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A Nurse-Led Ultrasound-Enhanced Vascular Access Preservation Program
Abstract
: Insertion of peripheral iv catheters is a common practice in medical-surgical care settings. The frequency with which attempts are made to insert catheters causes rapid peripheral vessel depletion (a reduction in the number of usable veins), leading to the overuse of unnecessary central line catheters. Reducing central line-associated bloodstream infections is a national health care priority. In this quality improvement report, the authors describe the implementation of a nurse-led vascular access preservation program using ultrasound technology as a method to reduce the use of nonessential peripherally inserted central catheters.
... Fourteen educational programs included video material of the procedure [12][13][14][22][23][24][25][26][27][28][29][30][31][32] and five included live demonstrations of the procedure [22,23,29,33,34]. Inter-study duration variations in the training sessions were seen from the shortest of 5 min to the longest of 9 h [35,36]. In general, the duration of the training was between two to 4 h (Additional file 3). ...
... Reeves [36] Cohort study 2(★) ...
... Chenkin et al. found that a onehour web-based learning program was equally efficient compared to a one-hour traditional classroom lecture [38]. Only three of the studies used an e-learning module as a part of their educational program [22,36,47]. This indicates that e-learning is not implemented to its capability. ...
Background
Placing a peripheral vein catheter can be challenging due to several factors, but using ultrasound as guidance increases the success rate. The purpose of this review is to investigate the knowledge already existing within the field of education in ultrasound-guided peripheral vein catheter placement and explore the efficacy and clinical impact of different types of education.
Methods
In accordance with PRISMA-guidelines, a systematic search was performed using three databases (PubMed, EMBASE, CINAHL). Two reviewers screened titles and abstracts, subsequently full-text of the relevant articles. The risk of bias was assessed using the Cochrane Collaboration risk of bias assessment tool and the New Ottawa scale.
Results
Of 3409 identified publications, 64 were included. The studies were different in target learners, study design, assessment tools, and outcome measures, which made direct comparison difficult. The studies addressed a possible effect of mastery learning and found e-learning and didactic classroom teaching to be equally effective.
Conclusion
Current studies suggest a potential benefit of ultrasound guided USG-PVC training on success rate, procedure time, cannulation attempts, and reducing the need for subsequent CVC or PICC in adult patients. An assessment tool with proven validity of evidence to ensure competence exists and education strategies like mastery learning, e-learning, and the usage of color Doppler show promising results, but an evidence-based USG-PVC-placement training program using these strategies combined is still warranted.
... Nursing curriculum evolves with evidenced-based best practices, and ultrasound-guided PIVC placement has shown to be a best practice measure in difficult-access patients. 9,[23][24][25][26][27][28][29][30][31][32][33] This study was designed to explore the lack of formal education on ultrasound-guided short PIVC placement in NP students' curriculum. This study further illuminates the need for formal education with hands-on training for ultrasound-guided PIVC placement. ...
... Introducing ultrasonography into bedside PIVC placement for difficult patient access can enhance nursing knowledge, as well as practice and patient outcomes. 2,9,[23][24][25][26][27][28][29][30][31][32] This study discovered that with basic education and simulation training, nurses' confidence level and skills in performing PIVC with ultrasonography was improved. Similarly, Ault and Galen 29,31 both studied the proficiency of nursing knowledge regarding vascular access. ...
... Other studies have shown that nurses are able to comprehend ultrasound PIVC placement and incorporate it into their practice with success. [24][25][26]28 However, there is no universal recommended standard training on ultrasound for PIVC insertion adopted by either nursing organization or academic settings. ...
HIGHLIGHTS
Ultrasonography is an important tool for vascular access practice. Ultrasound should be used for vascular access assessment and insertion. Ultrasonography should be incorporated into formal nursing education curriculum and simulation training.
Background
This study analyzed nurse practitioner students' knowledge of ultrasound-guided vascular access after the implementation of an educational and simulation course.
