Procedural competency for ultrasound-guided peripheral intravenous catheter insertion for nurses in a pediatric emergency department.

OBJECTIVES: To evaluate if nurses can reliably perform ultrasound-guided peripheral intravenous catheter placement in children with a high success rate after an initial training period. A secondary aim was to analyze complication rates of ultrasound-guided peripheral intravenous catheters. METHODS: A database recorded all ultrasound-guided peripheral intravenous catheter encounters in the emergency department from November 2013 to April 2019 including the emergency department nurse attempting placement, number of attempts, and whether it was successful. Patient electronic medical records were reviewed for the time of and reason for intravenous removal.The probabilities of first-attempt successful intravenous placement and complication at successive encounters after an initial training period were calculated. These probabilities were plotted versus encounter number to graph best-fit logarithmic regressions. RESULTS: A total of 83 nurses completed a standardized training program in ultrasound-guided peripheral intravenous catheter placement including 10 supervised ultrasound-guided peripheral intravenous catheter placements. In total, 87% (3513/4053) of the ultrasound-guided peripheral intravenous catheter placed after the training program were successful on the first attempt. The probability of successfully placing an ultrasound-guided peripheral intravenous catheter increased as nurses had more experience placing ultrasound-guided peripheral intravenous catheters (R2 = 0.18) and was 83% at 10 encounters.Twenty-five percent (904/3646) of ultrasound-guided peripheral intravenous catheters had complications, and there was no statistically significant relationship between the number of encounters per nurse and complication rates (R2 < 0.001). CONCLUSION: Nurses can reliably place ultrasound-guided peripheral intravenous catheters at a high success rate after an initial training period. First-attempt success rates were high and increased from 67% to 83% for the first 10 unsupervised encounters after training and remained high. The complication rate was low and did not change as nurses gained more experience.

Pre- and post-review of a standardized ultrasound-guided central venous catheterization curriculum evaluating procedural skills acquisition and clinician confidence.

BACKGROUND: To evaluate novice and expert clinicians' procedural confidence utilizing a blended learning mixed fidelity simulation model when applying a standardized ultrasound-guided central venous catheterization curriculum. METHODS: Simulation-based education and ultrasound-guided central venous catheter insertion aims to provide facility-wide efficiencies and improves patient safety through interdisciplinary collaboration. The objective of this quality improvement research was to evaluate both novice (<50) and expert (>50) clinicians' confidence across 100 ultrasound-guided central venous catheter insertion courses were performed at a mixture of teaching and non-teaching hospitals across 26 states within the United States between April 2015 and April 2016. A total of 1238 attendees completed a pre- and post-survey after attending a mixed method clinical simulation course. Attendees completed a 4-h online didactic education module followed by 4 h of hands-on clinical simulation stations (compliance/sterile technique, needling techniques, vascular ultrasound assessment, and experiential complication management). RESULTS: The use of a standardized evidence-based ultrasound-guided central venous catheter curriculum improved confidence and application to required clinical tasks and knowledge across all interdisciplinary specialties, regardless of level of experience. Both physician and non-physician groups resulted in statistically significant results in both procedural compliance (p < 0.001) and ultrasound skills (p < 0.001). CONCLUSION: The use of a standardized clinical simulation curriculum enhanced all aspects of ultrasound-guided central venous catheter insertion skills, knowledge, and improved confidence for all clinician types. Self-reported complications were reported at significantly higher rates than previously published evidence, demonstrating the need for ongoing procedural competencies. While there are growing benefits for the role of simulation-based programs, further evaluation is needed to explore its effectiveness in changing the quality of clinical outcomes within the healthcare setting.

Hand motion analysis for assessment of nursing competence in ultrasound-guided peripheral intravenous catheter placement.

