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How to start an IV without pain

Outpatient Surgery Magazine

Step inside the country's first needle-free hospital and find out how jet injectors have eliminated the pain and anxiety of starting an intravenous line.

The e-mail address says it all: istickm@uic.edu. It belongs to Patrick Darby, RN, an intravenous therapist at the University of Illinois (UIC) Medical Center in Chicago . For the last six years, Mr. Darby has started thousands of IVs — not with a needle and syringe, but with a jet injector that uses high pressure to propel a mist of lidocaine through the skin.

I recently toured UIC's outpatient surgical unit and heard for myself the pfft-pop, pfft-pop, pfft-pop of the jet injectors." Are you ready for the big stick?” asks Mr. Darby.

“Yeah, go ahead,” says the patient, tensing up.

“Already done," says Mr. Darby, having slipped the dreaded IV into the small circle of numbed skin on the back of the patient's hand, the jet injector's telltale calling card.

Like most mornings, Mr. Darby spends this one using the jet injector to start IV after IV on patients who are at once amazed and relieved that they didn't feel a thing.

“The patients will absolutely love you, Patient satisfaction for IV starts will skyrocket,” he says during a break in the action. “Being stuck is a big deal for a lot of patients. They could have a horrible disease and be in for massive surgery, and all they're worried about is the needle.”
Read on if the idea of achieving local analgesia for IV access with the press of a button appeals to you.

Needle-free numbing

At UIC, the country's first needle-free hospital, staff give mostly all drugs by jet injection, using needles only to insert intravenous or intra-arterial catheters or for special procedures, such as epidural punctures and surgical biopsies. Along with the fear and pain of needles, UIC has all but eliminated needlesticks, infection and infectious waste.

“We are on the verge of needle- and pain-free surgery centers,” says retired UIC anesthesiologist Elemer Zsigmond , MD , DSc, FCP, who's been researching needle-less injections for more than 20 years and two years ago founded the Jet Anesthesia Foundation. “It will soon be unethical
to touch a patient without first relieving his pain.”

The appeal of jet injection is that it reduces pain and improves safety better than the conventional needle-syringe technique or EMLA cream.

• Pain. Insertion of an intravenous catheter is a painful procedure performed daily in millions of patients worldwide — often without analgesia. A study published in the International Journal of Clinical Pharmacology shows patients often experience some pain, either at the time of intradermal lidocaine injection or at the actual time of IV catheterization or both. The study also found that the use of a jet injector is less costly, more efficacious and easier to administer than
needles or cream.

• Safety. More than a million needle-stick injuries are reported in the United States annually, and it's suspected that half as many more go unreported. The handheld jet injector delivers lidocaine in a fraction of a second, pushing it through the skin at a force of 1,500 pounds per
square inch. All you hear is a pop, and most people don't feel anything.

Pop shots

Painless shots might seem like a small thing, but patients' reaction has been phenomenal, UIC officials report. Many times their first question is, “Am I going to get those pop shots?” The outpouring of appreciation, even affection, amazes Mr. Darby, “The job satisfaction you get is just phenomenal,” he says.

In addition to being painless, proponents say jet injection has other clear advantages over the needle. It covers a larger area, making it easier to find a good place for insertion, and does not obscure the vein, making insertion easier. UIC uses the J-Tip Needleless Injection System, which easily fits into a pocket, several at a time, and is completely disposable.

Viewing the reaction of UIC patients, jet injections might also give an institution a competitive edge. At any rate, several of UIC's local rivals don't want to wait to find out. They are lining up to get training in the new system at UIC, and one of them has already begun using jet injection.

UIC's next step, within the next six months, is to introduce needle-free devices for injection of most medications within the hospital. For these shots, UIC will be using the Biojector 2000 and
Vitajet, two jet injectors with disposable nozzles.

Moving toward a needle-free future

Dr. Zsigmond originally urged the hospital to go needle-free. He thinks most providers will eventually follow UIC's lead

In the future, “all drugs will be delivered not by needles but by jet injectors,” says Dr. Zsigmond, and he has good reason to make such a claim. Healthcare facilities are reassessing use of needles and seem more interested than ever before in addressing patients' pain.

