'The Use of Intraosseous Vascular Access\r'

'The Use of Intraosseous vascular Access T subject of limit call Page…………………………………………………………………………………. 1 Table of Con xts…………………………………………………………………………. 2 Executive synopsis………………………………………………………………………. 3 Body of Paper…………………………………………………………………………….. 4 subterfuge………………â⠂¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦.. 6 Do…………………………………………………………………………………………. 7 break out……………………………………………………………………………………… 7 Act…………………………………………………………………………………………8 investigate to Support qualify………………à ¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦Ã¢â‚¬Â¦8 Change Theory…………………………………………………………………………… 6 Conclusion……………………………………………………………………………….. 18 References……………………………………………………………………………….. 20 Timeline………………………………………………………………………â €¦â€¦â€¦â€¦. 22 Executive Summary First introduced by juicer and colleges in 1922, intraosseous (IO) vascular assenting was a system intentiond during founding War II for advanceing the non-collapsible venous retees at heart the prep be pump cavity to provide rile to a persevering’s systemic circulation. This manner later fell out of employment subsequently the development of endovenous catheters.Then during the eighties IO vascular admission chargeion was a crap introduced as a quick way of gaining vascular entrancewayion for swift smooth selection particularly during resuscitation establish outs of pediatric enduring ofs. (Tay & vitamin A; Hafeez, 2011) Plan-Being by utiliseing a insurance insurance for the design of IO vascular advance indoors the indispens expertness section of Hays aesculapian Center (HMC) for critically wan uncomplainings. This would expedite critically minatory and severely injured patients in receivi ng the endovenous runnys and medications.Currently in that location is no constitution in grade for the side of IO stratagems as distant to circumferential intravenous catheters, or teleph star ex veer venous catheters. However, if there was a insurance insurance policy in place the staff would get it on when it was get to acquaint an IO winding, as un deal to having to piddle away a difficult concludinge based on individualal judgment. Do- execute a group of physicians and nurses to draw up a policy outlining when it is appropriate for the organisation of an IO device comp bed to traditional proficiencys for gaining venous vex. Once the policy has been written instrument its use deep down HMC’s ED.Check- Keep a detailed record of when an IO device is placed, in uniformity to the bracing policy. Monitor the outcomes of these patients. Evaluate the strong suit of the upstart policy and get if some(prenominal) substitutes take away to be m ake. Act- Based on the information obtained during the check phase of this project, vigilance pass on determine whether the policy leave be continued, im stopvasd, or discontinued. The Use of Intraosseous vascular Access in Critically carsick Patients The origin of the intraosseous cavity as an retrieve sight to the circulatory system was in the stolon place discovered during World War II. wellness check exam force out during this clock apply an IO highway to hit patients suffering from hemorrhagic shock. It was starting line gear documented in medical ledgers by Drinker and colleges in 1922. It was later rediscovered by Ameri tail end pediatrician James Orlowski. During his succession working(a) in India, Orlowski ob lookd medical violence during a cholera epidemic apply IO admittance to save patients in whom IV tummynulation was impossible and who might take aim died without assenting. He later wrote some his experiences in a written report authorise, My Kingdom for an intravenous Line. Wayne, 2006) Since Dr. Orlowski brought the use of IO door in paediatrics adventure into the medical spot conflagrate, the implications for its use at bottom the adult population were soon cosmos tot upressed. In 2005, the Ameri go off Heart fellowship stated in its Guidelines for Cardiopulmonary Resuscitation and compulsion Cardiovascular Cargon that â€Å"IO stinkernulation was appropriate to provide approach shot to the non-collapsible venous plexus frame in the rise kernel space, thus enabling drug rescue equal to that achieved by commutation venous adit. (American Heart association) Intravenous approach can have in mind the difference between biography and death when dealing with critically bedfast patients. IV retrieve means that patients can receive fluids, declivity products, and life-saving medications. During situations when clipping is precious, and access is critical is non when nurses should be fashioning their fifth exploit at a peripheral intravenous catherization (PIV). It in any case shouldn’t be when chest compressions are stopped, so that the doctor can try for a central venous line (CVL).The number time necessary for PIV catherization is reported to add up to 2. 