Ultrasound-guided Peripheral Intravenous Research Articles

Development of a Cost-Effective and High-Fidelity Gel Model for Peripheral Ultrasound-Guided Intravenous Access Training.

Introduction Simulation tools are crucial in medical educationbut current commercial models for ultrasound-guided intravenous (IV) access lack complexity and can be prohibitively expensive. This article proposes a cost-effective gel model system that replicates realistic vein and artery interactions, addressing the limitations of traditional models. An advanced gelatin model was constructed that incorporates intricate vein and artery configurations and enhances medical training by providing a more authentic experience. Patient testing will further validate its efficacy, promising improved accessibility for skill refinement in resource-constrained environments. Methods In a controlled study at theKirk Kerkorian School of Medicine at the University of Nevada, Las Vegas, 12 medical students with limited ultrasound experience participated in a workshop using novel and Blue Phantom™ models for ultrasound-guided IV catheter placement. The advanced gelatin model, created with Ziplock™ Tupperware®, ultrasonography gel-filled balloons, and gelatin, proved more effective, as assessed by participants' post-training comfort levels. The comparison of participants' pre- and post-training comfort levels with the models was the primary study objective. Participants were asked to complete a confidence survey based on a five-point Likert scale, and after using both models, this survey was re-administered to assess the participant's level of comfort after model use. The statistical analysis comparison of post-training survey data to the pre-training survey data was accomplished using SPSS version 29 (IBM Corp, Armonk, NY), where a paired t-test was set at a significance threshold of p <0.05. Results Analysis of data from both commercially made and advanced ultrasound-guided IV models using a paired t-test revealed a significant advantage for the advanced model. Participants, despite limited ultrasound experience, reported feeling over 4 points higher in skill confidence (p = 0.004) with the advanced model. Its popularity stems from diverse vasculature modeling, proving effective for both experienced practitioners and inexperienced individuals, maintaining value as user skill levels increase. Conclusion This study proposes an advanced model for ultrasound-guided peripheral IV access training, demonstrating a statistically significant increase in confidence levels. Despite limitations such as small sample size and single-site participation, the advanced model's adaptability and cost-effectiveness make it a strong contender for replacing current commercial models, potentially enhancing proficiency and confidence while reducing costs.

Ultrasound-Guided Peripheral Intravenous Access Training: A Prospective Observational Study of Emergency Nurses.

Background Ultrasound-guided peripheral intravenous (USGPIV) placement is more successful, comfortable, and longer lasting than traditional landmark-based IVs. While many hospitals have protocols for becoming credentialed in this skill, there is little information available about the USGPIV success rate during and after training. Objectives This pilot study aimed to quantify USGPIV attempts by emergency nurses undergoing USGPIV training and to determine if 10 successful USGPIVs predicted success in the next USGPIV. The secondary aims were to determine failure points for unsuccessful USGPIVs and the time to complete training. Methods Sixteen emergency nurses with no prior USGPIV experience were enrolled. Participants completed a one-hour didactic session and one hour of hands-on training with vein simulators. Participants had direct observation of all USGPIV attempts up until 10 successful cannulations. Each attempt was recorded along with reasons for USGPIV attempt failure and the time required to become credentialed. Results Participants attempted 200 USGPIVs with a success rate of 80% (160/200). Fourteen participants completed 10 successful USGPIVs, requiring a median of 11 attempts (IQR 10-13) and a success rate of 92.9% (13/14) on subsequent USGPIV attempts. Participants required a median observation time of 4.13 hours (IQR: 3.94-4.75). The most common point of failure was using dynamic ultrasound guidance to maintain needle tip visualization. Conclusions USGPIVs are a valuable skill that requires time and practice. Emergency nurses with no prior USGPIV experience can achieve the requirements for hospital credentialing and success on subsequent USGPIV insertion by completing 10 successful USGPIVs after a two-hour training session and four hours of direct observation.