Methods
Nurses' knowledge of ultrasound-guided peripheral intravenous catheter placement was analyzed using a ten-item questionnaire both before and after course. A sample of bachelor's degree-prepared nurses voluntarily participated in this study. Ultrasonography simulation was carried out with two handheld ultrasound devices and two ultrasound blocks.
Results
The findings demonstrated that there is a statistically significant increased comprehension of ultrasoundguided vascular access after simulation courses.
Conclusion
This study illuminates the need for formal education both in academic curriculum and through simulation to improve ultrasound-guided vascular access knowledge for patient care.
... Nursing curriculum evolves with evidenced-based best practices, and ultrasound-guided PIVC placement has shown to be a best practice measure in difficult-access patients. 9,[23][24][25][26][27][28][29][30][31][32][33] This study was designed to explore the lack of formal education on ultrasound-guided short PIVC placement in NP students' curriculum. This study further illuminates the need for formal education with hands-on training for ultrasound-guided PIVC placement. ...
... Introducing ultrasonography into bedside PIVC placement for difficult patient access can enhance nursing knowledge, as well as practice and patient outcomes. 2,9,[23][24][25][26][27][28][29][30][31][32] This study discovered that with basic education and simulation training, nurses' confidence level and skills in performing PIVC with ultrasonography was improved. Similarly, Ault and Galen 29,31 both studied the proficiency of nursing knowledge regarding vascular access. ...
... Other studies have shown that nurses are able to comprehend ultrasound PIVC placement and incorporate it into their practice with success. [24][25][26]28 However, there is no universal recommended standard training on ultrasound for PIVC insertion adopted by either nursing organization or academic settings. ...
Highlights
Ultrasonography is an important tool for vascular access practice. Ultrasound should be used for vascular access assessment and insertion. Ultrasonography should be incorporated into formal nursing education curriculum and simulation training.
... These conditions can lead to peripheral intravenous catheterization (PIC) failure, defined as the need for more than one catheterization attempt. (10) These multiple attempts result in venous network depletion, and make peripheral veins progressively difficult to access, (11,12) as well as delaying prescribed therapy, (12,13) causing stress, pain, and suffering for the child and family members. and in the long term, may be associated with fear of needle procedures, (14) a reality experienced in children with cancer. ...
... These conditions can lead to peripheral intravenous catheterization (PIC) failure, defined as the need for more than one catheterization attempt. (10) These multiple attempts result in venous network depletion, and make peripheral veins progressively difficult to access, (11,12) as well as delaying prescribed therapy, (12,13) causing stress, pain, and suffering for the child and family members. and in the long term, may be associated with fear of needle procedures, (14) a reality experienced in children with cancer. ...
Resumo Objetivo Estimar a prevalência de insucesso na inserção de cateteres intravenosos periféricos em crianças com câncer e sua associação com características demográficas, clínicas, da cateterização e terapia intravenosa utilizada previamente. Métodos Estudo de corte transversal e exploratório realizado na unidade de clínica oncológica pediátrica de um hospital público. Foram utilizados dados provenientes da observação de 130 cateterizações intravenosas periféricas e prontuários das crianças. Analisadas as características demográficas, clínicas, da cateterização intravenosa periférica e terapia intravenosa utilizada e sua relação com o insucesso da cateterização. Utilizou-se regressão de Poisson com variância robusta para determinar os fatores associados ao desfecho estudado, considerando p
... 5 Repeated cannulations can also result in venous depletion (fewer usable veins), with peripheral vessels becoming thrombosed and friable, making more invasive central venous catheters necessary. 6 Finally, the staff time needed to insert a PIVC and the financial costs of inserting a PIVC when it might not be needed can no longer be justified. 7 PIVCs are among the most common invasive devices used in hospitalized patients, with over 300 million sold in the United States each year. ...
