Peripheral Intravenous Access Rates Obtained by Emergency Medical Services in Pediatric Patients: A Retrospective Study

Introduction

Securing peripheral intravenous access is one of the basic practical skills required for work with emergency medical services. The incidence of obtaining and using intravenous access before arriving to the hospital varies greatly and ranges from 1.6% to more than 80% and from 30% to 80%, respectively [1]. IV access remains the primary drug delivery route in emergencies, including cardiopulmonary resuscitation in children [2]. In many cases, establishing the access is not problematic, but occasionally, especially when dealing with patients in poor clinical condition, the task is difficult [3]. In adult emergency patients, intravenous access is established on the first attempt in only 74% of cases, with the time until successful cannulation ranging from 2.5 to 13 minutes [4]. In the pediatric population, the task can be even more challenging. Difficulties in obtaining peripheral IV access are associated with age, weight, poor perfusion and visibility and palpability of the veins [5]. During cardiopulmonary resuscitation of a child, the time to obtain IV access exceeds 10 minutes, with the access impossible to obtain in 6% of children during resuscitation [6]. In the study, Reigart et al showed that in a pediatric hospital setting, peripheral IV access was successful in 53.5% of cases on the first attempt, with an average access time of 9 minutes. In the younger sub-population (below 2 years old), the rate was merely 38.9%, with 11 minutes until access establishment [7]. Wherever peripheral intravenous access is not available, alternative routes may be considered, such as intraosseous or intranasal access. Intraosseous access is easy to obtain but is associated with severe pain while establishing the access and during the subsequent administration of drugs and fluids [8]. Intranasal drug delivery is also easy to perform, but cannot be used to administer all drugs, including some medications used in the rapid sequence intubation (RSI) procedure, and this route is also incompatible with fluid therapy [9].

The more frequently a procedure is performed, the more experienced the staff is, improving the rate of correct and successful performance. In a study of peripheral IV cannulation in adults receiving care at a hospital emergency department, Carr et al showed that the more experienced the staff, the higher the percentage of obtaining peripheral access on the first attempt [10].

The objective of this study was to evaluate the rate of obtaining peripheral IV access in pediatric patients in a pre-hospital setting by emergency medical team members and to analyze the variables affecting the rate.

Material and Methods

ETHICS STATEMENT:

The study protocol was approved by the Bioethics Committee of the Medical University of Warsaw, Poland (AKBE/14/2025), which ruled that the study did not require consent due to its retrospective nature. The study was conducted in accordance with the principles set out in the 1964 Declaration of Helsinki and its later amendments. Database reports did not allow for the identification of individual patients at any stage of the study. Due to its retrospective design and the use of anonymized data, the requirement for informed consent was waived.

STUDY DESIGN AND SETTING:

This was a retrospective study using anonymized records from the database of Independent Public Healthcare Facility (SP ZOZ) “RM – Meditrans” in Siedlce, operating under the Action Plan for the State Medical Rescue System for the Masovian Voivodeship and Law on the National Emergency Medical Services [11]. The EMS system in this region serves a population of approximately 500 000 people and covers the counties of Siedlce, Mińsk, Łosice, Sokołów Podlaski, Garwolin, and Węgrów in the Masovian Voivodeship. It consists of 18 EMS teams (4 with physician and paramedics onboard and 14 with paramedics only) which conduct approximately 27 000 mission per year. There is also 1 HEMS team located in Sokołów Podlaski. We analyzed all EMS team dispatches to patients under 18 years of age between January 1, 2020, and December 31, 2022. Each EMS team dispatch within the system is reported into a digital database, which provides standardized data for clinical and operational assessment.

STUDY PARTICIPANTS:

This study analyzed interventions conducted by emergency medical services involving pediatric patients. The inclusion criterion was patient age under 18 years at the time of EMS dispatch. Records were excluded if data were incomplete or contained missing values that prevented basic statistical analysis.

