It is important that all persons engaged in delivering invasive upper extremity therapy to patients have a competent understanding and discipline in their approach to these interventions. One convenient way to think of this process is by adhering to the ” Five A’s” each time that an upper extremity intervention is planned. The “Five A’s” are as follows:

ASSESS whether or not invasive intervention is truly necessary and whether the patient has any contradictions to such interventions and that the site, time, medication or intervention, dose and patient are all appropriate  for the planned intervention.  This is a good time to also assess by asking  the Five Rights if the intervention involves  a drug or medication or infusion or a modified version of the Five Rights if the intervention is an IV or PICC line:.  The modified Five Rights can be thought of as follows:

  • Right person,
  • Right time
  • Right place
  • Right intervention
  • Right patient education and expectations of and signed and agreed to consent to the intervention.

ASK  patients where they prefer to have access or invasive interventions attempted AND if the patient has any area where interventions should not be attempted or where they have experienced problems in the past.

AFFIRM that the underlying anatomy and patients condition and the surrounding environment will support the delivery of such intervention and that the person attempting the intervention has all the necessary tools, skills and safety systems in place to assure success.

ATTEMPT only once with a repeat intervention  mandatory time out if the first attempt is not successful. Following a failed attempt, the following should occur:

ASSURE that following the intervention that the intervention went as planned and report and study as a system when it did not. Monitor the site of the intervention to assure that no complications occur.

Adherence to the “Five A’s” each time and intervention is planned involving an arm, coupled with the use of checklists and other tools assures that care is delivered in a safe and effective manner consistent with the tenant of minimizing potential harm to the patient and assuring maximal opportunity for a successful and complication free intervention.

EASE:  EASE is a method that can be applied to IV lines attempts, PICC line attempts and other forms of intravenous or intra-arterial interventions that assures that if an initial attempt fails,  there is  a pause during which the patient  is involved in options regarding any possible future attempts.   Patients often report dis-satisfaction and significant injury with regards to repeated IV , PICC  line, or phlebotomy attempts.  As such, it is important to consider not only the patients medical needs, but also the desires of the patient in a respectful and thoughtful manner.

Explain: Explain why you think the first intervention failed in matter-of-fact terms. Do not blame the failure on the patient.  Explain ways, if there are any in which the patient can help increase the chances of the next intervention being successful.

Agree: Agree on a plan of action as to what the patient wants to happen if this intervention is not possible. For example, does the patient wish for you to try again, do they wish for you to call another nurse or phlebotomist,    The patient should be asked if they wish to continue or offered an alternative if one exists. If the patient refuses further intervention, this should be immediately brough to the attention of the person who ordered the intervention. Remember, peripheral lines and PICC lines often have lower infection rates than central lines, so if at all possible a peripheral line,if applicable should be the patients preferred choice.

Span: Reach out to colleagues and others with more expertise or who might be able to offer suggestions. Include the patient if possible or appropriate in the process.  Often patients who have had difficulty with IV and PICC line starts know what has worked in the past.  Use the patient, your colleagues and others as a resource.

Engage: If the patient is unwilling to move forward after a failed attempt or a series of failed attempts, it is time to ask for help or further direction from the person who ordered the intervention or a senior staff member.  If you are the senior staff member or person who ordered the intervention it is vitally important that you engage the person at this time. Perhaps the patient has lost confidence that the procedure can be safely performed or the pain and anxiety is just too great.  Perhaps the patient is not convinced that this is the only option. It is important that the patient receives education and engagement at this point that is more intensive and informative.  The use of open and respectful communication is essential for active engagement.

Using these methods can assure a better chance of success with interventions and may even reduce the chance that interventions that are not truly needed take place at all. Interventions must serve a purpose and that purpose must justify their use. each intervention potentially increases the risk of injury and infection to the patient and the person engaged in the intervention. Use fo the 5 A’s and the EASE methodologies may help to assure more successful interventions.