Peripheral intravenous catheters (PIVCs) are among the most common invasive devices used in hospitalized patients, with over 300 million sold in the United States each year. However, about one-fourth of PIVCs are left in situ with no prescriber orders for IV medications or solutions, "just in case" they might be needed. PIVC insertion can be painful, is often unnecessary, and may increase a patient's risk of developing a bloodstream infection. This article reviews the evidence for the appropriate use of short PIVCs in hospitalized patients, assesses the ongoing need for PIVCs, provides recommendations for alternative options, and argues for promptly removing a PIVC that is no longer in use.
... One study used a smart sensor to measure the surgical drain output and has the potential to save time, ease the pressure on nursing staff and reduce the SSIs rate(Duren & Boxel, 2017). A study using an ultrasound device for peripheral venous assessment that can assist nurses in reducing non-essential peripherally inserted central catheter and catheter failure observed significant cost savings(Reeves et al., 2017). ...
Aim
Considering the increasing number of emerging infectious diseases, innovative approaches are strongly in demand. Additionally, research in this field has expanded exponentially. Thus, faced with this diverse information, we aim to clarify key concepts and knowledge gaps of technology in nursing and the field of infectious diseases.
Design
This scoping review followed the methodology of scoping review guidance from Arksey and O’Malley.
Methods
Six databases were searched systematically (PubMed, Web of Science, IEEE Explore, EBSCOhost, Cochrane Library and Summon). After the removal of duplicates, 532 citations were retrieved and 77 were included in the analysis.
Results
We identified five major trends in technology for nursing and infectious diseases: artificial intelligence, the Internet of things, information and communications technology, simulation technology and e‐learning. Our findings indicate that the most promising trend is the IoT because of the many positive effects validated in most of the reviewed studies.
... Em relação aos custos, o aparelho de ultrassonografia custa, em média, 5.000 dólares. Embora apresente um custo elevado, segundo o estudo de Reeves et al. (2017), houve uma economia de custos de mais de 250.000 dólares nos primeiros 20 meses de implantação da ultrassonografia nas punções periféricas, pois reduziu a quantidade de dispositivos gastos em punções sem sucesso, como também diminuiu a demanda de cateteres centrais. Além disso, observou-se aumento no nível de raciocínio clínico dos enfermeiros em relação ao plano de cuidados do paciente e na atuação de tomada de decisões compartilhadas. ...
A punção venosa periférica às cegas não é mais justificada diante dos recursos técnicos e tecnológicos presentes, como aplicação de escalas, uso da ultrassonografia vascular, infravermelho ou transiluminação. O objetivo deste estudo é analisar as evidências científicas relacionadas à utilização da ultrassonografia na punção venosa periférica. Trata-se de uma revisão integrativa da literatura realizada em agosto de 2019. Foram selecionados nove artigos, os quais apresentaram altos níveis de evidências científicas, segundo a classificação de Oxford Centre for Evidence-Based Medicine. Os resultados obtidos identificaram literatura controversa quanto à utilização da ultrassonografia em punções venosas periféricas na população pediátrica, sendo necessária a realização de mais pesquisas experimentais para aplicação na prática baseada em evidências. Os estudos revelam que o uso do ultrassom melhora o sucesso da inserção sem necessidade de repetidas inserções as quais são dolorosas para o paciente e dispendiosa em termos de recursos humanos e materiais extras para obtenção de uma colocação bem-sucedida. Assim, o uso da ultrassonografia é promover a redução de custos. Por conseguinte, esta revisão sugere que o uso da ultrassonografia é favorável em pacientes adultos com acessos venosos difíceis. Sua utilização reduz o número de solicitações para instalação de cateteres centrais não essenciais e, assim, garante maior
autonomia ao enfermeiro, reduz os riscos de infecção associados ao cateter central, melhora a satisfação do paciente.
Background:
Peripheral intravenous cannula insertion is the most common invasive healthcare procedure, however failure rates remain unacceptably high, particularly in patients with difficult intravascular access. This leads to treatment delays and increased complication risk, causing poorer outcomes among this patient subset. Ultrasonographic guidance reduces these risks and is therefore becoming a competency required of health professionals. However, there is no consensus on how to design teaching sessions to achieve this competency.
