Introduction

In 2021, the United States had approximately 139.8 million emergency department (ED) visits [1]. Unfortunately, the quality of care received in the ED is impacted by patient factors such as sex, race, and age, resulting in healthcare disparities [2–4]. For example, women are less likely to be examined within an hour of presenting to the ED with chest pain compared to men even when comorbidities are adjusted for and possibly due to sex based bias at presentation [5]. Additionally, there is evidence of bias based on sex, race, and ethnicity when patients are triaged in the ED [6]. Data shows that Black patients were less likely to be prioritized in rooming compared to White patients with similar triage scores. [3].Additionally, Black men and women were less likely to receive electrocardiograms, oxygen saturation measurements, and chest radiographs in the workup of chest pain than non-Black men [7]. Age also impacts care, and it has been shown that older patients wait longer for imaging in the ED compared to younger patients [8].

One unifying characteristic of ED care is the usage of peripheral intravenous catheters (PIVCs). About 75% of ED and 90% of hospitalized patients require peripheral vascular access for diagnostics, medications, fluids, or blood products [9–14]. In the ED setting specifically, early and reliable vascular access is crucial for the administration of these potentially life-saving therapies. For example, the emergent management of acute ischemic stroke requires rapid intravenous thrombolysis. Studies show that even modest reductions in door-to-needle time—by as little as 15 minutes—significantly improve patient outcomes [15,16]. Similarly, prompt vascular access is critical in the treatment of sepsis, where delays in administering intravenous fluids and antibiotics are associated with increased mortality [17]. Even though PIVC access is a routine procedure, the failure rates of PIVC placement are reported to range from 36% to 63% [11,12,18–20].

In a recently published large multicenter investigation of over 140,000 hospitalizations, Black patients and female patients were predictors of PIVC complications and failure in hospitalized patients [21]. However, outcomes related to PIVC placement were not reported in the analysis and generally remain understudied in the ED. Given that PIVC access is a foundational procedure for initiating a range of workups and therapies, we aim to determine the impact of health disparities on the time required to establish functional PIVC access.

Methods

Results

There were 319,938 PIVCs placed in the ED between January 1^st, 2021, and January 31^st, 2023, that met the inclusion criteria. The average age was 56 years old, and 59.11% were female. The median duration from ED arrival to PIVC placement was 1.28 hours (interquartile range [IQR] 0.72–2.29). The majority of patients identified as White (60.27%), followed by Black (33.09%), Asian (2.17%), American Indian or Alaskan Native (0.33%), or Other (4.14%). PIVCs were most commonly 20 gauge (n = 245,237, 79.96%) placed in the antecubital fossa (n = 206,129, 64.43%) using the traditional palpation technique (308,186, 96.33%). (Table 1)

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Table 1. Demographics, hospital course, PIVC characteristics, and outcomes of emergency department patients. For continuous variables, medians (interquartile ranges, IQRs) and means (standard deviation, SD) were presented. For categorical variables, frequencies (percentage) were presented. Abbreviations: ED = Emergency Department, PIVC = peripheral venous catheter.

https://doi.org/10.1371/journal.pone.0336171.t001

A multivariable linear regression model was performed. After adjusting for Charlson comorbidity index, ESI, hospital size, obesity, and insertion method, females waited 6.7% longer than males for PIVC placement (p < 0.001). Obese patients waited 6.8% longer than patients with a healthy weight (p < 0.001). Patients over age 65 waited 3.6% to 4.4% longer than patients between the ages of 18–64 (p < 0.001). Compared to patients who identified as White, Black patients waited 9.6% longer (p < 0.001), American Indians or Alaska Natives waited 6.5% longer (p = 0.019), and Asian patients waited 2.3% longer (p = 0.0356). (Table 2).