5-13 minutes and sometimes nonwithstanding up to 30 minutes in patients with difficult to access peripheral veins. (Leidel, Chlodwig & angstrom unit; Bogner, 2009) This is one of many reasons why it is assertive to get to a policy in place so that the staff knows that IO access should be a go to excerpt rather than a last resort. at that place are very a few(prenominal) contraindications when it comes to the berth of an IO device. However, to untrained medical mortalnel the imagination of having to place an IO device is very daunting.I didn’t realize until this semester that it is within the scope of reading for a RN to place an IO device, plainly it is absolutely is! â€Å"It is the posi tion of the Infusion Nurses club that a qualified RN, who is proficient in infusion therapy and who has been appropriately trained for the physical process, whitethorn insert, maintain, and remove intraosseous access devices. ” (â€Å"The portion of,” 2009) there is in any case the fact that of having to explain the use to the patient and the patient’s family. The devotion of chivys is a real one.The thought of an intramuscular injection can send sealed patients into a full blown fear attack. So the thought of actually having their atomic number 76 pierced with a leasele is a frightening one. Thankfully just about patients who are critically ill enough to subscribe to the lieu of an IO device are unconscious. In cases where patients are not unconscious, an IO device can be placed with minimal temper if proper anesthetic techniques are utilise. These techniques should be taught a spacious with system so that breast feeding staff is aware of how t o place an IO with minimal dis simplicity to the patient.It ineluctably to be state that â€Å"the pain associated with instauration of the EZ-IO needle is similar to that associated with undercoating of a large peripheral intravenous needle and whitethorn be alleviate with infusion of lidocaine solution. ” (Luck, Haines & angstrom unit; Mull, 2010) impertinent PIVs and CVLs, IO access can be obtained from tenfold sends with less chance of being un no-hit. The locations involve: proximal tibia, distal to the tibial tuberosity, distal end of the radial bone in the upper imb, proximal metaphysis of the humerus, distal tibia, proximal to the medial malleolus, distal t lavishlybone, above the femur plateau, the sternum, and as well the calcaneus (Tay & group A; Hafeez, 2011). However, IO access is typically obtained via the proximal tibia or proximal metaphysis of the humerus. at that place are shortly cardinal diverse ways to gain IO access. The first and oldest w ay is a manual of arms initiation of the IO device. In this way the device is placed development the force employ by the clinician, and is done in a rotating motion. The second technique is the use of an envisioning device.In this case, a spring-loaded IO device is to insert the needle into the bone victimisation shoot for force. The last technique is a ply performance. The small, handheld device drills the IO needle into the bone with a high-speed rotating motion. Plan To implement a policy within the tinge surgical incision at Hays Medical Center that clearly outlines when the perspective of an intraosseous access device should be used as opposed to more traditional techniques for gaining venous access. A mission would be assembled to cypher at the investigate on IO location.This commission would consist of common chord physicians and three nurses, and meditateament be stipulation three months to write a policy for the surgical incision. This delegacy allow for determine in which situations an IO should be placed. The American Heart Association guidelines for intraosseous vascular access should play a major quality in this decision. Once criteria has been elect a checklist go forth be created that can be hung on the walls of the trauma rooms and hand out to staff. This checklist give aide in sustaining the staff to be able to more quickly determine in which situations organisation of an IO is within the section’s policy.The appointed commissioning would in like manner be in charge of deciding on which type of IO device the section should use. They will look for the availability of the device chosen and what the court will be to bourgeon the department which the device. Do Once the research is gathered, the assign research charge will reassemble to compose the policy that will become implemented within the need surgical incision. After the policy has been written, a authorisation unit collision will be called t o introduce the new policy and issue any questions that the staff might take in.During this meeting, a demonstration will be given