A52Probing for Veins: A Cost-Effective, Reproducible Method for Teaching Ultrasound-Guided Peripheral Intravenous Access

Repeated attempts at peripheral intravenous (PIV) access cause increased discomfort and delays in treatment for patients in hospital. The use of ultrasound can improve success in PIV access, benefitting patient experience. Medical professionals are increasingly expected to use ultrasound when landmark techniques fail [1]. We sought to improve confidence using ultrasound for PIV cannulation with low-cost simulation models made from ADAMgel [2] or tofu in multiple teaching sessions. We organized teaching sessions with multiple specialties at St Richard’s Hospital. A total of 48 members of staff have been taught over four sessions. Prior to the teaching session learners were asked to complete a survey identifying previous ultrasound experience and rating confidence using ultrasound for PIV access. The teaching session consisted of an introductory multimedia presentation with a video demonstration, then practical experience. Models consisted of water-filled balloons placed in ADAMgel (Aqueous Dietary Fibre Antifreeze Mix gel) or tofu to simulate human tissue and veins, Models used to deliver teaching sessions. After ADAMgel became available this has been used exclusively due to it being more reusable compared to the tofu modelsA: tofu model with ultrasound image underneath.B: ADAMgel model with ultrasound image underneath The initial survey identified only 29% of staff had previously used ultrasound for PIV access, and half of these (15% overall) had only used it once or twice a year. Using a five-point Likert scale, 74% of respondents rated their confidence in using ultrasound as one or two out of five. All respondents thought they would benefit from further teaching in PIV access. Feedback after teaching sessions was favourable, with 95% of respondents finding the session very useful and 95% also believing it would increase their use of ultrasound in clinical practice. After the session, more than half rated their confidence in ultrasound cannulation as four or five out of five. We have demonstrated that there is a desire from medical staff to increase their competency in ultrasound-guided PIV cannulation. Using low-cost, high-fidelity simulation models with a blended learning method, we can deliver teaching sessions to a large number of medical staff. We hope to continue this teaching in collaboration with our sister sites throughout Sussex to increase confidence with ultrasound-guided PIV cannulation in this region. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

Feasibility study of cumulative sum (CUSUM) analysis as a competency assessment tool for ultrasound-guided venous access procedures.

Typically, physician training programs use a self-reported case-log competency assessment that does not measure procedure success or objectively assess competency. Cumulative sum (CUSUM) analysis could provide objective assessments of competency and progress over the training period. Our study objective was to determine the feasibility of CUSUM analysis to assess competency of ultrasound-guided peripheral intravenous (USG-PIV) line placement in pediatric anesthesiology fellows. We applied a CUSUM analysis to assess competency in USG-PIV placement in three consecutive pediatric anesthesia fellowship classes. After a didactic and hands-on training session, fellows placed a USG-PIV line and self-reported the outcomes via a web-based application. Fellows were deemed competent if the CUSUM curve crossed two consecutive boundary lines from above. Twenty-nine fellows reported 1,388 USG-PIV attempts, with 74% success. Most fellows (26/29; 90%) achieved competency by the end of the fellowship. Two fellows identified in the mid-year CUSUM as not progressing towards competency achieved competency after targeted interventions. Fellows achieving competency (11/29 vs 25/29; odds ratio, 15; 95% confidence interval [CI], 1.98 to 113.56; P = 0.01) and attempts needed to achieve competency (19 vs 11; mean difference, 8.5; 95% CI, 3.3 to 13.7; P = 0.002) were significantly lower in younger patients and significantly higher in older patients. Our study showed that CUSUM can be used to assess competence in USG-PIV procedures performed by pediatric anesthesia fellows and to identify learners not progressing toward competency in procedural skills. Ultrasound-guided venous access required more attempts to achieve competency in younger patients.

Ultrasound-Guided Peripheral Intravenous Catheter Insertion Training Reduces Use of Midline Catheters in Hospitalized Patients With Difficult Intravenous Access.