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Table 2. Multivariable Linear Model of PIVC Wait Time in Total Population. For continuous variables, medians (interquartile ranges, IQRs) and means (standard deviation, SD) were presented. For categorical variables, frequencies (percentage) were presented.

https://doi.org/10.1371/journal.pone.0336171.t002

Among PIVCs placed under ultrasound-guidance (n = 11,752), a multivariable linear model was performed and adjusted for the the Charlson comorbidity index, ESI, hospital size, and obesity. It demonstrated that females waited 8.9% longer than males for ultrasound-guided PIVC placement (p < 0.001). Obese patients waited 6.1% longer than patients with a healthy weight (p < 0.001). Patients between 65 and 80 years old waited 9.2% longer than patients between the ages of 18 and 64 (p < 0.001), while patients over 80 years old waited 4.3% longer (p = 0.045). Compared to patients who identified as White, Black patients waited 7.4% longer (p < 0.001), American Indians or Alaska Natives waited 29.33% longer (p = 0.0192), and Asian patients did not wait significantly longer (p > 0.05). (Table 3).

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Table 3. Multivariable Linear Model of PIVC Wait Time in Ultrasound Guided PIVC Population. For continuous variables, medians (interquartile ranges, IQRs) and means (standard deviation, SD) were presented. For categorical variables, frequencies (percentage) were presented.

https://doi.org/10.1371/journal.pone.0336171.t003

Discussion

This multicenter observational study of over 300,000 PIVCs placed in the ED is one of the first to examine the relationship between health disparities and time to establish a PIVC. Our findings reveal inequities in PIVC wait times that persist even after adjusting for baseline comorbidities and severity of illness at ED presentation. Females experienced a 6.7% longer wait time for PIVC placement compared to males, and Black patients waited 9.6% longer than their White counterparts. Additionally, adults over age 65 experienced at least a 4% increase in wait time. These findings not only highlight the prevalence of disparities in vascular access but also point to systemic gaps that disproportionately impact vulnerable patient populations.

Disparities in vascular access were especially pronounced among elderly, female, Black patients, and obese patients when considering the classification of Difficult Venous Access (DIVA) [19]. This group, which comprises up to 59.3% of hospitalized patients, represents the most challenging cases of vascular access and often necessitates advanced visualization technologies such as ultrasound [25–27]. Biological differences likely exacerbate these challenges—women often have smaller veins, individuals with darker skin tones may have less visible veins, and obesity is a well-documented risk factor for DIVA [28–31]. These factors, combined with limited resources, skills, and clinician shortages, inherently complicate vascular access and perpetuate inequities in care delivery which may also be present due to structural and interpersonal bias and stereotyping [32].

Efforts to address these challenges have included early escalation to ultrasound-guided PIVC placement, as recommended by recently updated clinical practice guidelines [26,27]. While this approach has improved success rates in some instances, it also places increased demands on healthcare resources and workforce capacity. Many institutions lack adequately trained clinicians to perform ultrasound-guided PIVC placements efficiently, leading to longer wait times for DIVA patients [32]. Unfortunately, these delays further amplify the inequities experienced by vulnerable groups, exacerbating disparities in patient outcomes.

Our study brings to the forefront a critical issue affecting disadvantaged populations. The prolonged wait times observed suggest that these groups are more likely to undergo multiple placement attempts, resulting in higher rates of needlesticks and patient discomfort. Despite advancements in vascular access methods, these findings underscore the pressing need for targeted interventions, increased workforce education, and continued research to address the underlying disparities. Achieving equitable access to vascular care is essential to improving outcomes for all patients, particularly those who face systemic barriers to timely and effective treatment.

Limitations

This study has several limitations. First, as a retrospective analysis using EHR data, the accuracy and completeness of documentation may vary, potentially introducing bias. However, the large sample size and inclusion of multiple hospital sites help mitigate this concern. Second, unmeasured confounders such as ED staffing levels, patient throughput, and departmental workflow were not accounted for, which may have influenced PIVC placement wait times. Third, race and ethnicity were categorized into broad groups, which may not fully capture the nuances of individual identity or the intersection of multiple racial and ethnic backgrounds. Despite these limitations, the findings provide valuable insights into disparities in vascular access and highlight the need for further investigation.

Conclusions

This study reveals persistent disparities in PIVC placement wait times, disproportionately affecting Black patients, women, the elderly, and those with obesity. Addressing these inequities requires targeted interventions to improve workflow efficiency and vascular access training. Future efforts should focus on ensuring equitable, timely care for all patients.