Methods:
Systematic review was conducted to identify characteristics of effective teaching sessions for current and training health professions to achieve ultrasound guided peripheral intravenous cannulation competency. Secondary outcomes included defining competency and to assess benefits to patients and healthcare systems. Eligibility for inclusion required description of teaching of ultrasound guided peripheral intravenous cannulation to qualified or training health professionals who went on to perform it in human patients or volunteers with reported outcomes or success rates. Studies were excluded if not accessible in full, not peer-reviewed or presented research that had been presented elsewhere previously. Of the 1085 records identified on review of 6 databases, 35 were included for final review based on eligibility criteria.
Results:
Almost all (97.1%) used mixed modality teaching comprising of didactic and simulation portions, although time allocated varied widely. A median of 5 proctored procedures was required for competency. Competency was independent of previous experience or staff seniority. Mean reported insertion attempts was 1.7, success rate was 82.5% and first-time success rate was 75.5%. All included studies described improvement in their participants or healthcare system including significantly reduced midline insertion rates, central venous catheter insertion rates and associated bacteremia and sepsis, self-reported cannulation difficulty, specialist input, therapy delays and premature catheter failure rates. Further, there was significantly improved procedural confidence, knowledge and competence.
Conclusion:
Simple teaching interventions can lead to competent ultrasound guided peripheral intravenous cannula insertion by novices, resulting in numerous positive outcomes for patients and healthcare systems.
Introduction: Venipuncture is the most common invasive procedure a child will encounter in the hospital. Netherton syndrome and many other pediatric blood and genetic disorders, such as Diamond-Blackfan anemia, Pompe disease, and sickle cell disease, all require routine phlebotomy and infusions (Vlachos and Muir, Blood. 116(19):3715–23, 2010; Gupta et al., Front Immunol. 11:1929, 2020). Vein preservation in the chronically ill patient population is critical to prevent or postpone the unnecessary escalation of vascular access device requirement. Ultrasound provides an accurate vein assessment and increases the first attempt success for peripheral intravenous catheter (PIVC) placement by trained clinicians. In the chronically ill pediatric patient, ultrasound-guided small-bore PIVC placement to the cephalic vein in the forearm has been demonstrated to provide years of successful therapy.Case Report: The patient was a 5-year-old male with a past medical history of Netherton syndrome, including severe dermatosis, desquamation of the epidermis, immunodeficiency, and developmental delay. The patient receives intravenous immunoglobulin (IVIG) monthly at the outpatient hematology, oncology, and genetic unit. Given the patient’s severe skin condition, the Infectious Disease specialist recommended avoiding port placement due to the high risk of infection associated with repeated access. As a result, for the past 5 years, the Vascular Access Service had alternated ultrasound-guided venous cannulation of the cephalic vein to the right and left forearm for infusion and phlebotomy.Conclusion: Ultrasound-guided PIVC placement to the cephalic vein in the forearm provides a long-term peripheral option for intermittent infusions in the chronically ill pediatric patient. The vein should be closely monitored for stenosis to anticipate the need for a tunneled or implantable vascular access device.KeywordsUltrasound-guided peripheral intravenous catheterCephalic veinNetherton syndromeIntravenous immunoglobulinChild life specialist
Background:
Ultrasound-guided imagery to obtain peripheral intravenous (USGIV) access is a technique that can be used to increase successful peripheral intravenous catheter insertion rates. Improving rates of USGIV use will subsequently decrease central venous catheter use and thus decrease the time to treatment initiation, reduce costs, and improve patient satisfaction.
Purpose:
Current available programs teach nurses USGIV use for the adult population, mainly with a focus on the emergency department. To address this gap in knowledge, a USGIV program aimed at the specific needs of the neonatal intensive care unit (NICU) nurse was developed and implemented.
Method:
Twelve NICU nurses were trained in USGIV access during a 4-hour combination didactic and simulation-based program. Participants took a pretest survey assessing baseline knowledge and confidence levels related to USGIV access. After didactic lecture, participants worked at stations focused on USGIV access. An 80% benchmark for each participant was set for successful USGIV attempts during simulation. Participants' knowledge and confidence levels were reassessed at the end of the program.