Difficult intravenous (IV) access (DIVA) is a prevalent condition in the hospital setting and increases utilization of midline catheters (MCs) and peripherally inserted central catheters (PICCs). Ultrasound-guided peripheral intravenous (USGPIV) insertion is effective at establishing intravenous access in DIVA but remains understudied in the inpatient setting. We evaluated the effect of an USGPIV simulation-based mastery learning (SBML) curriculum for nurses on MC and PICC utilization for hospitalized patients. We performed a quasi-experimental observational study. We trained nurses across all inpatient units at a large tertiary care hospital. We queried the electronic medical record to compare PICC and MC utilization for patients with DIVA during 3 periods: before USGPIV SBML training (control), during pilot testing of the intervention, and during the SBML intervention. To account for variations in insertion practices over time, we performed an interrupted time series (ITS) analysis between 2 periods, the combined control and pilot periods and the intervention period. One hundred forty-eight nurses completed USGPIV SBML training. Midline catheters inserted monthly per 1000 patient-days for DIVA decreased significantly from 1.86 ± 0.51 (control) to 2.31 ± 0.28 (pilot) to 1.33 ± 0.51 (intervention; P = 0.001). The ITS analysis indicated a significant intervention effect (P < 0.001). Peripherally inserted central catheters inserted monthly per 1000 patient-days for DIVA also significantly decreased over the study periods; however, the ITS failed to show an intervention effect as PICC insertions were already decreasing during the control period. A hospital-wide USGPIV SBML curriculum for inpatient nurses was associated with a significant reduction in MCs inserted for DIVA.

Training Program for Ultrasound-Guided Intravenous Catheter Insertion.

Ultrasound guidance is now widely available in military treatment facilities and civilian hospitals alike, both in the USA and in forward-deployed military environments. Technical mastery of ultrasound-guided peripheral intravenous (USGPIV) catheter insertion can be easily achieved through a short training course. Mastery can be achieved even when trainees have a limited medical background before course attendance. An evidence-based practice project team sought to improve the knowledge, confidence, and skills in the placement of USGPIV catheters by clinicians at Naval Hospital Jacksonville. Completion of an USGPIV training program can equip healthcare providers with knowledge and confidence for placement of peripheral access necessary in critical situations such as those requiring medications or blood products. The project team conducted a literature review to evaluate the appropriateness of USGPIV training for the nurses and military medical technicians in this setting. The team developed and delivered a USGPIV training program based on adaptations from the literature. During the training period, knowledge and confidence scores were reported by each trainee to evaluate the perceptions of the quality of training. The number of attempted catheter placements and ultrasound utilization was recorded in the pre- and post-implementation periods to evaluate the project's effect on the delivery of patient care. Statistical analysis was conducted to evaluate project outcomes. In the pre-intervention period, none of the 252 intravenous catheters were placed with the USGPIV technique, compared to 50 of 267 in the post-intervention period. These results demonstrate an 18.7% increase in the USGPIV access approach by nursing staff. Mean knowledge scores significantly increased following the delivery of the training, 60% versus 80% in the pre- and post-training assessments, respectively (P < .001). Mean self-reported skill confidence scores also significantly improved (P < .001). Knowledge and self-reported confidence in USGPIV access improved for the trainees. Mean knowledge improved from 60% to 80%, while mean confidence scores increased from 2.74 to 3.79 for corpsman and from 3.0 to 3.88 for nurses. Utilization of the USGPIV technique increased by 18.7% in the post-intervention period. These results demonstrate that implementing this training program can improve knowledge, confidence, and use of ultrasound during the placement of PIV catheters.

Training the Trainers in Ultrasound-guided Access to Improve Peripheral Intravenous Catheter Placement among Children Presenting for Anesthesia.

We implemented an evidence-based difficult IV algorithm and ultrasound-guided PIV placement training for attending pediatric anesthesiologists at a tertiary academic pediatric institution. The algorithm outlined risk factors for difficult IV access, established a goal of 3 or fewer attempts, and recommended early ultrasound use after 1 unanticipated attempt and the first attempt for anticipated difficult IV. Group sessions, including instruction and simulated practice, preceded a period of individual training in the operating room using a punch card to monitor each trainee's progress while also serving to motivate continued engagement. We performed a cross-sectional analysis of consecutive cases from December 1, 2015, to September 30, 2019, comparing a 22-month baseline period (n = 12,581) with the training period (n = 6,725) and the following year (n = 6,557). Cases requiring more than 3 attempts decreased from 4.0% to 2.7% overall and from 10% to 6.2% among patients 24 months or less of age. The time required to establish PIV access was unchanged. Factors associated with increased attempts were identified. Implementing a difficult IV algorithm and training among attending pediatric anesthesiologists in ultrasound-guided PIV placement reduced attempts but not the time required to establish PIV access.

