Implementation of an Ultrasound-Guided Peripheral Vascular Access Device Insertion Program

Kevin Arnold, DNP, MSN, BBA, BS, BSN, RN November 4th, 2018 9:00AM Conflict of Interests Disclosure

• No conflict of interest exists Introduction

• Ultrasound guidance for peripheral vascular access device insertion has been shown to benefit many stakeholders. While barriers exist to implementing this practice, six themes in the literature surface aiding efforts to advance these programs. In this presentation, we will discuss these major themes, current evidence, and the process for setting up a training program. Background of the Problem

• History-Present • The challenges with inserting PIVs have been abundant for decades.1 • Difficulty in access is present. 2 Repetitive attempts, declining patient satisfaction, and a reduction in productivity. 3 • Advanced skill with typically limited use • Benefits demonstrated Exploring Themes in the Literature

• Success of Use (SU) • success deltas • nurse driven & other disciplines • training methods • Patient Benefits (PB) • difficult stick patients • yield on demand for central venous catheters • patient satisfaction SU: Success Deltas

• Quantifying the delta of improvement can add tangible value that may be associated with patient outcomes and traditional staff nursing demands. SU: Success Deltas Helpful Articles: 4 Adhikari, Blaivas, Morrison, and Lander Comparison of infection rates among ultrasound-guided versus traditionally placed 2010 peripheral intravenous lines. 5 Edwards and Jones Development and Implementation of an Ultrasound-Guided Peripheral Intravenous 2018 Catheter Program for Emergency Nurses. Feinsmith, Huebinger, Pitts, Baran, and Outcomes of a Simplified Ultrasound-Guided Intravenous Training Course for 2018 6 Haas Emergency Nurses. 2 Gosselin, Lapre, Lavoie, and Rhein Cost Effectiveness of Introducing A Nursing-Based Programme of Ultrasound Guided 2017 Peripheral Venous Access in A Regional Teaching Hospital.

7 Kantor, Su, Milliren, and Conlon Ultrasound-guidance and Other Determinants of Successful Peripheral Artery 2016 Catheterization in Critically Ill Children. 8 Moore An emergency department nurse-driven ultrasound-guided peripheral intravenous 2013 line program. 9 Scoppettuolo et al. Ultrasound-Guided 'Short' Midline Catheters for Difficult Venous Access in the 2016 Emergency Department: A Retrospective Analysis. 10 Seto et al. Real-Time Ultrasound Guidance Facilitates Transradial Access: RAUST (Radial 2015 Artery Access With Ultrasound Trial). 11 Tan, et al. Cost-Effectiveness Analysis of Ultrasound-Guided Seldinger Peripherally Inserted 2016 Central Catheters. SU: Success Deltas Insertion success:

12 • 2.17  1.31 Vitto M., Myers, Vitto C., and Evans (2016) 3 • 1.15 Duran-Gehring et al. (2016) 13 • 1.4 Dargin, Rebholz, Lowenstein, Mitchell, and Feldman (2010) 14 • 1.37 Keyes, Frazee, Snoey, Simon, and Christy (1999) 15 • 1.5 Rose and Norbutas (2008) 16 • 1.35 Schoenfeld, Boniface and Shokoohi (2011) 8 • 1.22 Moore (2013) 17 • 1.3 Moore (2014) 1 • 1.25 Brannam, Blaivas, Lyon, and Flake (2006) 18 • 3.3  1.6 Bauman, Braude, and Crandall (2009) 19 • 1.4 Au, Rotte, Grzybowski, Ku, and Fields (2012) • 1.57 Scoppettuolo et al. (2016) 9 • 6.9  3.1 (Peripheral arterial line) Kantor, Su, Milliren, and Conlon (2016) 7 • 3.4  1.65 (Transradial cardiac catherization) Seto et al. (2015) 10 SU: Success Deltas

Infection Prevention: • 7.8  5.2 Adhikari, Blaivas, Morrison, and Lander (2010) 4

Time to Completion: • 74.8 min  26.8 Bauman, Braude, and Crandall (2009) 18 • 108 sec to 88 sec (Transradial cardiac catherization) Seto et al. (2015) 10 • 8.8 min to 8.1 min (Peripheral art line) Kantor, Su, Milliren, and Conlon (2016) 7

Cost Effectiveness: • 59.18%  89.29% Tan et al. (2016) 11 • 37 Article review: few attempts Weiner, Geldard, and Mittnacht (2013) 20 SU: Success Deltas

Influenced outcomes: • operator skill level • previous experience

Common findings of ultrasound guidance: • Improved success rate • Improved first attempt success • Fewer attempts and complications • Reduction in time to completion • Reduction in infection rates SU: Nurse Driven vs. Other Disciplines Helpful Articles: 18 Bauman, Braude, and Crandall (2009) "Ultrasound-guidance vs. standard technique in difficult vascular access 2009 patients by ED technicians." McKay and Weerasinghe (2018) created an "Can we successfully teach novice junior doctors basic interventional 2018 21 article called ultrasound in a single focused training session?"