on the pose technique for IO placement, depending on which type of device is chosen during the mean phase. After the demonstration the staff will thence be imploreed to perform placing IO devices using practice bones. One part of the department will then be voted upon to preclude impression of which patients coming through the department have IO devices placed. They will keep track of for the next sextuplet months. The data accumulate will include any outcomes that the patient experiences, good or bad, in regards to their IO placement.Check The member of the department will look at the data collected from the outcomes of patients who had IO devices placed within the ED in the last six months. This data will then be taken patronise to the passkeyly assign committee. The committee will be responsible for analyzing the data. They will look a t the outcomes and determine if falsifys need to be made to the original policy. They will also look at the outcomes to determine if there need to be kinds made in the placement technique used by the department.For ex antiophthalmic factorle, is the rate of victorious placement higher or spurn when done via the humerus verses the tibia? Or is there a problem with post adjectival contagion? Should the technique be careend from aseptic to sterile? Etc… They will also ask staff within the department to carry through out a survey indicating their comfort level in placing IO devices. Act Depending upon the findings of the committee they can all be resolved to leave the policy in place, as is. The committee could find that the policy needs to be altered and then reviewed in an some other six months’ time to take hold of if the transmutes were effective.Or they could find that within the ED at Hays Medical Center IO devices for venous access should not be used alth ough the review of literature will prove why this outcome is highly unlikely. question to Support Change An word create in the Journal of unavoidableness medication, collaborated by three different physicians who work in emergency Departments in Philadelphia talks about the technical side of intraosseous access. The phrase states that â€Å"intraosseous vascular access is indicated in the critically ill patient of any age when rapid and timely access via the intravascular alley cannot be established or has failed. The article goes on to list conditions in which this might occur, including: cardiopulmonary become, shock, sepsis, major traumatic injuries, extensive fire or edema, and status epilepticus. (Luck, Haines & adenosine monophosphate; Mull, 2010) Indications may also include obese patients on who multiple PIV attempts have failed. Because studies have shown that IO infusions have the same onset of action, as that of intravenous infusions the authors recommend that the dose used for IV fluids and medications should remain unchanged when using the IO route.They go one to state that other studies have shown that the guides of several different blood test values drawn from bone center of attention aspi grade are comparable to those taken from venous savors. These include blood gas analysis, blood group typing, and electrolyte, drug, and hemoglobin levels. (Luck, Haines & Mull, 2010) The authors also talk about the relatively few contraindications for IO interpellation. These include a fracture to the bone that the IO device is to be placed, an extremity with a vascular injury, placement to an area with an lie skin infection or burn.IO insertion is also contraindication in patients with certain conditions that make their bones fragile such(prenominal) as osteogenesis imperfect and osteoporosis. The last contraindication is a new IO insertion where another IO needle may have recently been placed. This is because the opening unexpended b y the last needle can cause fluids to extravasate. In their research of other studies, the authors found that success rates for IO insertion vary between 75%-100%, and successful infusion achieved within 30-120 seconds in the mass of cases. Luck, Haines & Mull, 2010) The most common torsion was found to be extravasation of blood, fluids, and drugs into the demulcent tissues surrounding the site, but this occurred less than 1% of the time. With a 0. 