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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 current research, I 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. This could potentially leave many critically ill patients requiring
resuscitation without a means to receive needed fluids, medications, or blood. Current research, some
of which I will review, 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
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 non-emergent patient situation refers to the potential of an eventual increase in patient
morbidity or mortality if action is not taken.
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, pre-procedure 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 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
Schalk et al contend that establishing vascular access is a crucial step in the treatment of
critically ill patients.
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
They go on to explain, Underutilization exists despite 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 an 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
training to be placed, 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.

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.
realize that we are not 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 been approved, reflects a truly evidence based resource supported by the
literature review and references within the policy.

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
infusiona systematic review. Resuscitation, 83(1), 20-26. (LOE 1)