Out of 6335 EMS interventions meeting the age-based inclusion criterion, 6331 cases were eligible and included in the final analysis after applying the exclusion criteria. For detailed analysis, the population was divided into age subgroup: 0–1 year; 2–4 years; 5–11 years; 12–18 years.

DATA COLLECTION AND VARIABLES:

During data analysis, the following variables were extracted from the EMS electronic database: sex and age of the patients, date and time of departure, place of the call, reasons for the intervention of the emergency medical teams, whether the patient was transported to the hospital, and whether peripheral IV access was established in the pre-hospital setting.

STATISTICAL ANALYSIS:

The data obtained from the analysis of medical records were subjected to statistical analysis using IBM SPSS Statistics for Windows, version 25.0 (IBM Corp., Armonk, NY, USA). Baseline data were compared using the chi-square test assess significant differences between the analyzed qualitative variables. The impact of individual variables on the establishment of peripheral venous access in children was evaluated through logistic regression analysis employing the stepwise selection method. The strength of associations between the dependent variable and predictors was expressed as the odds ratio (OR) with 95% confidence intervals (CI). A two-tailed p-value of <0.05 was considered statistically significant.

Results

CHARACTERISTICS OF EMS INTERVENTIONS AND STUDY POPULATION:

In the analyzed patient population intravenous access was established at the pre-hospital stage in 1073 cases, accounting for nearly 17% of the total number. Within the study period, most EMS team dispatch cases occurred in 2022 (43.60%), in the spring (25.97%), between 8: 00 pm and 3: 59 pm (41.86%), and in rural areas (60.29%). Most of the patients were male (53.56%), aged 12 to 18 years (43.37%). Detailed characteristics of the analyzed cases when EMS team were dispatched to pediatric patients are presented in Table 1.

FREQUENCY OF PERIPHERAL INTRAVENOUS CANNULATION:

A comparative analysis was carried out for the group of patients who had IV access established versus those who had not. It revealed significant differences in the frequency of cannulation depending on the year of intervention, season, time of call, origin of call, patient age, follow-up status, intravenous pharmacotherapy, and whether medical aid was sought because of trauma or poisoning (p<0.05). A detailed analysis is presented in Table 2.

PREDICTORS OF INTRAVENOUS CANNULATION:

This was followed by a logistic regression analysis of the factors established as statistically significant in the primary analysis. The unadjusted model showed all of these factors to have a significant effect on whether IV access was sought in pediatric patients at the pre-hospital stage. Patients ages deserve particular attention in this regard. The analysis indicates that, considering the youngest group of patients (below 1 year) as a baseline, the odds ratio for cannulation is twice as high in children aged 1 to 4 years (OR=2.05), 9 times higher in children aged 5 to 11 years (OR=9.18) and 22 times higher for the oldest age group considered (12 to 18 years old) (OR=22.66). Furthermore, the analysis showed that the odds ratio for establishing intravenous access is nearly 2 times higher (OR=1.96) for trauma patients, nearly 4 times higher (OR=3.88) for cases of poisoning, and nearly 6 times higher (OR=5.86) for patients transferred to HEMS teams, as compared to those transported to the hospital by the EMS teams. A detailed analysis is presented in Table 3.

Discussion

Vascular access plays a crucial role in modern healthcare, facilitating the effective administration of medications and intravenous fluids through peripheral intravenous catheters (PIVC) and intraosseous (IO) devices. In pre-hospital settings, the timely establishment of vascular access is often essential, and any delays or failures in its acquisition may significantly worsen patient outcomes, particularly in emergency situations such as cardiac arrest, severe thermal burns, or major multi-organ trauma [1,12,13].

A retrospective analysis conducted in this study revealed that the overall frequency of peripheral IV cannulation among pediatric patients treated by emergency medical services teams was surprisingly low, at 16.94%. In contrast, findings from Seymour et al, who examined an adult out-of-hospital population, showed that nearly half of the patients transported to hospital had IV access established [14]. Notably, in our study, the lowest cannulation rates were observed among children under 1 year of age. This finding is consistent with observations reported by Evison et al, who noted that although clinical indications for cannulation are generally similar across age groups, paramedics tend to be more cautious when considering IV access in children due to the associated emotional distress and trauma for both the child and their caregivers [15].

