Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient or their family, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [257], C).

   In a cardiac arrest, it may not be possible to gain consent. E
2. 2.Show
   Wash hands with bactericidal soap and water or an alcohol‐based handrub, apply an apron and assemble the necessary equipment.
   To minimize the risk of infection (DH [64], C; Fraise and Bradley [98], E).
3. 3.Show
   Assess the patient and the chosen limb to determine what size of intraosseous needle is required (Action figure 3).
   To ensure that the correct needle is selected (Vizcarra and Clum [360], E).
4. 4.Show
   Obtain assistance as required.
   To maintain safety. E

Procedure

1. 5.Show
   Wash hands with bactericidal soap and water or an alcohol‐based handrub, and apply gloves.
   To minimize the risk of infection (DH [64], C; Fraise and Bradley [98], E).
2. 6.Show
   Take the medication and the prescription chart to the patient. Check the patient's identity by asking them to state their full name and date of birth. If the patient is unable to confirm these details, then check the patient identity band against the prescription chart. If an electronic identity check system for the patient and/or medicine identification is in place, then use it in accordance with hospital policy and procedures. Check the patient's allergy status by asking them or by checking the name band. Note: in an emergency setting, it may not be possible to follow all of these steps.
   To ensure that the medication is administered to the correct patient and prevent any errors related to drug allergies (NPSA [262], C).
3. 7.Show
   Inspect the needle set packaging to ensure sterility and then open the sterile pack and all packaging.
   To ensure the device is safe to use and reduce the risk of complications. E
4. 8.Show
   Draw up a syringe of 0.9% sodium chloride (10 mL).
   To prepare for priming. E
5. 9.Show
   Connect the 10 mL syringe to the connector (e.g. EZ‐Connect) and prime with 0.9% sodium chloride. If lidocaine 2% is indicated, prime the set with the lidocaine.
   To prepare for administration and remove air from the set. E
6. 10.Show
   Leave the syringe connected to the connector.
   To prepare for administration once sited. E
7. 11.Show
   Connect the needle set to the driver, leaving the needle cap on until ready to insert.
   To prepare for insertion. E
8. 12.Show
   Palpate the site to locate the appropriate anatomical landmarks for the needle set placement (Action figure 12).
   To ensure the intraosseous needle is placed in the correct position for optimal drug administration and minimization of tissue damage (Vizcarra and Clum [360], E).
9. 13.Show
   Select the insertion site. For the proximal tibia, it is approximately 2 cm below the patella and approximately 2 cm (depending on the patient's anatomy) medial to the tibial tuberosity along the flat aspect of the tibia.
   To ensure the optimal site is used for insertion. E
10. 14.Show
    Wash hands and apply gloves.
    To minimize the risk of infection (Fraise and Bradley [98], E).
11. 15.Show
    Clean the site using 2% chlorhexidine in 70% alcohol and allow the site to air dry (Action figure 15).
    To minimize the risk of infection (DH [64], C; Fraise and Bradley [98], E).
12. 16.Show
    Stabilize the insertion site, keeping hand and fingers away from the needle.
    To guard against unexpected patient movement and avoid a sharps injury. E
13. 17.Show
    Remove the needle cap (Action figure 17).
    To prepare for insertion. E
14. 18.Show
    Identify the two markings on the needle. The distal mark should be visible once the needle is inserted into the skin. The proximal mark is the maximum insertion point.
    To ensure that the insertion landmarks are identified. E
15. 19.Show
    Insert the intraosseous needle (e.g. EZ‐IO) through the skin at a 90° angle to the bone until the bone is reached (Action figure 19). The distal mark on the needle should be visible. If not, consider using another size of needle or site.
    To ensure that the needle reaches the medullary space. E
16. 20.Show
    Press the driver trigger while applying minimal pressure, driving through the bone until a give is heard or felt. Allow the driver to do the work.
    To ensure that no excess pressure is applied and that the needle is inserted within the bone. E
17. 21.Show
    Release the driver trigger when the proximal mark on the needle at the hub end is level with the skin.
    To ensure that the needle reaches the medullary space. E
18. 22.Show
    Remove the intraosseous needle's power driver from the needle set while stabilizing the needle hub.
    To prepare for drug or fluid administration. E
19. 23.Show
    Hold the base of the needle hub with one hand while turning the upper part of the needle anticlockwise.
    To remove the stylet and prepare for fluid or drug administration. E
20. 24.Show
    Remove the stylet from the needle (Action figure 24).
    To prepare the needle for drug or fluid administration. E
21. 25.Show
    Dispose of the stylet into a sharps container immediately.
    To ensure safe disposal and avoid injury to staff (HWR [137], C; MHRA [201], C; NHS Employers [227], E; NHS Employers [228], C).
22. 26.Show
    Confirm placement by:

    1. ensuring the catheter is firmly seated and does not move
    2. observing blood at the catheter hub
    3. aspirating marrow from the catheter.
    To ensure the needle is in the correct position. E
23. 27.Show
    Apply a suitable dressing (e.g. EZ‐Stabilizer).
    To secure the intraosseous port and prevent dislodgement. E
24. 28.Show
    Connect the primed connector to the exposed Luer‐Lok hub and flush with the designated solution (Action figure 28).
    To ensure patency of the intraosseous needle. E
25. 29.Show
    Disconnect the 10 mL syringe from the connector.
    To prepare for drug and/or fluid administration. E
26. 30.Show
    Connect a primed intravenous administration set or administer bolus drugs.
    To deliver the prescribed medication or fluids. E

Post‐procedure

1. 31.Show
   Remove gloves and discard waste, placing it in the correct containers, for example sharps into a designated container.
   To ensure safe disposal and avoid injury to staff (EASHW [84], C; HWR [137], C; MHRA [201], C).
2. 32.Show
   Document the time and date of insertion, the size and length of needle, the number of attempts, the location of the device, and the name of the practitioner who inserted the device.
   To maintain accurate records, provide a point of reference in the event of any queries and prevent any duplication of treatment (NMC [257], C).

   To ensure staff are aware of the insertion date as an intraosseous device should not remain in place for longer than 24 hours (NMC [257], C).
3. 33.Show
   Assess the site for potential complications or extravasation.
   To minimize the risk of complications and to treat any complications promptly. E