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New study: Time to rethink pre-hospital IV fluids in trauma
IV fluids can delay treatment, cause harm
There is mounting evidence in the literature that the routine practice by paramedics of administering IV fluids to severely injured patients before they are transported to the hospital is not only unnecessary, but may also cause harm. In fact, new data from a large, retrospective study, using five years worth of information from the American College of Surgeons National Trauma Data Bank (NTDB), strongly suggest that this widespread practice should be discouraged (see reference).
While the issue is of prime concern to the state and regional agencies that govern and train emergency medical personnel, experts stress emergency department personnel have a strong role to play in changing a practice that has been a standard of care for decades despite a dearth of scientific evidence supporting its use.
"This is going to take a concerted effort from a lot of different groups. It is not going to be something that individuals can take on themselves and try to change one patient at a time," stresses Elliott Haut, MD, FACS, the lead author of the study and an associate professor of surgery and anesthesiology, critical care medicine, at Johns Hopkins University School of Medicine in Baltimore, MD. "I think it needs to change at a big level."
IV fluids delay transport
The study, published in the February 2011 issue of the Annals of Surgery, examined the care outcomes of 776,734 patients, approximately half of whom received IV fluids prior to transportation to the hospital. Researchers found that patients who received the IV fluids were 11% more likely to die than those who did not, and the impact was particularly notable among specific groups of patients:
Part of the problem, observes Haut, is that it takes time to administer IV fluids, and this delays transportation of the patient to the hospital. In fact, eliminating this step would actually take some complexity out of the process. "There are a lot of times when I wish the paramedics would just pick the patients up and bring them in, lights and sirens, as fast as they can with minimal intervention," explains Haut, who is a practicing trauma surgeon. However, he stresses the study data suggest that it is not just about delayed treatment; the IV fluids may actually be causing harm in these patients as well.
While IV fluids are administered to raise blood pressure (BP), thereby keeping the body's systems working, Haut explains that low BP can temporarily stop bleeding. Consequently, when a trauma patient's BP rises rapidly, it can cause the patient to start bleeding again before he gets needed care in the hospital.
"We looked at this very large group in aggregate and found there is potential harm associated with [IV fluids], but I certainly think in some specific cases, IV fluids may be beneficial," says Haut. If a patient has to travel a long distance to reach a trauma center, for example, it is possible that the IV fluids would provide some benefit, he says, although he did not study this issue.
ED physicians have a strong role
While emergency medical personnel communicate with ED staff while they are still in the field, much of what they do is protocol-driven, Haut emphasizes.
"Long gone are the days when they had to call in and ask for every intervention or every single medication that needs to be given before someone arrives," he says. However, Haut adds that ED physicians often serve as medical directors of EMS agencies. Furthermore, in some cases, such as Maryland, for example, Haut points out that emergency medicine physicians actually run the emergency medical systems. This puts them in a prime position to influence the pre-hospital care of trauma patients.
"I do think they have a key role to play not on an individual paramedic or EMT basis, but on a systems-level approach," adds Haut.
Haut acknowledges that while his study has attracted attention, it will take time to change a practice that is as well-established as the administration of IV fluids in the field. "I think it is prompting people to really discuss things and question the dogma of what we have been doing for a very long time, and why we have been doing it," he says. "I am working with the people who run the EMSs throughout the state to try and change [the practice] in the pre-hospital setting."
In the meantime, Haut is planning further studies to look at the issue in greater detail. For example, he is working with colleagues to essentially redo the study with data from both the NTDB and a large EMS database. In addition, he wants to look into the pre-hospital care of urban gunshot wound patients. "We are going to collect data from trauma centers throughout the country in different cities, and get information about that specific patient population," he explains. "We are going to look not just at the question of IV fluids, but all the different procedures that get done for that patient population."
For more information on pre-hospital IV administration, contact:
Elliott Haut, MD, FACS, Associate Professor of Surgery and Anesthesiology, Critical Care Medicine, Johns Hopkins University School of Medicine in Baltimore, MD. E-mail: firstname.lastname@example.org.
Before posting wait times, get clinical staff on board
If you're interested in making your ed wait times available to the public via the internet or text messaging, make sure you take the time to get the clinical staff on board with the approach first, stresses Marty Carr, MD, the medical director for the EDs at Methodist Le Bonheur Healthcare in Memphis, TN.
"This is not something where you can walk up to the doctors and say you're going to do it," says Carr. "Everybody's got to buy into it."
Carr advises colleagues to do some internal measurements first so that you can spot areas in need of improvement and make adjustments before going live with the wait times. It also gives the staff time to adjust to the added stress that comes with posting performance metrics publicly.
David Cummings, RN, CEN, corporate administrator, patient care operations, at Methodist Le Bonheur Healthcare, says,"There is a lot of pressure on them to make sure we are as efficient as possible. All of our providers and staff really feel that pressure to quickly, efficiently, and safely see patients. And safety is the most important thing."