IV Access Patient Survey

IV Access Patient Survey - Part of the One & Done Initiative

OMB CONTROL NUMBER: 0704-0553

OMB EXPIRATION DATE: 05/31/2025

AGENCY DISCLOSURE NOTICE

The public reporting burden for this collection of information, 0704-0553, is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at [email protected]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.

1. Have you ever had a difficult or bad experience getting an IV?

Yes

No – Go to Q3

Maybe

2. Please explain. Do not include any personal identifiable or protected health information.

3. Where was your IV started today?

Preoperative

Emergency Dept

Inpatient

Radiology

Other

4. How many attempts were made to place your IV?

[number input only]

5. Was Ultrasound used to place your IV?

Yes

No

Not sure

6. On a scale of 1 to 5 with 1 being “extremely bad” and 5 being “extremely good,” how would you rate your overall experience with your IV placement today?

1 = Extremely bad

2 = Somewhat bad

3 = Neither good nor bad

4 = Somewhat good

5 = Very good

7. If you were offered a One & Done option, how likely are you to choose this option?

The One & Done Program offers to ensure patients an IV placement with a 98% or greater success rate on the first try performed by a clinician trained in the 1STIC technique. This IV access is intended to be the only needle stick a patient will get for the entire hospital stay and can be used to give medications, give fluids, and draw blood for labs.

Very likely

Likely

Neither likely nor unlikely

Unlikely

Very unlikely

8. Please provide any additional comments you would like toa dd. Do not include your name or other personal identifiable or protected health information.