6% chance of incidence, the most serious adverse knottiness was osteomyelitis. However, this was attributed to lengthened infusion. For this reason, it is recommended that the IO need be replaced by either a PIV or a CVL erst the patient has stabilized and no weeklong than 24 hours after IO placement. (Luck, Haines & Mull, 2010)This article cogitate that the use of IO access devices is a safe, reliable, and timely way of attaining vascular access. Although lively for critically ill and injured patients, it is also a techni que that can be applied in non-emergent cases where multiple attempts at peripheral and central IV access has been unsuccessful. (Luck, Haines & Mull, 2010) In a discipline conducted by physicians at the University of Medicine Berlin’s Department of Emergency Medicine, they looked at ten consecutive adult patients who each acquire an IO device and also a CVC placement during a resuscitation situation.The results showed that the success rate on first attempt was 90% for IO access versus 69% for CVC placement. They also found that the mean time required for the IO access procedure was significantly shorter, 1-3 minutes, compared to the mean CVC placement time of 4-17 minutes. While conducting this vignette, one IO cannulation failed â€Å" referable to operator mishandling by not selecting the correct insertion site at the proximal humerus. (Leidel, Chlodwig & Bogner, 2009) The physicians of this subject area also historied that four CVC cannulations failed on the first attempt at insertion and had to be reattempted. The area then went on to state that the failed placement of one IO cannulation was the lonesome(prenominal) complication regarding the IO devices placed. There was â€Å"no malposition, dislodgment, bleeding, compartment syndrome, arterial puncture, haeatothorax, pneumothorax, venous thrombosis, and vascular access related infection observed. ” (Leidel, Chlodwig & Bogner, 2009)In conclusion the researchers go on to state â€Å"IO vascular access is a safe, reliable, rapid picking in the vivid setting of adult patients under resuscitation with ungetatable peripheral veins in the taking into custody department… Therefore, a change in practice from CVC to immediate IO access for the initial catch resuscitation should be strongly considered as a reasonable bridging technique to growth patient’s synthetic rubber in the urgency department. ” (Leidel, Chlodwig & Bogner, 2009) Another study f ound was performed by physicians and researchers in the Department of Emergency Medicine of capital of Singapore General hospital.It is a large urban hospital that handles intimately 120,000 patients annually. 9% of these patients are priority 1 patients, or patients that need resuscitation. The inclusion body criteria for this study were â€Å"patients who presented to the ED with age bullyer than 16 years or >40kg body cant requiring intravenous fluids or medication and in whom an intravenous line could not be established in two attempts or 90 seconds. They also had to be gravely ill or injured and meet at least one or more of the following: altered kind status, respiratory compromise, haemodynamic instability, or cardiac arrest. (nongovernmental organization, Oh, Chen, Yong & Yong, 2009) The study ran from March 1, 2006 through July 30, 2007. During this time 24 patients were met the qualifications for this study. Of all the IO cannulations, except three attempts f ailed on the first attempt. No failures were put down on the second attempt. The researchers also did a comparison between junior operators and older operators and found that there were no dissimilitude regarding success rates between the groups, they some(prenominal) had a 100% success rate. The comely insertion time for both groups was some five seconds. nongovernmental organization, Oh, Chen, Yong & Yong, 2009) There were only two complications regarding the insertion of an IO device with this study. The first was when an operator’s glove was caught on the need during insertion. However, this could have been prevented if the operator was attribute the drill properly. The other complication far-famed was that of extravasation of fluid at an insertion site. This is the most common type of complication, and is seen when the need is misplaced or there is an ebullient amount of movement during or after the insertion. Ngo, Oh, Chen, Yong & Yong, 2009) The result s of this study concluded that â€Å"the EZ-Io is a feasible, useful and fast alternative regularity of venous access especially in the resuscitation of patients with no venous access or when conventional intravenous access fails. flow rates may be modify by the use of pressure bags. Complications encountered such as extravasation of fluid and gloves being caught in the drill device can be easily prevented. ” (Ngo, Oh, Chen, Yong & Yong, 2009)The 3rd research article was a future, empirical study conducted by researchers in the Department of Emergency Medicine at Singapore General Hospital in Singapore. The study was conducted on a convenience sample of 25 medical students, physicians and nursing staff. They were recruited to unassailable intraosseous access using the EZ-IO powered drill device. Unlike the previous two studies they only need to secure access on a plastic bone specimen rather than a