Ultrasound-guided peripheral intravenous access in chronic kidney disease patients.

Ultrasound-guided peripheral intravenous (USPIV) catheters are being placed in emergency department (ED) patients with increasing frequency. USPIV catheters have been shown to improve the success rates of cannulation. It is unknown what the long-term effect of USPIV placement will be on fistula creation in chronic kidney disease (CKD) patients considering these ultrasound-guided peripheral lines often target the same deeper vessels used for fistulas. This study aimed to survey whether emergency medicine programs place restrictions on USPIV placement in patients with CKD stages 3-5. This was a survey study encompassing all 110 emergency ultrasound fellowship directors in the United States at the time the survey was conducted. Data was collected on an anonymous and voluntary basis. The primary outcome was the number of programs with restrictions on USPIV placement in patients with CKD stage 3 or greater. Of the 56 programs that responded, 21% reported having policies limiting which patients were appropriate for USPIV. Despite this, only one program reported placing restrictions on USPIV in CKD stage 3 or greater (p < 0.0001). Emergency departments do not have or follow restrictions placed on USPIV placement in patients with CKD stage 3 or greater. The use of these veins in the ED may result in thrombosis as well as inflammation and permanent scarring which could negatively impact the ability to utilize those vessels for fistula creation. Future studies are needed to further characterize the impact of USPIV on fistula creation.

Using Ultrasound-guided PIV Insertion in the Pediatric Population to Decrease Insertion Attempts

Intravenous (IV) therapy using a peripheral IV (PIV) in children is a medical intervention frequently used in hospitals. Current evidence supports ultrasound-guided PIV placement in the adult patient population. The purpose of this study was to implement an evidence-based practice approach to determine if ultrasound-guided IV insertion decreased the number of attempts for successful cannulation and improved staff and patient satisfaction with the treatment in the pediatric inpatient population. Data collection was conducted in a pediatric medical surgical unit and pediatric intensive care unit (PICU). After the implementation of ultrasound-guided IV insertion, the average number of attempts necessary for successful insertion decreased from 2 to 1.37. Findings support the integration of ultrasound-guided IV insertion into the standard of care on pediatric medical surgical units and PICUs.

First-Attempt Success Rate of Ultrasound-Guided Peripheral IV Access using a Handheld Ultrasound Machine in a Simulation Model

Background: Although peripheral Intravenous (IV) cannulation is a routine procedure performed by nurses, IV access can be difficult to achieve, particularly in emergency patients who have critical illnesses. Ultrasound is used in this procedure to increase the success rate in novice practitioners. Objective: We aimed to determine the first-attempt success rate of ultrasound-guided peripheral IV (USGPIV) performed by emergency nurses in simulation model after having undergone training in the procedure. Materials and Methods: This was prospective descriptive study. The participants consisted of 61 emergency nurses at Srinagarind Hospital Emergency Department from January to April 2020. USGPIV cannulation training was provided by an emergency physician who is also a specialist in emergency ultrasound. After training, we calculated the number of attempts and time required to successfully complete USGPIV in a simulation model. Following this, participants responded to a questionnaire to evaluate their confidence in performing the procedure, as well as its feasibility and practical application. Data were analyzed using a Kolmogorov-Smirnov test, and p&lt;0.05 was considered to be significant. Results: Sixty-one emergency nurses were included. The first-attempt success rate of USGPIV was 85.25% (95% CI 0.761, 0.944), and the mean time required was 47.33+4.89 sec. (95% CI 37.547, 57.103). Fifty-nine participants (96.72%) completed the questionnaire. All items had a mean score of greater than 3 points, with confidence score being the highest. Conclusion: Emergency nurses with no previous experience with USGPIV were able to perform a simulated version of the procedure with a high first-attempt success rate after a short training session. Further studies should be conducted to evaluate nurses’ USGPIV competency in real patients. Keywords: Ultrasound, Peripheral IV cannulation, Emergency medicine, Emergency nurse

Medical Student Ultrasound-Guided Intravenous Catheter Education: A Randomized Controlled Trial of Overtraining in a Simulation-Based Mastery Learning Setting.