INTRODUCTION: Objective measures such as hand motion analysis are needed to assess competency in technical skills, including ultrasound-guided procedures. Ultrasound-guided peripheral intravenous catheter placement has many potential benefits and is a viable skill for nurses to learn. The objective of this study was to demonstrate the feasibility and validity of hand motion analysis for assessment of nursing competence in ultrasound-guided peripheral intravenous placement. METHODS: We conducted a prospective cohort study at a tertiary children's hospital. Participants included a convenience sample of nurses with no ultrasound-guided peripheral intravenous experience and experts in ultrasound-guided peripheral intravenous placement. Nurses completed hand motion analysis before and after participating in a simulation-based ultrasound-guided peripheral intravenous placement training program. Experts also completed hand motion analysis to provide benchmark measurements. After training, nurses performed ultrasound-guided peripheral intravenous placement in clinical practice and self-reported details of attempts. RESULTS: A total of 21 nurses and 6 experts participated. Prior to the hands-on training session, experts performed significantly better in all hand motion analysis metrics and procedure time. After completion of the hands-on training session, the nurses showed significant improvement in all hand motion analysis metrics and procedure time. Few nurses achieved hand motion analysis metrics within the expert benchmark after completing the hands-on training session with the exception of angiocatheter motion smoothness. In total, 12 nurses self-reported 38 ultrasound-guided peripheral intravenous placement attempts in clinical practice with a success rate of 60.5%. DISCUSSION: We demonstrated the feasibility and construct validity of hand motion analysis as an objective assessment of nurse competence in ultrasound-guided peripheral intravenous placement. Nurses demonstrated rapid skill acquisition but did not achieve expert-level proficiency.

Should nurses be trained to use ultrasound for intravenous access to patients with difficult veins?

Peripheral venous access is the most common invasive procedure performed on patients in the UK and is traditionally the responsibility of nursing staff. In an emergency, intravenous therapy can be lifesaving. Approximately 11% of adults have difficult venous access and are often subjected to repeated failed attempts, resulting in delayed diagnosis and treatment. Eventually, rescue methods are used by a doctor, but this increases demand on their time and the workflow of emergency departments. This article explores whether training nurses to obtain venous access using ultrasound would have a positive effect on doctors' workload and benefit adult patients with difficult veins. Research indicates that nurses can successfully use ultrasound to reduce the number of attempts, time to access and patient discomfort, and can prevent the insertion of unnecessary central lines. Ultrasound training programmes for nurses demonstrate benefits for patients and clinicians.

A successful model to learn and implement ultrasound-guided venous catheterization in apheresis.

BACKGROUND: Apheresis treatments can be performed with peripheral venous catheters (PVC), although central venous catheters (CVC) are inserted when PVCs fail or patient with history of difficult vascular access prior to the apheresis. Ultrasound guidance for PVC has shown promising results in other settings. PURPOSE: To investigate if ultrasound guidance for PVC could be implemented among apheresis nurses. Second, how implementation of ultrasound guidance affected the number of CVCs used for apheresis per patient. METHOD: Apheresis nurses completed a systematic training program for ultrasound-guided vascular access. All independent catheterizations were registered during the implementation stage. The number of CVCs in the pre- and postimplementation stages of the ultrasound guidance was compared. RESULTS: Six nurses completed the training program within a median of 48 days (range 38-83 days). In 77 patients, 485 independent ultrasound-guided PVC placements were performed during the implementation stage. All apheresis treatments (485/485) were accomplished using PVCs without requiring CVC as rescue. During the preimplementation stage, 125 of 273 (45.8%) procedures required a CVC for completion of apheresis procedures; during the postimplementation stage only 30 of 227 (13.2%) procedures required a CVC (p < 0.001). In the postimplementation stage, no CVCs were placed as rescue caused by failed PVCs but were only placed for patients where the ultrasound machine was unavailable. It indicates an effective success rate of 100% for ultrasound-guided PVC use. CONCLUSION: This study showed that ultrasound guidance could be implemented among apheresis nurses as a routine tool eliminating the need of CVC as a rescue.

The use of ultrasound for peripheral IV placement by vascular access team nurses at a tertiary children's hospital.

PURPOSE: Children receiving treatment in the hospital frequently require intravenous (IV) access. Placement of short peripheral catheters can be painful and challenging especially in those children who have difficult access. Many children's hospitals have teams of specialized vascular access nurses experienced in peripheral catheter insertion, and at times use vein visualization devices, including ultrasound (US), to assist in peripheral IV placement. Our objectives were to describe the prevalence and success rate of US-guided peripheral IV placement by vascular access team nurses at a single tertiary children's hospital. METHODS: We retrospectively reviewed quality assurance data kept by our institution's vascular access team between February, 2014 and March, 2014. Data extracted included: age, gender, number of attempts, if difficult, if ultimately successful and modality used to aid IV placement. Descriptive statistics and chi-square tests were used to analyze and report data. RESULTS: There were 1111 patient-nurse encounters reported for peripheral IV placement over a six-week period, and a total of 1579 attempts. Ultimately 84% of the patients had successful IV placement. Overall, visualization and palpation was the most frequently used technique (50.1%), followed by near-infrared light (40.6%), US (8.0%), and transillumination (1.3%). The success rate of US (60% overall and 59.2% difficult) was not significantly different from other advanced visualization techniques. CONCLUSIONS: Vascular access team nurses use US infrequently for peripheral IV placement, including in children with difficult access. Methods to increase its skillful use in difficult access patients and improve successful IV placements should be explored.