It took the AIDS epidemic to underline the danger of needlesticks. The Centers for Disease Control and Prevention reports that hospital workers are injured more than 1,000 times a day by needles and other sharp devices. As a result of sharps injuries, Nursing Management magazine estimates that each year more than three dozen U.S. healthcare workers contract HIV, 2,000 hepatitis C and 400 hepatitis B.

In 1999, the Occupational Safety and Health Administration directed healthcare facilities to use needle-free systems when possible and otherwise to use only safety-engineered sharps devices.
In 2001, OSHA enacted the 2000 Needlestick Safety and Prevention Act, which puts the 1999 recommendations into law and establishes fines of up to $7,000 for each violation. OSHA reports that several institutions are fined each year.

The federal regulations call for needles with safety mechanisms to shield needles after use, disposal of needles in special containers and maintenance of a log for needlestick injuries. All these measures add to the cost of using needles, bringing them closer to the traditionally
higher price of jet injections.

Meanwhile, the CDC estimates that even using all the precautions under the 2000 law will not stop 35 percent of needle injuries. The alternative, of course, is to eradicate needles in virtually all parts of the hospital, which UIC s about to do.

In addition to mounting concerns with sharps safety, Dr. Zsigmond points to the healthcare establishment's newfound interest in addressing patients' pain.

In 2000, the Joint Commission on Accreditation of Healthcare Organizations issued a standard declaring that patients have “a right to pain management.” The standard, RI.2.160, applies to the transient pain from a needle as well as to the more significant pain of chronic back pain, migraine headache or cancer.

JCAHO states that the surveyed hospital must show that it “plans, supports and coordinates activities and resources to ensure that pain is recognized and addressed appropriately,” and it should educate “all relevant providers” in assessing and managing pain.
During a site visit under the joint commission's new “tracer” survey system, surveyors might ask patients if they experienced any pain and how the hospital dealt with it, say JCAHO officials.

Resurrecting an industry

The new promise of jet injection comes just in the nick of time for the industry. It follows a period of serious decline due to concerns about the spread of infection from primitive early devices.

The concept of needle-free injections goes back to 19th century France , when workmen using high-powered grease guns inadvertently injected themselves. The original medical injector, the “peace gun,” was developed in 1962 by Pittsburgh researcher Robert Hingson, MD, to mass-immunize Africans against smallpox.

The U.S. military and World Health Organization quickly adopted the clunky device, which could vaccinate dozens of people without stopping for a refill. But the delivery pressure was so high that fluids containing pathogens sprayed out of the patient and onto the nozzle of the gun, infecting those who were vaccinated next.

In the 1980s, the device was blamed for an outbreak of hepatitis B at some weight-loss clinics in California . In 1997, the Department of Defense, the industry's largest customer, announced that it would be dropping the device due to concerns about infection.
But at about the same time as the military was dropping the concept, companies were developing a new generation of low-workload jet injectors, operating under lower pressure and completely or partially disposable to avoid contamination.

The needle-free industry is still quite small. Bioject, one of the largest makers, reported revenues of $6.3 million in 2003. But it has a trade group, the Association of Needle-Free Injection Manufacturers, formed in 1997, which represents five manufacturers and also five developers, revealing the hope for the future.
Kurt Lynam, national sales manager for Bioject, says the U.S. Navy is getting interested in the technology again and has asked Bioject to develop a new product. In addition, Bioject has signed with Serono Group, a Geneva , Switzerland-based maker of pediatric prescription drugs, to produce what seems to be the first fully loaded needle-free syringe to be sold by a drugmaker. Pharma represents a huge potential market for the industry.

Mr. Lynam says the government's new sharps safety standards have wiped out the price difference between his product and needle syringes. He says the price of one safety needle, including disposal, is 36 cents to $2.30, compared with 65 cents to 85 cents for each single-use tip for his needle-free product. That price does not include the cost of Bioject's reusable base, which costs less than $1,200.