Correct performance of a procedure depends on how often it is performed. With higher frequency, the success rate increases. In addition, there are numerous studies in the literature that addressed the issue of difficulties in obtaining vascular access in pediatric patients. Dunstan et al found that in 39% of children, the first attempt to obtain an IV cannula was unsuccessful, and the factors influencing the difficulty in obtaining venous access were: age below 3 years, limited number of available veins, less experience of staff, and unfavorable environmental conditions [16]. On the other hand, Bennett et al indicated that this procedure can be difficult for both medical staff and stressful for patients and their families. They suggest that choosing the most appropriate vascular access is crucial for improving short-term and long-term care in pediatric patients [17].

Our findings indicate that patients who required hospital transport or were in an emergency condition were more likely to receive vascular access in the pre-hospital setting. Notably, peripheral intravenous access rate in children transported to the hospital by HEMS teams is nearly 6 times higher than the baseline. This is probably because children qualified for transport by HEMS teams are typically in a more severe clinical condition, thus requiring cardiovascular access. Engels et al link the increased frequency of PIVC placement with the clinical severity of the patient and the need for IV administration of fluids or medications, which is also confirmed by our results [18]. Moreover, as expected, our study found that trauma cases were more likely to have peripheral IV access established, with the trauma-related diagnosis increasing the cannulation rate nearly 2-fold (OR=1.96). In poisoning cases, the cannulation rate was almost 4 times higher (OR=3.88). The findings of Seymour et al also support this association, showing that most patients who received IV access were transported to the hospital and that pre-hospital IV placement was more frequent among patients assessed by EMS personnel as being in a life-threatening or emergency condition, particularly those with cardiovascular disease [14].

Patient age increases the probability of successful cannulation. In the adolescent subgroup (12–18 years old), the cannulation rate was 22 times higher than in children younger than 1 year of age. This means that in the subgroup of youngest children, peripheral IV access was established the least frequently. This youngest patient group is the most difficult in terms of securing peripheral IV access due to anatomical differences and the emotional stress associated with working with the youngest children. Chu et al, in their study of 935 cases of peripheral venous cannulations in children, showed that the highest failure rate (18.4%) occurred in infants, suggesting greater difficulties in obtaining IV access in younger patients [19]. Similarly, Casal-Guisande et al found that establishing vascular access in infants is particularly challenging due to anatomical factors such as smaller vessel diameter, increased subcutaneous tissue, and patient movement, all of which limit the visibility and palpability of veins [20]. Moreover, in many studies, patient age was identified as a risk factor [21–24].

The overall rate at which peripheral IV access is established in the pediatric population in pre-hospital setting is low. This raise concerns as to whether the EMS personnel have sufficient experience and practical skills necessary to carry out the procedure. This requires further analysis and development of algorithms for management of difficulties in obtaining peripheral IV access by EMS personnel in pediatric patients.

Conclusions

LIMITATIONS:

This study is not without limitations. Primarily, the retrospective nature of the analysis, based on EMS documentation, restricts the possibility of establishing causal relationships. While the study encompassed a substantial number of EMS interventions involving pediatric patients, the fact that it was limited to a single regional EMS provider may constrain the applicability of the findings to other areas or healthcare systems governed by different operational standards. Although the use of standardized digital records reduced the likelihood of data entry errors, the range of available variables was confined to those routinely recorded during EMS operations. Crucial aspects such as the complexity of venous access procedures or the clinical experience of EMS personnel were not documented and thus could not be evaluated. The absence of such data may have influenced the strength or interpretation of some associations. Despite these limitations, our study provides valuable insights into an under-researched area of pre-hospital pediatric care and may serve as a foundation for further multicenter studies involving more diverse populations and additional clinical parameters.