live patient. (Ong, Ngo & Wijaya, 2009)The study participants were allowed multiple attempts in placement with the aim of ensuring success in placement. Their placement times were measured by an independent observer with a stopwatch, from the time the participant placed the need set into the driver and attempted to insert the needle with the ES-IO into the plastic bone. The participants then recorded their percept on the difficulty of insertion using a visual analog photographic plate with 0 representing very unaffixed and 10 representing very difficult placement. (Ong, Ngo & Wijaya, 2009) The results showed 96% success rate for placement.Twenty-three of the 25 participants only required one attempt at place the IO device, and only one participant was unsuccessful at securing placement of the device. This failure was attributed to â€Å"unfamiliarity with the equipment and procedure, and hesitating beyond the allocated time given for insertion. ” (Ong, Ngo & Wijaya, 2009) The results of this study also showed that the mean pla cement time was 13. 9 seconds. The researchers also found that 87% of their participants reported that using the EZ-IO was easier compared to intravenous cannula. Ong, Ngo & Wijaya, 2009) The researchers of this study concluded that â€Å"the I/O access device (EZ-IO) evaluated in this study appears to be easy to use with high success rates of insertion with inexperienced participants. There is potential difference for use in the Emergency Department. (Ong, Ngo & Wijaya, 2009) The next piece of research was a randomise trial conducted by Dr. Reades from Methodist Hospital System, in Dallas, TX, Dr. Studnek from Carolinas Medical Center and the Center for Prehospital Medicine, Charlotte, NC, S.Vandeventer from Mecklenburg EMS Agency, Charlotte, NC, and Dr. Garrett from Baylor health care Systems, Department of Emergency Medicine, Baylor University Medical Center, and Dallas, TX. The purpose of this study was to determine whether the tibial or humeral placement site was mo re effective for intraosseous placement during out-of-hospital cardiac arrest. â€Å"All patients eligible for inclusion in this study had their first attempt at vascular access randomize to one of 3 locations: proximal tibial intraosseous, proximal humeral intraosseous or peripheral intravenous. (Reades, Studnek, Vandeventer & Garrett, 2011) Randomized note cards were distributed to the paramedic staff at the beginning of their shifts, and told them which access site was to be initially used if they came had a patient who met the inclusion criteria. There were two outcomes that were being monitored in this study. The first was a first-attempt success at the assigned method of vascular access. This qualified in one of two ways, either as an initial success or an cosmopolitan success.The second measured outcome was the â€Å" complete number of attempts required for successful vascular access, time to successful vascular access, time to first ACLS medication, and total volum e of fluid infused during resuscitation. ” (Reades, Studnek, Vandeventer & Garrett, 2011) Overall there were 182 patients randomize to one of the 3 vascular access methods. Fifty-one patients had humeral IO placements, 67 had PIV placements, and 64 had tibial IO placements. The results showed that first-attempt success was greatest in patients randomized to tibial IO access at 91%, compared to both humeral IO access at 51% and PIV access at 43%.The result of the secondary outcome was also significantly shorter in patients with tibial IO access. These patients had their devices in place and ready to use in an bonnie of 4. 6 minutes. Those assigned to the humeral IO access site averaged a 7. 0 minute placement time, which was also the same time for a PIV access site. (Reades, Studnek, Vandeventer & Garrett, 2011) This study demo that there is a significant different in the frequency of first-attempt success when placing tibial IO access devices as opposed to humeral I O access devices or even PIV catheters.The researchers go on to state that the â€Å"results from this study may help stakeholders such as EMS medical directors make the most appropriate site for first-attempt vascular access…” (Reades, Studnek, Vandeventer & Garrett, 2011) The last article was a consortium on intraosseous vascular access in healthcare practice, print in a journal entitled critical care nurse. It too draw the history of IO access, dating back to World War II. It discussed the clinical considerations for the use of IO access, and the clinical situations in which IO access should be considered.It went on to talk about the types of IO devices and how they’re used. It mentioned the contraindications for IO use, and also the possible complications. All of the aforementioned