Results:
Posttest scores increased by an average of 25%, demonstrating increased knowledge. The pre- to posttest confidence scores increased by a minimum of 1.6 points (based on a 5-point Likert scale). All participants (n = 12) successfully demonstrated proficiency by achieving at least 80% of attempted USGIV access on a mannequin.
Implications for practice and research:
This project demonstrated that USGIV catheter can be employed in neonatal patients by training NICU nurses in USGIV techniques.
Background
More than 1 billion peripheral vascular access devices are inserted annually worldwide with potential complications including infection, thrombosis, and vasculature damage. Vasculature damage can necessitate the use of central catheters, which carry additional risks such as central catheter–associated bloodstream infections. To address these concerns, one institution used expert nurses and a consult request system with algorithms embedded in the electronic medical record.
Objectives
To develop a uniform process for catheter insertion by means of a peripheral vascular access service dedicated to selecting, placing, and maintaining all inpatient peripheral catheters outside of the intensive care units.
Methods
Descriptive analysis and χ2 analysis were done to describe the impact of the peripheral vascular access service.
Results
In 2018, 6246 consults were reviewed. Of these, 26% did not require vascular access. Similarly, in 2019, 7861 consults were reviewed, and 35.3% did not require vascular access. Use of central catheters decreased from 21% in 2017 to 17% in 2018 and 2019.
Conclusions
The peripheral vascular access service allowed patients to receive appropriate peripheral vascular access devices and avoid unnecessary peripheral catheter placements. This may have preserved patients’ peripheral vasculature and thus prevented premature central catheter placement and contributed to an overall decrease in central catheter days. With the peripheral vascular access service, peripheral vascular access devices were selected, placed, and maintained by experts with a standardized process that promoted a culture of quality and patient safety.
Introduction:
Difficult intravenous (IV) access (DIVA) is frequently encountered in the hospital setting. Ultrasound-guided peripheral IV catheter (USGPIV) insertion has emerged as an effective procedure to establish access in patients with DIVA. Despite the increased use of USGPIV, little is known about the optimal training paradigms for bedside nurses. Therefore, we developed and evaluated a novel, sustainable, USGPIV simulation-based mastery learning (SBML) curriculum for nurses.
Methods:
This is a prospective cohort study of an USGPIV SBML training program for bedside nurses over a 12-month period. We evaluated skills and self-confidence before and after training and measured the proportion of the nurses achieving independent, proctor, and instructor status. Procedure logs and surveys were used to explore the nurse experience and utilization of USGPIV on real patients with DIVA 3 months after the intervention.
Results:
Two hundred thirty-eight nurses enrolled in the study. The USGPIV skill checklist scores increased from median of 6.0 [interquartile range = 4.0-9.0 (pretest) to 29.0, interquartile range = 28-30 (posttest), P < 0.001]. The USGPIV confidence improved from before (mean = 2.32, SD = 1.17) to after (mean = 3.85, SD = 0.73, P < 0.001) training (5-point Likert scale). Sixty-two percent of the nurses enrolled achieved independent status, 47.5% became proctors, and 11.3% course trainers. At 3-month posttraining, the nurses had attempted a mean of 35.6 USGPIV insertions with an 89.5% success rate.
Conclusions:
This novel USGPIV SBML curriculum improves nurses' insertion skills, self-confidence, and progresses patient care through USGPIV insertions on hospitalized patients with DIVA.
Background
Difficult intravenous access (DIVA) is a common problem in Emergency Departments (EDs), yet the prevalence and clinical impact of this condition is poorly understood. Ultrasound-guided peripheral intravenous catheter (USGPIV) insertion is a successful modality for obtaining intravenous (IV) access in patients with DIVA.
Objectives
We aimed to describe the prevalence of DIVA, explore how DIVA affects delivery of care, and determine if nurse insertion of USGPIV improves care delays among patients with DIVA.