A randomized controlled trial assessing the use of ultrasound for nurse-performed IV placement in difficult access ED patients.

OBJECTIVE: This study analyzed outcomes associated with nurse-performed ultrasound (US)-guided intravenous (IV) placement compared to standard of care (SOC) palpation IV technique on poor vascular access patients. METHODS: This was a randomized, prospective single-site study. Phase 1 involved education/training of a cohort of nurses to perform US-guided IVs. This consisted of a didactic module and hands-on requirement of 10 proctored functional IVs on live subjects. Phase 2 involved patient enrollment. emergency department patients meeting strict criteria of poor access were randomized to US-guided or SOC palpation arm. A functional IV placed by a study nurse was considered successful. Unsuccessful placement implied the study nurse failed, and a rescue IV was attempted. Time to IV placement was the total time required to obtain a functional IV and, if needed, a rescue IV. RESULTS: A total of 124 subjects were enrolled; 63 were randomized to the US-guided arm, and 61 were randomized into the SOC arm; 2 patients were excluded, leaving 59 patients. Success rate was 76% for the US-guided arm and 56% for the SOC arm (P=.02). Compared to the SOC arm, the odds ratio for success for the US-guided arm was 2.52 (95% confidence interval, 1.09-5.92). The mean time to IV placement for the US-guided arm was 15.8 and 20.7 minutes for the SOC arm (P=.75). CONCLUSION: In difficult access patients, nurses were more successful in obtaining IV access using US guidance than palpation SOC technique. Lengthier placement times were observed more frequently when the SOC IV technique was used.

Implementing a Program for Ultrasound-Guided Peripheral Venous Access: Training, Policy and Procedure Development, Protocol Use, Competency, and Skill Tracking.

Peripheral intravenous (IV) access provides a means to administer medications, IV fluids, and blood products and allows for the sampling of blood for analysis. The traditional approach to obtaining peripheral IV access relies on vessel visualization in the arm and/or palpation of the blood vessel beneath the skin. However, the general population is aging, obesity is commonplace, and IV drug abuse is widespread, making peripheral IV access difficult. Use of ultrasound-guided peripheral IV access fills a practice gap in safe patient care between traditional peripheral IV access methods of vein visualization and/or palpation and ultrasound-guided central venous access.

Ultrasound-guided small vessel cannulation: long-axis approach is equivalent to short-axis in novice sonographers experienced with landmark-based cannulation.

INTRODUCTION: Our primary objective was to describe the time to vessel penetration and difficulty of long-axis and short-axis approaches for ultrasound-guided small vessel penetration in novice sonographers experienced with landmark-based small vessel penetration. METHODS: This was a prospective, observational study of experienced certified emergency nurses attempting ultrasound-guided small vessel cannulation on a vascular access phantom. We conducted a standardized training, practice, and experiment session for each participant. Five long-axis and five short-axis approaches were attempted in alternating sequence. The primary outcome was time to vessel penetration. Secondary outcomes were number of skin penetrations and number of catheter redirections. We compared long-axis and short-axis approaches using multivariable regression adjusting for repeated measures, vessel depth, and vessel caliber. RESULTS: Each of 10 novice sonographers made 10 attempts for a total of 100 attempts. Median time to vessel penetration in the long-axis and short-axis was 11 (95% confidence interval [CI] 7-12) and 10 (95% CI 6-13) seconds, respectively. Skin penetrations and catheter redirections were equivalent and near optimal between approaches. The median caliber of cannulated vessels in the long-axis and short-axis was 4.6 (95% CI 4.1-5.5) and 5.6 (95% CI 5.1-6.2) millimeters, respectively. Both axes had equal success rates of 100% for all 50 attempts. In multivariable regression analysis, long-axis attempts were 32% (95% CI 11%-48%; p=0.009) faster than short-axis attempts. CONCLUSION: Novice sonographers, highly proficient with peripheral IV cannulation, can perform after instruction ultrasound-guided small vessel penetration successfully with similar time to vessel penetration in either the long-axis or short-axis approach on phantom models.