22 Olivira and Lawrence (2016) "Ultrasound-guided peripheral intravenous access program for emergency 2016 physicians, nurses, and corpsmen (technicians) at a military hospital." Reusz and Csomos (2015) created an article "The Role of Ultrasound-Guidance for Vascular Access." 2015 23 called 24 Shoenfeld, Shokoohi, Boniface (2011) "Ultrasound-guided peripheral intravenous access in the emergency 2011 department: Patient-centered survey." SU: Nurse Driven vs. Other Disciplines

RN: • Ample studies, high cofounding variables, variety of endpoints, use of mean (average)  LVN: • Additional studies needed. MD (Residents): • Ample studies, veeeeerrrry brief training models. • 99% learned with 73% competency. 21 ED Technicians: • Success 97.5%, first attempt 86.8%, mean 1.15. 3 • Higher complication rate and arterial puncture. 16 • Additional studies needed. SU: Nurse Driven vs. Other Disciplines

Influenced outcomes: • Training program • User setting: RN, MD, Tech

Common findings: • PIVs, Midlines, PICCs, Peripheral art lines, Transradial cardiac catherization SU: Training Methods Helpful Articles: 25 Baddoo, Djagbletey, and Owoo "A Simple Tissue Model for Practicing Ultrasound Guided Vascular Cannulation." 2014

26 Erickson et al. "Ultrasound-Guided Small Vessel Cannulation: Long-Axis Approach is Equivalent to Short- 2014 Axis in Novice Sonographers Experienced with Landmark-Based Cannulation."

Gottlieb, Sundaram, Holladay, and "Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of 2017 27 Nakitende Evidence-Based Best Practices." 28 Griffiths et al. "A Randomised Crossover Study to Compare the Cross-Sectional and Longitudinal 2017 Approaches to Ultrasound-Guided Peripheral Venepuncture in a Model."

Jaffer, Normahani, Singh, Aslam, "Randomized Study of Teaching Ultrasound-Guided Vascular Cannulation Using a 2015 29 and Standfield Phantom and the Freehand Versus Needle Guide–Assisted Puncture Techniques."

17 Moore "Ultrasound First, Second, and Last for Vascular Access." 2014 30 Primdahl et al. "Validation of the peripheral ultrasound-guided vascular access rating scale." 2018 31 Rice et al. "An Assessment Tool for the Placement of Ultrasound-Guided Peripheral Intravenous 2016 Access." 32 Rippey, Blanco, and Carr "An Affordable and Easily Constructed Model for Training in Ultrasound-Guided Vascular 2015 Access." 33 Thomas and Moore "The Vanishing Target Sign: Confirmation of Intraluminal Needle Position for Ultrasound 2013 Guided Vascular Access." 34 White, Lopez, and Stone Developing and Sustaining an Ultrasound-Guided Peripheral Intravenous Access Program 2010 for Emergency Nurses SU: Training Methods

Didactic: • Components - physics, equipment, scanning, and procedure 34 • Note worthy - “The Vanishing Target Sign” by Tomas and Moore 33

Simulation: • Simple tissue pork belly and a longitudinal shaped balloon 25 • Common practice gel blocks • High-fidelity simulator 32 SU: Training Methods

Cross-sectional vs. Longitudinal: • Better results with cross-sectional 28 • Long-axis attempts were 32% faster than short-axis attempts 26 • Inconclusive which is best

Freehand vs. Need guide: • Lower rate of posterior-wall punctures and fewer skin punctures 29 • Additional studies needed SU: Training Methods

Influenced outcomes: • Hours of class/training • Setting • End user (RN, MD, etc.)

Common findings: • Yielded better outcomes: user of simulation, longer training program, mentorship PB: Difficult Stick Patients Helpful Articles:

1 "Emergency nurses’ utilization of ultrasound-guidance for placement of Brannam, Blaivas, Lyon, and Flake 2004 peripheral intravenous lines in difficult-access patients."

3 "Ultrasound-guided peripheral intravenous catheter training results in physician- Duran-Gehring et al. 2016 level success for emergency department technicians."

L. Stolz, U. Stolz, Howe, Farrell, and "Ultrasound-Guided Peripheral Venous Access: A Meta-analysis and Systemic 35 2015 Adhikari Review."

36 Sou et al. "A clinical pathway for the management of difficult venous access." 2017

Vezzani, Manca, Vercelli, Braghieri, and "Ultrasonography as a Guide During Vascular Access Procedures and in the 37 2013 Magnacavallo Diagnosis of Complications."

12 "Perceived difficulty and success rate of standard versus ultrasound-guided Vitto, M., Myers, M., Vitto, C. and Evans 2016 peripheral intravenous cannulation in a novice study group."

"Single-operator ultrasound-guided intravenous line placement by emergency 38 Weiner, S. et al. nurses reduces the need for physician intervention in patients with difficult-to- 2013 establish intravenous access." PB: Difficult Stick Patients

Costs Savings: • Reduction in hospitalization time and time to treatment 2 • Reduction in need for physician intervention 38 Success: • Many studies support successful outcomes in defined population of patients with difficult vascular access. • Lowered first stick success for after hours support team 36 PB: Difficult Stick Patients

Common findings: • Clinicians should make every attempt to acquire the skills allowing them to better support their patient with difficult venous access. PB: Yield on Demand for CVCs Helpful Articles: Au, Rotte, Grzybowski, Ku, and "Decrease in central venous catheter placement due to use of ultrasound-guidance for 2012 19 Fields peripheral intravenous catheters."