Methods
We retrospectively queried the electronic medical record for all ED patients who had a peripheral IV (PIV) inserted at a tertiary academic medical center from 2015 to 2017. We categorized patients as having DIVA if they required ≥3 PIV attempts or an USGPIV. We compared metrics for care delivery including time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED length of stay (LOS) between patients with and without DIVA. We also compared these metrics in patients with DIVA with a physician-inserted USGPIV versus those with a nurse-inserted USGPIV.
Results
A total of 147,260 patients were evaluated during the study period. Of these, 13,192 (8.9%) met criteria for DIVA. Patients with DIVA encountered statistically significant delays in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients without DIVA (all p < 0.001). Patients with nurse-inserted USGPIVs also had statistically significant improvements in time-to-IV-access, time-to-laboratory-results, time-to-IV-analgesia, and ED LOS compared to patients with physician-inserted USGPIVs (all p < 0.001).
Conclusion
DIVA affects many ED patients and leads to delays in PIV access-related care. Nurse insertion of USGPIVs improves care in patients with DIVA.
Background
Training nurses in ultrasound-guided peripheral intravenous catheter placement might reduce the use of more invasive venous access devices (peripherally inserted central catheters (PICC) and midline catheters).
Methods
We implemented an abbreviated training in ultrasound-guided peripheral intravenous catheter placement for nurses on an inpatient medical unit and provided a portable ultrasound device for 10 months.
Results
Nurses on this unit placed 99 ultrasound-guided peripheral intravenous catheters with a high level of success. During the implementation period, PICC and midline catheter placement decreased from a mean 4.8 to 2.5 per month, meeting criteria for special cause variation. In the postimplementation period, the average catheter use reverted to 4.3 per month on the intervention unit. A comparison inpatient medical unit without training or access to a portable ultrasound device experienced no significant change in PICC and midline catheter use throughout the study period (mean of 6.0 per month).
Conclusions
These results suggest that an abbreviated training in ultrasound-guided peripheral intravenous catheter placement for nurses on an inpatient medical unit is sufficient to reduce PICC and midline catheters.
Introduction:
Vascular access procedures are among the most commonly performed procedures in the emergency department. The objective of the current study was to compare the contrast extravasation rate for ultrasound-guided peripheral intravenous (USGPIV) catheter placement by emergency nurses with peripheral intravenous catheters placed by standard landmark techniques.
Methods:
A retrospective chart review of all ED patients at our urban tertiary-care institution who underwent contrasted computed tomography examination and suffered contrast extravasation events was performed. A logbook of all ED patients who underwent USGPIV placement and an institution-wide electronic patient safety incident-reporting system was reviewed for all contrast extravasation events between May 2014, and February 2017. Data were analyzed using descriptive statistics, Student t-tests for continuous data, and χ2 or Fisher's exact test for categorical data.
Results:
One thousand five hundred USGPIV catheters were placed by 27 emergency nurses. Contrast material was administered 29,508 times, and, of these, 291 were administered via USGPIV placement. There were 74 peripheral IV lines with documented contrast extravasations (0.25%) as reported in the safety-event database; 12 (4.1%) were from the USGPIV population, and 62 (0.21%) occurred in the standard landmark technique population. Relative risk of contrast extravasation events with USGPIV placement was 19.4 (95% confidence interval [CI], 10.6-35.6), and the absolute risk difference was 3.9% (95% CI 1.6%-6.2%).
Discussion:
USGPIV placement by trained emergency nurses has higher rates of contrast extravasation than with standard landmark technique placement.
Objective
To identify, describe, and evaluate interventions to reduce unnecessary central venous catheter (CVC) use to prevent central-line–associated bloodstream infections (CLABSIs) in adults.
Design
Systematic review.
Methods
The review has been registered in PROSPERO, an international prospective register of systematic reviews. We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health (CINAHL) from inception until August 28, 2018, to collect experimental and observational studies. We included all studies that implemented interventions to reduce unnecessary CVC use, defined as interventions aimed at improving appropriateness, awareness of device presence, or prompt removal of devices.
