIENDLINESS OF IO DEVICES
The evolution of medical technology has been instrumental in the development of a wide variety of IO devices [39]. A lack of proper IO equipment hinders the ability to perform the required procedure [40]. Despite groundbreaking and innovative efforts in developing suitable IO technologies, disparities in accessibility remain. Recent studies have reported that one of the barriers faced by EMS providers in performing IO procedures is delayed acquisition of IO kit devices [41]. Despite numerous reasons to appreciate and support the development of new IO devices, several other issues have emerged. Among them is the cost of the devices, especially in resource-limited healthcare settings [42]. Cost is of great consideration in all aspects of patient care [43]. Additionally, concerns regarding user-friendliness need to be addressed to provide more robust healthcare services [44]. One study assessing IO device preferences and satisfaction finds that EMS providers preferred a powered IO system with passive needle-safety, easy-to-use features, and battery-powered enhancements that improve device reliability [45].
CONCLUSION
Awareness and understanding of IO usefulness in emergency situations is not enough if EMS providers lack crucial knowledge and expertise to perform the technique. Remote simulation-based training of IO techniques using recently developed 3D-printed simulators is recommended. This method has proven to be effective in equipping the EMS workforce with crucial skills and confidence to perform IO procedures. Additionally, local health authorities should ensure the timely availability of IO-focused guidelines and user-friendly IO devices for EMS providers.
Notes
Conflicts of interest
The author has no conflicts of interest to declare.
Funding
The author received no financial support for this study.
Data availability
Data sharing is not applicable as no new data were created or analyzed in this study.