Simulation-based mastery learning (SBML) improves skill transfer to humans. However, limited data exist to support the practice of performing additional training attempts once mastery has been achieved. We explored whether implementing this concept in an SBML model improves skill transfer in ultrasound-guided peripheral intravenous (USGPIV) catheter placement from simulator to humans. Forty-eight first- and second-year medical students underwent SBML for USGPIV placement to mastery standards on a simulator once to achieve minimum passing standard based on a 19-item checklist. Next, they completed either 0, 4, or 8 additional mastery level simulated performances in nonconsecutive order before attempting USGPIV placement on a human. An unplanned post hoc retention phase occurred 6 months later where participants' USGPIV skills were reassessed on a second human volunteer using the same checklist. In this sample, the success rate among the 3 training cohorts did not improve as the number of additional training sessions increased (exact P = 0.60) and were comparable among the 3 cohorts (exact P = 0.82). The overall checklist performance was also comparable among the 3 cohorts (exact P = 0.57). In an unplanned (small) sample of returning participants, the USGPIV retention rate exceeded 80% for those originally assigned to 4 or 8 sessions, whereas the retention rate fell less than 50% for those originally assigned to control. Among these returning participants, the overall success rate was 58% on the initial assessment and was 68% on retention. In this sample of novices, we were unable to show that up to 8 additional mastery level performances of USGPIV placement on a simulator following SBML training improve skill transfer for both USGPIV placement success and total checklist performance.

Positive effects of ultrasound-guided peripheral IV insertion on pediatric sickle cell anemia/thalassemia patients receiving automated red cell exchange procedures or chronic transfusion therapy.

Peripheral vascular access and venipuncture are major causes of distress and anxiety for children and their parents. This is especially difficult for patients with hemoglobinopathies (thalassemia major and sickle cell disease) who require chronic blood transfusions. These patients require peripheral venous access for regular blood transfusions and (in the case of sickle cell disease) for automated red cell exchange procedures. Peripheral intravenous (PIV) catheters are much preferred to central venous lines as they carry far fewer risks. However, when patients experience multiple unsuccessful attempts to initiate a PIV, it can be traumatizing and cause anxiety for future visits. Establishing therapeutic trust and ensuring a smooth experience are of paramount importance for these chronic patients who require regular blood transfusions. The purpose of this study was to determine whether ultrasound-guided PIV insertion decreases PIV-associated pain and anxiety, and whether the number of attempts and amount of time spent accessing PIVs in children with difficult peripheral intravenous (DPIV) access is reduced. This was a pilot study with both retrospective and prospective components. Hemoglobinopathies are relatively rare in our population and our study cohort was small (N = 18). We identified four DPIV access patients. We recorded each time these patients had a PIV inserted as an encounter. We found that while there was a small amount of time gained by using ultrasound-guided PIV insertion, patient and parent satisfaction was significantly improved.

Survey of ultrasound-guided peripheral intravenous practices: a report of supply usage and variability between clinical roles and departments.