Results
In total, 1,892 unique citations were identified. Among them, 1 study (7.1%) was a randomized controlled trial, 9 studies (64.3%) were quasi-experimental studies, and 4 studies (28.6%) were cohort studies. Furthermore, 13 studies (92.9%) demonstrated a decrease in CVC use after intervention despite different reporting methods, and the reduction rate varied from 6.8% to 85%. Also, 7 studies (50.0%) that reported the incidence of CLABSI described a reduction in CLABSIs ranging from 24.4% to 100.0%. Data on secondary outcomes were limited, and results of the descriptive analysis showed 70%–84% compliance with these interventions, less catheter occlusion, shorter duration of hospitalization, and cost savings.
Conclusions
Interventions to reduce unnecessary CVC use significantly decrease the rate of CLABSI. Healthcare providers should strongly consider implementing these interventions for prevention of CLABSI in adults.
Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.
To assess characteristics, satisfaction, and disposition of emergency department (ED) patients who successfully received ultrasound (US)-guided peripheral intravenous (IV) access.
This is a prospective observational study among ED patients who successfully received US-guided peripheral IV access by ED technicians. Nineteen ED technicians were taught to use US guidance to obtain IV access. Training sessions consisted of didactic instruction and hands-on practice. The US guidance for IV access was limited to patients with difficult access. After successfully receiving an US-guided peripheral IV, patients were approached by research assistants who administered a 10-question survey. Disposition information was collected after the conclusion of the ED visit by accessing patients' electronic medical record.
In total, 146 surveys were completed in patients successfully receiving US-guided IVs. Patients reported an average satisfaction with the procedure of 9.2 of 10. Forty-two percent of patients had a body mass index (BMI) of greater than 30, and 17.8% had a BMI of more than 35. Sixty-two percent reported a history of central venous catheter placement. This patient population averaged 3 ED visits per year in the past year. Fifty-three percent of the patients were admitted.
Patients requiring US-guided IVs in our ED are discharged home at the conclusion of their ED visit about half of the time. These patients reported high rates of both difficult IV access and central venous catheter placement in the past. Patient satisfaction with US-guided IVs was very high. These data support the continued use of US-guided peripheral IVs in this patient population.
The UIHC Department of Nursing is nationally known for its work on use of research to improve patient care. This reputation is attributable to staff members who continue to question "how can we improve practice?" or "what does the latest evidence tell us about this patient problem?" and to administrators who support, value, and reward EBP. The revisions made in the original Iowa Model are based on suggestions from staff at UIHC and other practitioners across the country who have implemented the model. We value their feedback and have set forth this revised model for evaluation and adoption by others.
Approximately every 5 years, the Infusion Nurses Society publishes evidence-based practice standards. This article provides an overview of the process used in standards development, describes the format of the standards, and provides a short summary of selected standards as applied to home care. The Standards are an important document that should be available to every home care organization that provides home infusion therapy.
Peripheral intravenous (IV) catheter insertion, the most common invasive hospital procedure performed worldwide, is associated with a variety of complications and an unacceptably high overall failure rate of 35% to 50% in even the best of hands. Catheter failure is costly to patients, caregivers, and the health care system. Although advances have been made, analysis of the mechanisms underlying the persistent high rate of peripheral IV failure reveals opportunities for improvement.
Objective:
The objective was to determine risk factors associated with difficult venous access (DVA) in the emergency department (ED).
Methods:
This was a prospective, observational study conducted in the ED of an urban tertiary care hospital. Adult patients undergoing intravenous (IV) placement were consecutively enrolled during periods of block enrollment. The primary outcome was DVA, defined as 3 or more IV attempts or use of a method of rescue vascular access to establish IV access. Univariate and multivariate analyses for factors predicting DVA were performed using logistic regression.
