title: Barriers and facilitators to intraosseous access in adult resuscitations when peripheral intravenous access is not achievable.
abstract: OBJECTIVE
  Studies suggest that intraosseous (IO) access is underutilized in adult resuscitations, despite recommendations from advanced trauma and cardiac life support guidelines. The objective was to determine factors associated with IO access use by physicians during adult resuscitations when intravenous (IV) access is not immediately achievable.
  
  
  METHODS
  This study was an online survey among physicians purposefully recruited from various clinical care areas at three teaching hospitals. Questions were generated from the qualitative results of 20 iterative interviews, verified for internal validity, and piloted. The interview guide was based on the constructs of the Theory of Planned Behavior (TPB), which elicits salient attitudes, social influences, and control beliefs that potentially influence intention to use IO access. Recruitment took place in September 2012 until reaching more than 100% of the required sample size (n = 200). Internal consistency was measured using Cronbach's alpha, and the effect of TPB constructs and specific beliefs were assessed with regression analyses.
  
  
  RESULTS
  For the 205 respondents, the mean age was 35 years (range = 20 to 66 years), and 53.3% were male. Participants' departmental affiliations were 50.3% emergency medicine (EM), 16.9% internal medicine, 14.9% anesthesia, 10.8% general surgery, and 7.2% critical care. Residents comprised 60.7% of the sample, and 39.3% were attending physicians. Median intention to use IO access when IV is not immediately achievable was 4.67 (interquartile range [IQR] = 4 to 5) out of 5 (5 highest) and predicted by the following TPB constructs: attitudes (AdjCoefficients = 0.504; 95% confidence interval [CI] = 0.334 to 0.673), social influences (AdjCoefficients = 0.285; 95% CI = 0.172 to 0.398), and control beliefs (AdjCoefficients 0.217; 95% CI = 0.113 to 0.320). Physicians were more likely to use IO access if they believed that it provided rapid vascular access for delivering large volumes of fluids, could prevent delays in care, and was associated with a low complication rate. Conversely, the perception that nurses are not familiar or supportive of IO access and a lack of physician confidence regarding the appropriate indications for IO access were barriers to use.
  
  
  CONCLUSIONS
  These data are an important step in the knowledge-to-action process, as they identify specific factors associated with physician use of IO access. Interventions addressing these actionable facilitators and barriers are likely to have a positive effect on increasing the appropriate physician use of this potentially life-saving technique in adult patients requiring emergent vascular access.
authors.affiliation: The Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario.
authors.forename: Warren
authors.initials: W
authors.lastname: James Cheung
authors.forename: Hans
authors.initials: H
authors.lastname: Rosenberg
authors.forename: Christian
authors.initials: C
authors.lastname: Vaillancourt
mesh_terms: D000328:Adult; D000368:Aged; D016638:Critical Illness / Q000628:therapy; D004635:Emergency Medicine / Q000193:education; D005260:Female; D006801:Humans; D017148:Infusions, Intraosseous / Q000379:methods* / Q000706:statistics & numerical data; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D012151:Resuscitation / Q000379:methods*; D055815:Young Adult