The purpose of this study was to investigate ultrasound-guided peripheral intravenous (UGPIV) supply usage practices by clinicians working in vascular access, in emergency departments (EDs), or in other roles. In 2019, a voluntary cross-sectional descriptive survey was conducted via SurveyMonkey. Data collected included demographics, practice-oriented information, procedural activities, and supplies used for UGPIV insertions. Frequency distributions and results of Fisher's exact test and one-way analysis of variance were reported using R v.3.5.2. A total of 26,649 surveys were distributed with a response rate of 5.5% (n = 1475). Forty-eight percent of respondents (n = 709) indicated that they worked in a vascular access role, 310 (21%) worked in an ED, and 455 (31%) categorized their role as other. Clinically meaningful differences existed in all variables for UGPIV procedures and supplies between departments (P < 0.0001) and in all care settings. Using an investigatorconstructed overall metric of supplies used, important differences were demonstrated between personnel supply use in vascular access roles and other roles (P < 0.0001) and personnel in EDs and other roles (P < 0.0001). Use of supplies for UGPIV insertions varies by department. The variability in supply usage for UGPIV insertions revealed by this survey suggests a need for clinical education on guideline application and evaluation of compliance with policies to promote standardization of supplies for UGPIV insertion.

Survey of Ultrasound-Guided Peripheral Intravenous Practices: A Report of Supply Usage and Variability Between Clinical Roles and Departments

HighlightsAbstractBackground: The purpose of this study was to investigate ultrasound-guided peripheral intravenous (UGPIV) supply usage practices by clinicians working in vascular access, in emergency departments (EDs), or in other roles.Methodology: In 2019, a voluntary cross-sectional descriptive survey was conducted via SurveyMonkey. Data collected included demographics, practice-oriented information, procedural activities, and supplies used for UGPIV insertions. Frequency distributions and results of Fisher’s exact test and one-way analysis of variance were reported using R v.3.5.2.Results: A total of 26,649 surveys were distributed with a response rate of 5.5% (n = 1475). Forty-eight percent of respondents (n = 709) indicated that they worked in a vascular access role, 310 (21%) worked in an ED, and 455 (31%) categorized their role as other. Clinically meaningful differences existed in all variables for UGPIV procedures and supplies between departments (P &amp;lt; 0.0001) and in all care settings. Using an investigator-constructed overall metric of supplies used, important differences were demonstrated between personnel supply use in vascular access roles and other roles (P &amp;lt; 0.0001) and personnel in EDs and other roles (P &amp;lt; 0.0001).Conclusions: Use of supplies for UGPIV insertions varies by department. The variability in supply usage for UGPIV insertions revealed by this survey suggests a need for clinical education on guideline application and evaluation of compliance with policies to promote standardization of supplies for UGPIV insertion.

The practical integration of a hybrid model of ultrasound-guided peripheral venous access in a large apheresis center.

Apheresis treatments require adequate venous access using peripheral intravenous (PIV) catheterization or central venous catheters (CVC). Ultrasound-guided PIV (USGPIV) can be used to decrease the need of CVC insertions for apheresis procedures. A hybrid model of USGPIV and standard of care (SOC) for PIV access was developed. Nurses performed USGPIV on all patients considered for PIV access if felt SOC PIV access was not possible. Information was collected regarding nurses' confidence with access, number of attempts required, site of access, complications, and need for CVC. In all, 226 PIV access attempts were made during a 2-month period. All apheresis procedure types were represented. A total 65% were accessed by SOC and 35% by USGPIV. USGPIV was successful on first try on 90% draw/inlet access and 87% successful on first try on return access. Access above the antecubital fossa was required in 31% of USGPIV for draw/inlet veins, and 22% of return veins. Nurses' confidence with accessing PIV was increased by USGPIV, based on 7-point Likert scale assessments. During the recording period, 2/226 (0.9%) apheresis procedures required a CVC. In a separate cohort of only hematopoietic progenitor cell collections, CVC insertion was required in 44/238 (18.5%) patients, in 7 months prior to adoption of USGPIV and 5/152 (3.3%) patients in 7 months following adoption of USGPIV. A hybrid model of using SOC and USGPIV for PIV access for apheresis procedures resulted in decreased need for CVC access, high levels of successful initial access attempts, and increased nursing confidence in PIV access.

Handheld Ultrasound: Overcoming the Challenge of Difficult Peripheral Intravenous Access in the Emergency Department.