Getting the most from ultrasound guidance for CVC insertion.

Ultrasound is an imaging technique that uses ultra-high frequency sound waves. The interaction of the sound waves with body tissue enables an image to be produced. Following guidance from the National Institute for Health and Care Excellence (NICE) (2002), the use of two-dimensional ultrasound imaging for central venous catheter (CVC) insertion has increased. Ultrasound provides the nurse with visualisation of the target vein as well as any other surrounding structures. It also demonstrates any variation in anatomy that the patient may have. Increased first-time puncture rates and decreased complications are among the benefits of ultrasound use for CVC placement described in the literature. However, NICE (2002) guidance recommended that education and training be sought by those using this technology. The aim of this article, therefore, is to provide useful information regarding ultrasound-guided venous access and to describe some techniques to improve image quality.

Single-operator ultrasound-guided intravenous line placement by emergency nurses reduces the need for physician intervention in patients with difficult-to-establish intravenous access.

BACKGROUND: Emergency physicians (EPs) have become facile with ultrasound-guided intravenous line (USIV) placement in patients for whom access is difficult to achieve, though the procedure can distract the EP from other patient care activities. OBJECTIVES: We hypothesize that adequately trained Emergency Nurses (ENs) can effectively perform single-operator USIV placement with less physician intervention than is required with blind techniques. METHODS: This was a prospective multicenter pilot study. Interested ENs received a 2-h tutorial from an experienced EP. Patients were eligible for inclusion if they had either two failed blind peripheral intravenous (i.v.) attempts, or if they reported or had a known history of difficult i.v. placement. Consenting patients were assigned to have either EN USIV placement or standard of care (SOC). RESULTS: Fifty patients were enrolled, of which 29 were assigned to USIV and 21 to SOC. There were no significant differences in age, race, gender, or reason for inclusion. Physicians were called to assist in 11/21 (52.4%) of SOC cases and 7/29 (24.1%) of USIV cases (p = 0.04). Mean time to i.v. placement (USIV 27.6 vs. SOC 26.4 minutes, p = 0.88) and the number of skin punctures (USIV 2.0 vs. SOC 2.1, p = 0.70) were not significantly different. Patient satisfaction was higher in the USIV group, though the difference did not reach statistical significance (USIV 86.2% vs. SOC 63.2%, p = 0.06). Patient perception of pain on a 10-point scale was also similar (USIV 4.9 vs. SOC 5.5, p = 0.50). CONCLUSIONS: ENs performing single-operator USIV placement in patients with difficult-to-establish i.v. access reduces the need for EP intervention.

Greece reports prototype intervention with first peripherally inserted central catheter: case report and literature review.

Placement of peripherally inserted central catheters (PICCs), definitely offers a clear advantage over any other method regarding central venous catheterization. Its ultrasonographic orientation enhances significantly its accuracy, safety and efficacy, making this method extremely comfortable for the patient who can continue his or her therapy even in an outpatient basis. We present the first reported case of a PICCS insertion in Greece, which has been performed by a university-degree nurse. The aim of this review of literature was to present the evolution in nursing practice in Greece. A PICC was inserted in a 77-year-old male patient suffering from a recent chemical pneumonia with a history of Alzheimer's disease. A description of all the technical details of this insertion is reported, focusing on the pros and cons of the method and a thorough review of the history and advances in central venous catheterization throughout the years is also presented. PICCs provide long-term intravenous access and facilitate the delivery of extended antibiotic therapy, chemotherapy and total parenteral nutrition. We strongly believe that PICCs are the safest and most effective method of peripherally inserted central venous catheterization. Larger series are necessary to prove the above hypothesis, and they are under construction by our team.

Use of ultrasound guidance for peripheral intravenous placement in difficult-to-access patients: advancing practice with evidence.

Placement of peripheral intravenous (PIV) lines in difficult-to-access patients can be daunting. Multiple unsuccessful peripheral sticks, numerous PIV restarts, and potentially excess use of peripherally inserted central catheters can result. The goals of this project were to decrease the number of peripherally inserted central catheter referrals and lower the number of PIV restarts by having clinical nurses employ ultrasound guidance when initiating deep PIVs. After 10 months of nurses using the ultrasound as needed to insert a PIV line, the number of total peripherally inserted central catheter referrals decreased by 20%.