Evidence Based Practice - Ultrasound Guided Peripheral IV Placement

Submitted by William Ganter

Tags: catheters clinical nurse critical care Emergency nurse patient safety

Evidence Based Practice - Ultrasound Guided Peripheral IV Placement

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Abstract

This study aims to show that nurse driven placement of ultrasound guided peripheral intravenous access in the emergency department will improve patient care. Estimates suggest up to 80% of patients in critical care settings require peripheral intravenous access. Peripheral intravenous catheter placement is the most common invasive procedure performed in critical care areas, with data collected showing over one billion of these procedures being performed annually worldwide. Studies suggest that up to one third of these patients have difficult intravenous access. Patients with difficult intravenous access have decreased care and delays to treatment. This retrospective, comparative study seeks to determine if the evidence supports the hypothesis that ultrasound guided peripheral intravenous catheters placed by nursing improves care.

Keywords: peripheral intravenous catheter, ultrasound guided, difficult intravenous access, critical care, emergency department

Nurse Driven Ultrasound Guided Intravenous Access

Peripheral intravenous catheters (PIV) are defined by Beecham & Tackling (2021) as “indwelling single-lumen plastic conduits that allow fluids, medications and other therapies such as blood products to be introduced directly into a peripheral vein.” Conventional techniques of placement involve palpation, anatomic, and landmark locating by experienced healthcare providers. These devices are essential invasive devices used in emergency departments and critical care areas.

Beecham & Tackling (2021) state that “Placement of peripheral lines is the most commonly performed invasive procedure in acute healthcare settings with more than 1 billion lines being used annually worldwide.” A major drawback to PIV placement by the conventional techniques is within the patient population who have difficult intravenous access (DIVA). These patients experience significant decreases in quality of care based upon a number of Emergency Department metrics. Bedside ultrasound is an available resource to physicians in the emergency department and has been shown to be a valuable assistive technique when placing PIV, in particular in the DIVA population. There are a number of studies that support this paper’s hypothesis that nurse driven ultrasound guided PIV (USGPIV) is a valuable resource in critical care areas and improves patient care.

Background and Significance

In the acute care setting, studies have shown that many patients can be categorized as having difficult intravenous access (DIVA). Blanco (2019) suggests that up to one third of critically ill patients have DIVA. Davis, et al (2021) states that “We categorized patients as having DIVA if they required ≥3 PIV attempts or an USGPIV.” It has become common practice to have bedside ultrasound available in the emergency department for use by physicians for procedures such as left ventricular function and Focused Assessment Sonography in Trauma (FAST) exams. There are studies that suggest that ultrasound guided IV placement can decrease peripheral IV attempts in patients with DIVA. Using inclusion criteria of all patients between the ages of 18 and 70 years of age fitting previously defined criteria of DIVA, nurses utilizing ultrasound guided IV placement can decrease peripheral IV attempts. These decreased PIV attempts lead to higher quality care as medications, labs, and imaging tests are not postponed due to the PIV delay.

The population under review with this study is patients who have difficult intravenous access. Classifying patients with DIVA has been done in multiple studies concerning this issue. The typical definition or inclusion criteria has depended upon the study. Retrospective studies typically classify patients with DIVA as those who either required multiple PIV attempts or who required an USGPIV. Prospective studies have included patients who either have been randomized or who the provider (either RN or MD) has assessed using typical PIV methods or patient medical history and classified them as DIVA.

Physician performed bedside ultrasound is common practice for physicians but as the technology becomes more familiar to all critical care providers it is becoming a more common practice to have specialty trained nurses performing bedside ultrasound procedures, including PIV placement. A number of studies have shown improvements in care when nurses are trained in USGPIV. Studies have shown a number of improvements in patient care because of nurse driven USGPIV. In particular, critical care nurses who regularly place PIV using conventional techniques have the experience and knowledge to benefit from this training. This paper makes the suggestion that all Emergency Department nurses should have access to training in USGPIV. Large academic institutions commonly have around the clock access to an intravenous access team who are trained in USGPIV, among other advanced catheter placement techniques. Community hospitals and non-Level I trauma centers likely do not have this around the clock access to specialized teams like an IV Access Team. Because of this, the emergency department nurses are commonly considered “master” of PIV access. The emergency departments within these smaller hospitals certainly have access to bedside ultrasound devices and with additional training provided to the nurses, USGPIV has shown to be safe and will improve care.

Synthesis

USGPIV vs Conventional PIV placement

Previous studies show that USGPIV is an acceptable alternative to standard PIV and central line placement in the acute care setting. A prospective, randomized evaluation completed by Bahl, et al in 2019 of two treatments, standard long catheter vs extended dwell catheter, had supporting evidence showing safety and applicability of USGPIV. This study prospectively looked at 120 participants to determine safety and applicability of USGPIV and extended dwell catheters and found extended dwell USGPIV catheters have significantly improved survival rates with similar insertion success characteristics. Further studies, including a prospective observational study completed by Blanco in 2019 provided evidence that supports that ultrasound guided PIV is a viable alternative to both standard peripheral intravenous catheter placement and central line placement. Important considerations with catheter placement are infection and failure rate. Central line placement is the common procedure for critically ill patients, in particular those with DIVA. This is a sterile, surgical procedure done at bedside with significant risk of infection and bleeding. USGPIV placement does not suffer as severely from those central line complications and risks. In addition, Blanco found that despite high premature failure rate, USGPIV is an effective alternative to central line placement.