Results:
A total of 743 patients were enrolled, of which 88 (11.8%) met the criteria for DVA. In the adjusted analysis, only 3 medical conditions were significantly associated with DVA: diabetes (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.1-2.8), sickle cell disease (OR 3.8, 95% CI 1.5-9.5), and history of IV drug abuse (OR 2.5, 95% CI 1.1-5.7). Notably, age, body mass index, and dialysis were not. Of patients who reported a history of requiring multiple IV attempts in the past for IV access, 14% met criteria for DVA on this visit (OR 7.7 95% CI 3-18). Of the patients who reported a history of IV insertion into the external jugular, ultrasound-guided IV placement, or a central venous catheter for IV access, 26% had DVA on this visit (OR 16.7, 95% CI 6.8-41).
Conclusions:
Nearly 1 of every 9 to 10 adults in an urban ED had DVA. Diabetes, IV drug abuse, and sickle cell disease were found to be significantly associated with DVA.
Purpose
A preliminary observational study was undertaken to evaluate the risk of failure of ultrasound-guided peripheral intravenous (USGPIV) catheterization of a deep arm vein for a maximum of 7 days, after peripheral intravenous (PIV)-cannulation failure.
Methods
This prospective study included patients referred to the intensive care unit for placement of a central line, with a polyurethane cannula commercialized for arterial catheterization. Catheter length and diameter were chosen based on preliminary US measurements of vein diameter and skin–vein distance.
Results
Catheterization was successful for all 29 patients. Mean vein diameter was 0.42 ± 0.39 cm; mean vein depth was 0.94 ± 0.52 cm. Mean catheter duration was 6 (median 7) days. Two occluded catheters were removed prematurely. No thrombophlebitis, catheter infection or extravasation was observed.
Conclusion
Our results suggest that catheters inserted with the Seldinger method are adapted to prolonged peripheral deep-vein infusion. US can play a role in catheter monitoring by identifying early thrombosis formation.
Study objective:
We examine the central venous catheter placement rate during the implementation of an ultrasound-guided peripheral intravenous access program.
Methods:
We conducted a time-series analysis of the monthly central venous catheter rate among adult emergency department (ED) patients in an academic urban ED between 2006 and 2011. During this period, emergency medicine residents and ED technicians were trained in ultrasound-guided peripheral intravenous access. We calculated the monthly central venous catheter placement rate overall and compared the central venous catheter reduction rate associated with the ultrasound-guided peripheral intravenous access program between noncritically ill patients and patients admitted to critical care. Patients receiving central venous catheters were classified as noncritically ill if admitted to telemetry or medical/surgical floor or discharged home from the ED.
Results:
During the study period, the ED treated a total of 401,532 patients, of whom 1,583 (0.39%) received a central venous catheter. The central venous catheter rate decreased by 80% between 2006 (0.81%) and 2011 (0.16%). The decrease in the rate was significantly greater among noncritically ill patients (mean for telemetry patients 4.4% per month [95% confidence interval {CI} 3.6% to 5.1%], floor patients 4.8% [95% CI 4.2% to 5.3%], and discharged patients 7.6% [95% CI 6.2% to 9.1%]) than critically ill patients (0.9%; 95% CI 0.6% to 1.2%). The proportion of central venous catheters that were placed in critically ill patients increased from 34% in 2006 to 81% in 2011 because fewer central venous catheterizations were performed in noncritically ill patients.
Conclusion:
The ultrasound-guided peripheral intravenous access program was associated with reductions in central venous catheter placement, particularly in noncritically ill patients. Further research is needed to determine the extent to which such access can replace central venous catheter placement in ED patients with difficult vascular access.
Infusion therapy is one of the most invasive, complex, and pervasive therapies in the current health care system, yet there is very little investment in organizational knowledge management and intellectual human capital required to maintain patient safety. Catheter complications, fluid and medication errors, inadequate nutritional support, and transfusion of incompatible blood products manifest evidence of the ongoing problem. The number of infusion therapy teams has greatly decreased because of questionable cost-cutting strategies; however, it is clear from identified trends in health care that infusion teams and the concept of an infusion alliance has a distinct place within a modern health care organization.
Infusion nursing: standards of practice
- Infusion