335 Procedural Competency in Ultrasound-Guided Peripheral Intravenous Catheter Insertion in a Pediatric Emergency Department

Abstract

To evaluate if there is a threshold number of encounters after which providers reliably perform ultrasound guided peripheral intravenous (USGPIV) catheter placements in children with a high success rate. A secondary aim was to analyze complication rates of USGPIV catheters placed by providers. As part of a quality improvement program, a database was maintained for all USGPIV encounters in our emergency department (ED) from June 2011 to May 2017. Our ED is located within a free-standing tertiary care children’s hospital and sees over 90,000 children annually. The name of the ED practitioner attempting placement and whether it was successful was recorded for all USGPIV encounters. Patient electronic medical records were reviewed for the reason for IV removal. ED practitioners included attending physicians, pediatric emergency medicine (EM) fellows, nurses, and pediatric and EM residents. All USGPIVs were placed by a single-operator using dynamic ultrasound guidance in an out-of plane approach. The probability of successful IV placement at each encounter was calculated using Microsoft Excel (2008). These probabilities were plotted versus encounter number to graph a best-fit logarithmic regression. Using this regression equation, the number of encounters needed to achieve a probability of success of 90% was calculated. The probability of a complication after each successful USGPIV placement was also calculated, plotted versus encounter number, and overlayed with a logarithmic regression line. We analyzed 3,047 encounters involving 88 providers. Of those, 2,860 (94%) were successful and 187 (6%) were unsuccessful. 35 providers had 10 or more encounters. The probability of successfully placing an USGPIV increased as providers had more experience placing USGPIVs (Figure 1). After 2 encounters, the probability of success was 80%. After 10 encounters, the probability of success reached 88%. At 14 encounters, the probability of success was 90%. IV removal reason was available for 1,178 encounters. 850 (72%) were removed because they were no longer needed. 260 (22%) had complications, and 68 (6%) were unintentionally dislodged. Complications included infiltration, phlebitis, line occlusion, and “other” (eg, pain or bleeding at site). Complication rates were calculated and graphed for 31 providers who had at least 5 encounters. There was no statistically significant relationship between the number of encounters per provider and complication rates (R2 =0.015). Our data suggests a threshold number of encounters after which providers reliably place USGPIVs in children with a high success rate. In our single institution study, a 90% success rate was achieved after an average of 14 encounters. Additionally, we found an overall low complication rate of 22%, and no change in complication rates as providers gained more experience.