Mr. Lynam predicts that once a large provider like UIC completely embraces needle-free technology, other providers will understand that it is possible and gathering word-of-mouth will stoke patient demand. “If you don't know that there's a more acceptable product out there, you might say this is OK,” he says. “But if you know there's a better product, you'll want it.”

Getting enough mass

Officials at the UIC Medical Center , a 463-bed teaching hospital that performs 12,700 surgeries a year, are betting that they have enough muscle to get the jet injection industry off the ground and into flight.

Dr. Zsigmond says his proposal for a needle-free hospital won approval from the board of trustees of the University of Illinois , which oversees the hospital, in 1995. He says then-Gov. George Ryan, who sat on the board, was instrumental in gaining the approval.

The most convincing piece of evidence, says Dr. Zsigmond, was his study finding that, on a pain scale of zero to 25, patients had zero no pain with two needle-free devices, compared with a level of 4.7 for needle injections.
UIC phased in implementation, and staff who weren't in the first steps were so eager to use the syringes that they broke into supply cabinets to get them, say UIC officials. The technology has now spread to other departments, such as plastic surgery, where lidocaine injections prepare patients for some facial procedures.

Hugh Rose, chief financial officer at the hospital, says payers that reimburse the hospital based on charges usually cover local anesthetics to alleviate pain. But those who pay a per diem rate or a Medicare DRG, which cover most inpatient procedures at UIC, do not recognize added expenses. So while inpatient procedures tend to show losses under the program, outpatient procedures tend to be covered. UIC charges patients $35 for each jet injection.

Aiming for a healthcare revolution

UIC officials insist their goal isn't to improve their bottom line or market share. Their goal, quite simply put, is to spark a revolution in U.S. healthcare for needle-free, pain-free technology and to serve as a model institution for hospitals wishing to convert to a needle-free environment.

“We're not in this to make a ton of money or get more patients into our hospital,” says Andrew onnelly, PharmD, MBA, director of pharmacy at UIC. “It's just the right thing to do.”

To prove its point, UIC is reaching out to train potential rivals in its new technology, charging only for its costs and even sharing its formula for buffered lidocaine that is used in the jet injections.
Since pure lidocaine can sting, UIC pharmacists buffer it by adding sodium bicarbonate. Working under sterile hoods in the main pharmacy, staff prepare about 100 syringes per hour, each holding 0.2cc of the product.

The buffered product is stable for just one week and then has to be thrown out, causing a logistical problem for small providers that don't have a sterile pharmacy on-site. If that describes your facility, Dr. Donnelly suggests you outsource the work to compounding services that already deliver syringes filled with other medications.

The UIC training program provides a manual, a four-hour lecture by experts and a two-hour demonstration of the device at UIC. Then UIC experts visit the trainees to check for competency.

Mr. Darby, who leads the hands-on training, says that while jet injection is easy to learn, things can go wrong. For example, older patients or those on chemotherapy or steroids have very delicate veins that can be harmed by the high-pressure delivery of jet injection, causing a swelling the size of an egg. But he says the swelling eventually goes away and he simply inserts the line somewhere else.

The first organization to get training was St. Alexis Medical Center, a 344-bed hospital in Hoffman Estates , Ill. , part of Elk Grove Village, Ill.-based Alexian Brothers Health System.

Last December, St. Alexis began administering needle-free lidocaine to start IVs, blood draws and peripherally inserted central catheters in outpatient surgery and the ED. On Jan 1, the program will be extended it to on-staff nurses on all nursing units.

“It makes the nurse feel a bit more confident,' says Carol Szafranski, RN, charge nurse for IV therapy at St. Alexis. “Knowing the patient is under a local anesthetic, you're willing to go after that particular vein. You don't do as many IV sticks.”

But above all, she says, “it's a very big patient satisfier. We get a lot of letters from patients that mention the jet injector.”

No needle, no pain

If the thought of one less needlestick for staff and patients isn't reason enough to consider jet injectors, consider that patients' anxiety level often is higher for the IV start than it is for surgery.
“I hear that over and over,” says Mr. Darby. “Once we get them past that, they can relax.”

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