The purpose of this study was to evaluate the performance of a handheld ultrasound device for difficult peripheral intravenous (PIV) access performed by nurses and paramedics in the emergency department (ED). This was a retrospective review at an academic medical center. Participants were ED nurses and paramedics with competence in ultrasound-guided PIV placement. Participants were asked to log their use of the handheld device when used on patients deemed to have "difficult" access and complete a questionnaire, which consisted of items related to the effectiveness and ease of use of the device. Data were collected over the course of 1 year. An electronic medical record review was performed to track the success rates and the occurrence of any associated complications throughout the hospital stay. Nurses and paramedics logged a total of 483 cases in which PIV access was attempted with the handheld ultrasound device. Ninety-two percent (95% confidence interval [CI], 89%-94%) of the ultrasound-guided PIV lines attempted were placed successfully. Eighty-four percent (95% CI, 80%-87%) of the lines were placed successfully on the first attempt. In most cases (396 of 483 [82%]), no complications associated with the PIV occurred. A total of 429 questionnaires were completed over the study period. Most of the operators (84%; 95% CI, 80%-87%) stated that the handheld device was adequate to perform ultrasound-guided PIV access. The handheld ultrasound device performed well in terms of usability and reliability for PIV access.

Contrast Extravasation as a Complication of Emergency Nurse-Performed Ultrasound-Guided Peripheral Intravenous Catheter Placement

IntroductionVascular 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. MethodsA 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. ResultsOne 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%). DiscussionUSGPIV placement by trained emergency nurses has higher rates of contrast extravasation than with standard landmark technique placement.

Ultrasound-Guided Peripheral Intravenous Catheters to Reduce Central Venous Catheter Use on the Inpatient Medical Ward

The traditional technique of placing a peripheral intravenous (IV) catheter is successful in most cases on inpatient wards. However, when the traditional method fails, a central venous catheter may be placed to maintain IV access. These catheters are associated with risks including central line-associated bloodstream infection. We evaluated the effectiveness and acceptability of an ultrasound-guided peripheral IV service to reduce the number of newly placed central venous catheters on an inpatient ward. Central venous catheters were counted daily on intervention and control wards using a standard protocol, and rates of newly placed catheters were compared using a Poisson regression model. Nurses were surveyed to assess acceptability and perceived benefit. We found a reduction in the rate of newly placed central venous catheters on the intervention unit compared with the control unit at 90 days: mean 0.47 versus 0.67 newly placed central venous catheters/day, but the difference was not significant (P = .08). Nurses were in favor of the ultrasound-guided IV service, with perceived benefit to their patients. Ultrasound-guided peripheral IV might reduce unnecessary central venous catheters on general inpatient wards. A portable ultrasound used for this purpose was found to be acceptable by nursing staff.

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

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.

Development and Implementation of an Ultrasound-Guided Peripheral Intravenous Catheter Program for Emergency Nurses

ProblemEmergency medical care often necessitates placement of peripheral intravenous (PIV) catheters. When traditional methods for obtaining PIV access are not successful, ultrasound guidance is a rescue technique for peripheral vascular placement that improves the quality of patient care. MethodsThe aim of this training program was to develop a process where emergency nurses would be competent to perform ultrasound guided PIV to improve the quality of patient care delivered while reducing throughput time. Administrative program development required creating a nursing practice statement, procedure guideline, operational plan, and competency validation. A training program comprising both didactic and hands-on training was developed and provided by emergency medicine physicians with formal ultrasound fellowship training. ResultsIn determining whether the training program was adequate in preparing the student to place an ultrasound-guided PIV, 92.9% of students “agreed” or “strongly agreed.” In having confidence in their ability to obtain an ultrasound guided PIV catheter placement, 35.7% of respondents “agreed” and 64.3% “strongly agreed.” In finding it difficult to be successful in achieving ultrasound guided PIV catheter placement, 71.4% of students “strongly disagreed” and 14.3% “disagreed.” All students (100%) felt it was a feasible task to train nurses to successfully place ultrasound-guided PIV catheters and 71.4% of students strongly support continuing to provide this training program and competency validation. DiscussionEstablishment of an effective didactic and hands-on training program resulted in emergency department nurses becoming competent in placement of ultrasound guided PIV catheters to provide optimal patient care.Image 1