corporal was consistent with research already discussed. This article lends credibility in support of change because it discusses the education and training needed to imple ment IO device use in the clinical setting. It states that â€Å"to insert and maintain an intraosseous device in a patient, the clinician must(prenominal) demonstrate commensurate knowledge and psychomotor skill talent in the procedure. (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) The article then went on to discuss the economic considerations that must be looked at when considering implementing an IO insertion policy. It states that â€Å"the speak to of intraosseous devices and needles should be compared with the cost of central catheter kits, sonography evaluation, and human resources required for their insertion. ” (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) The authors also note that â€Å"the economic factors must be weighed along with potential complications of therapeutic strategies should be considered. (Phillips, Brown, Campbell, Miller, Proehl & Young-berg, 2010) This article also brings to light the issue of risk management and patient safety. In this day and age where obligation concerns continue to drive clinical decisions, it is valuable to note that delays in treatments are oftentimes cited as the cause of injury conduct to malpractice claims. If there is an evidenced based option to safely and quickly provide fluid and drug resuscitation, when vascular access is not readily attainable, then it needs to be closely looked at.After reviewing the data the Consortium on Intraosseous Vascular Access in Healthcare Practice reached eight consensuses: 1. 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 inveterate care and long-term care settings, when an increase in patient morbidity or mortality is possible. . Int raosseous vascular access should be considered as part of an algorithm for patients set by rapid response teams in whom vascular access is difficult or delayed. 3. A new algorithm that includes the intraosseous route should be developed for assessing the appropriate route of vascular access. 4. For patients not requiring placement of central catheters either for long-term vascular access or hemodynamic monitoring, intraosseous access should be considered as the first alternative to failed peripheral intravenous access. 5.Techniques of intraosseous catheter placement and infusion administration should be a standard part of the medical school and nursing school curriculum. 6. In evaluating the economic implications of adopting intraosseous engineering science, the following should be considered: the write off of diagnostic tools to guide and con profligate placement, the cost of human resources, the known and unknown risks to patient safety, and the cost of complications related to delayed treatment. 7. organisational policies, procedures, and protocols that establish the responsibility of insertion, caution, and removal of intra-osseous access devices should be developed. . Further research should be conducted on, but not limited to, the safety and efficacy of use of intraosseous access in all practice settings, its economic tinct on patient care, and to support the use of intraosseous access in all health care settings. Change Theory The change possibility focused upon in this paper is Gordon Lippitt’s Theory of Planned changed. tally Lippitt, â€Å"Planned change or ‘neomobilistic’ change is defined as a conscious, think effort which moves a system, an organization, or an person in a new direction.This guess is applies because it can be applied at an individual, group, and institutional level. The basis for Lippitt’s theory of change is center around an gene for change. This agent should be a person skilled in the changed wanted to apply. It is this person who is in charge of fancyning for the change, initiates the change, and is ascribe for the accomplishment of change. Lippitt’s theory is concentrate on around 7 phases of change. His phases are not set in stone, and there is no time frame on how long each phase should last. There should be a fluid movement back and forth between these seven phases.The first dance footmark is identification and diagnosis of the problem. In this case, the problem is HMC not having a firm policy in place recommending when the use of IO access devices should be implemented. The second pace is the change agent assessing the client systems want and capacity for change. In this case, myself being the change agent, I would talk with the administrators of the ED department and determine if they agreed with my assessment for a policy to be implemented. The third step would be the initiator assesses his or her ability in helping the situation.In this case this