A key finding in the Blanco study is the failure of USGPIV within 26 hours of placement. Although this seems to be a short time period until failure, with critically ill patients it offers a great improvement in care. As mentioned previously, this study is arguing that nurse driven USGPIV improves care in particular in settings like community hospitals without 24 hour access to IV Access Teams. The 26 hour failure window allows timely placement of a peripheral line that can be used to stabilize a patient until advanced IV teams are available or a physician is able to dedicate the time to a sterile procedure such as central line placement.

Physician vs Nurse inserted USGPIV

Evidence supports the use of USGPIV and further studies show a significant improvement in patient care can be achieved in the patient population of DIVA. Davis et al conducted a large, retrospective, comparative study that looked at electronic medical record data of patients requiring PIV access at a tertiary medical center. This study used data collected over 3 years, 2015-2017. Of the 147,260 patients reviewed, 13,192 met DIVA criteria. The study then compared metrics from EMR of these 13,192 patients. Davis et al (2021) state that “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).” In addition to the finding that patient’s with DIVA see decreased quality of care, they found that patients with DIVA who underwent nurse placement of USGPIV saw significant improvements in the previously mentioned ED metrics as compared to physician inserted USGPIV. As Davis, et al (2021) state, “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).” Sou et al conducted an inception cohort study that looked at nurse driven USGPIV. They found supporting evidence for nurse placement of USGPIV. Sou et al (2017) state that “The use of ultrasound guidance for peripheral intravenous catheter insertion by the after-hours clinical support team for patients with difficult venous access has been successful at our institution with 9 out of every 10 catheters inserted at first attempt with significantly lower recorded pain scores.”

Recommendations

Research has shown that nurses in the emergency department are uniquely qualified and experienced at identifying patients with DIVA. Studies have also described nurses as “masters” of placing peripheral intravenous catheters and certainly Emergency Department nurses have the most experience in placing peripheral intravenous catheters. The current research reviewed supports this studies recommendation that nurse driven USGPIV placement is safe and effective and improves patient care.
A nursing implication considered in this research is the effect DIVA has on nursing staff.

A combined retrospective and prospective cohort study conducted by Whalen et al in 2018 suggested that DIVA of critical patients has a negative impact on ED staff and resources but that by using a designated DIVA team hospitals can potentially reduce resource utilization and improve patient safety. As mentioned previously, smaller institutions do not have access to 24 hour DIVA teams and so ED RNs should be offered training in USGPIV placement. In effect, the Emergency Department staff would be considered the IV Access Team since the Emergency Department is an around the clock department. By providing this training, emergency departments can improve patient care, improve staff well-being, and decrease resource utilization.

In conclusion, this study looked at patients meeting criteria for difficult intravenous access, a unique patient population within critical care. There is strong evidence that shows these patients experience significant delays to care. The recommended solution to improve care for these patients is training to be provided for emergency department nurses in ultrasound guided peripheral intravenous catheter placement. Studies have compared nurse driven USGPIV placement compared to physician placed USGPIV and the evidence supports this nurse driven procedure. USGPIV is also an improvement in care, as supported by evidence, compared to central line placement or multiple PIV attempts. Although larger level one trauma centers may have access to IV access teams around the clock, smaller community hospitals do not have this luxury. Emergency Department nurses trained in USGPIV can bridge the gap and utilize all available techniques and best evidence based procedures for difficult intravenous access placement to improve quality of care for this patient population.

References

  • Bahl, A., Hang, B., Brackney, A., Joseph, S., Karabon, P., Mohammad, A., Nnanabu, I., & Shotkin, P. (2019). Standard long IV catheters versus extended dwell catheters: A randomized comparison of ultrasound-guided catheter survival. The American journal of emergency medicine, 37(4), 715–721. https://doi.org/10.1016/j.ajem.2018.07.031 
  • Beecham, G.B., Tackling, G. (2021, August 15). Peripheral Line Placement. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK539795/ 
  • Blanco P. (2019). Ultrasound-guided peripheral venous cannulation in critically ill patients: a practical guideline. The ultrasound journal, 11(1), 27. https://doi.org/10.1186/s13089-019-0144-5 
  • Davis, E. M., Feinsmith, S., Amick, A. E., Sell, J., McDonald, V., Trinquero, P., Moore, A., Gappmaier, V., Colton, K., Cunningham, A., Ford, W., Feinglass, J., & Barsuk, J. H. (2021). Difficult intravenous access in the emergency department: Performance and impact of ultrasound-guided IV insertion performed by nurses. The American journal of emergency medicine, 46, 539–544. https://doi.org/10.1016/j.ajem.2020.11.013 
  • Presley, B., Isenberg, JD. (2021, July 31). Ultrasound Guided Intravenous Access. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK525988/ 
  • Sou, V., McManus, C., Mifflin, N., Frost, S. A., Ale, J., & Alexandrou, E. (2017). A clinical pathway for the management of difficult venous access. BMC nursing, 16, 64. https://doi.org/10.1186/s12912-017-0261-z 
  • Whalen, M., Maliszewski, B., Sheinfeld, R., Gardner, H., & Baptiste, D. (2018). Outcomes of an Innovative Evidence-Based Practice Project: Building a Difficult- Access Team in the Emergency Department. Journal of Emergency Nursing, 44(5), 478-482. https://doi.org/10.1016/j.jen.2018.03.011