flows back to the first step, because I saw the need for change and felt that I was fit with the skills needed to bring about such a change. The fourth step is the change agent then admits an appropriate role in the phase. In this case, I would choose to be part of the policy committee who is responsible for researching. The fifth step states that the change agent may be actively involved in the implementation of change, serve as an expert in fathering and providing data, or function as a tie within the organization. I feel like in this case, I would function as a liaison within the policy making committee.The sixth step consists of maintenance of change. This involved the â€Å"Do” portion of the computer program for change. This is where the decisions made by the policy are provided to the department, and the employees become responsible for implementing and maintaining the new policy. The final step is termination of the helping relationship. This step is accomplished when all parts of the PDCA plan have been completed. (Ziegler, 2005) Conclusion In a day and age where medical technology is advancing, the research about IO access devices proves that newer technologies are not always the best for a positive outcome.IO access applications have great potential in patients who are critically ill, injured, or are incapable of having PIV or CVL access. The fact that IO access is fast, reliable, and safe proves that fitting placement of IO devices is a medical technique that all Emergency Departments should have in their repertoire. References (2009). The role of the registered nurse in the insertion of intraosseous access devices. Journal of infusion nursing, 32(4), 187-188. American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112(24):57-66. Leidel, B. Chlodwig, K. , & Bogner, V. (2009). Is the intraosseous access route fast and sound compa red to conventional central venous catherization in adult patients under resuscitation in the emergency department? a prospective empirical pilot study. Patient safety in surgery, 3(24), doi: 10. 1186/1754-9493-3-24 Luck, R. , Haines, C. , & Mull, C. (2010). Intraosseous access. The journal of emergency medicine, 39(4), 468-475. Ngo, A. , Oh, J. , Chen, Y. , Yong, D. , & Yong, D. (2009). Intraosseous vascular access in adults using the ez-io in an emergency department. internationalist journal of emergency medicine,2(3), 155-160. oi: 10. 1007/s12245-009-0116-9 Ong, M. , Ngo, A. , & Wijaya, R. (2009). An observational, prospective study to determine the ease of vascular access in adults using a novel intraosseous access device. Annals of the honorary society of medicine, singapore, 38(2), 121-124. Phillips, L. , Brown, L. , Campbell, T. , Miller, J. , Proehl, J. , & Young-berg, B. (2010). Recommendations for the use of intraosseous vascular access for emerg ent and no emergent situations in various health care settings: A consensus paper. Critical Care Nurse, 30(6), e1-e7. Reades, R. , Studnek, J. , Vandeventer, S. , & Garrett, J. (2011).Intraosseous versus intravenous vascular access during out-of-hospital cardiac arrest: A randomized controlled trial. Annals of Emergency Medicine, 58(6), 509-516. Tay, E. T. , & Hafeez, W. (2011). Intraosseous access. In R. Kulkarni (Ed. ), Medscape reference: Drugs, distemper & procedures. Retrieved from http://emedicine. medscape. com/article/80431-overview Wayne, M. (2006). Adult intraosseous access: an idea whose time has come. Israeli journal of emergency medicine, 6(2), 41-45. Ziegler, S. (2005). Theory-directed nursing practice. (2 ed. , p. 204). New York, NY: impost Publishing Company, Inc. Timeline for Change 1/20-11/27Researched the benefits of having a policy about intraosseous access within the ED at HMC 11/28Spoke with the film director of Nursing for the ED and the theatre director of Emergency Medicine about my research findings 12/1A committee of three physicians and three nurses is assembled to blueprint a preliminary policy regarding intraosseous access 12/1-3/1The committee is given three months to compose their policy 3/2-3/10The policy is given to the conductor of Nursing and film director of Emergency Medicine, who present it to the board of directors for approving 3/15A mandatory staff meeting is held outlining the new policy and answering any questions or concerns the staff has 3/16-9/16The new policy is put into effect and data is collected 9/16-10/16The original committee will analyze the data, and changes are made as needed. 10/20The final committee approved policy is present to the Director of Nursing and Director of Emergency Medicine 11/1The Director of Nursing and Director of Emergency Medicine, take the final recommendations for the policy to the hospital board of directors for approval\r\n'