39 Cappa et al. "Effect of Ultrasound-Guided Peripheral Intravenous 2015 Catheter Placement by Nurses and Paramedics on Central Line Placement in the Emergency Department."

40 Galen and Southern "Ultrasound-Guided Peripheral Intravenous Catheters to Reduce Central Venous Catheter 2018 Use on the Inpatient Medical Ward."

Gregg, Murthi, Sisley, Stein, and "Ultrasound-guided peripheral intravenous access in the intensive care unit." 2010 41 Scalea Ozakin, Can, Acar, Kaya, and "An Evaluation of Complications in Ultrasound-Guided Central Venous Catheter Insertion 2016 42 Cevik in the Emergency Department."

Morata, Ogilvie, Yon, and "Decreasing peripherally inserted central catheter use with ultrasound-guided peripheral 2017 43 Johnson intravenous lines."

44 Shokoohi et al. "Ultrasound-guided peripheral intravenous access program is associated with a marked 2013 reduction in central venous catheter use in noncritically ill emergency department patients." PB: Yield on Demand for CVCs

Decrease in demand for CVCs: • 80% reduction 44 • 85% reduction 19 • 30% reduction 39 • 46.7% reduction 43 • Avoided 34 CVCs (n=148) 41 • 40 discontinued 41 • Avoided 386 CVCs (n=830) 3 • in ED difficult stick patients. PB: Patient Satisfaction Helpful Articles: Pandurangada, Tucker, Bagan, and "Patient satisfaction with nurse placed ultrasound guided peripheral IV." 2016 45 Bahl 46 Dwyer "Improving patient satisfaction by using ultrasound for IV insertion." 2016

24 Shoenfeld, Boniface, and Shokoohi "ED technicians can successfully place ultrasound-guided intravenous catheters in 2011 patients with poor vascular access." PB: Patient Satisfaction

Patient Satisfaction • 4.4  7.7 /10 Bauman, Braude, and Crandall 18 • 9.2 Schoenfeld, Shokoohi, and Boniface 16 • 8.0  10.0 Pandurangadu, Tucker, Bagan, and Bahl 45

Patients: • Higher level of satisfaction • Felt their clinicians listened to them when they stated their prior history of difficulty Advancing Scientific Knowledge

• Advancing scientific knowledge through theoretical foundations • Integration of theory and known literature • Integration of theory and known literature • Benner’s theory of skill of acquisition 47 • Nurses flow from novice to expert 48

Setting Up a Program

• Capital/Disposables • Models/Settings • Selecting pioneers • Class size • Mentoring • Establishing competency • Challenges Capital / Disposables

• Ultrasound machines • Under 10K options • Devices • PIVs / Midlines • One-handed preference • Probe covers: 12 in - 48 in • Other products • Sterile Gel Models/Settings

• PICC team • RN • PIV team • LVN • Super users among facility • ED Techs • Rapid Response • MDs • ED • Residents • IR Selecting Pioneers

✓ History of hand/eye coordination activities • Playing video games, musical instruments, etc. ✓ Scheduling for class and check-offs possible ✓ Strong desire to learn skill ✓ Good attitude in helping other nurses with skill • will make self available to others ✓ Good vision for viewing close objects ☺ Class Structure

• Instructor/Student Ratio: maximum of 1:4 • Lecture: 2 - 3 hrs • Simulation Practice: 1 -2 hrs • Typical day: 8am – noon Class 1pm – 4pm Check offs • Mentoring check-offs ASAP • > 2 weeks = poor retention of didactic Class Structure

Policy 49 Competency 49 Activity Log 49 Class PowerPoint 49

• Available for free download: Contact author at [email protected] Mentoring

• Timeframe: Mentoring check-offs ASAP • > 2 weeks = poor retention of didactic • 4 hour sessions • Location: • Emergency Department ideal location, PM hours • PIVs, blood draws, get their labs • Various other locations • Avoid requests for difficult sticks Establishing Competency

• Varying definitions • Proficiency learning curve expected: • 81% (training), 90% at 20 insertions • 20-30 sticks 17 • 20 to 25 more successful than 20 (PICC) 27 Establishing Competency

• Various methods of establishing competency • Checklist assessment 31 ✓ P-UGVA Rating Scale 30 • Novices, Intermediates, Experts • Excellent reliability (Cronbach’s alpha = 0.91) in ability to discriminate among levels Establishing Competency

• Primdahl et al. (2018) • P-UGVA Rating Scale 30 • Prep of utensils • Ergonomics • Prep of US device • ID of blood vessels • Anatomy Scoring table: Total • Hygiene 1 2 3 4 5 6 7 8 Score

• Coordination of needle

• Completion of procedure Total Score >29 qualifies nurse to progress to mentoring with live patient insertions. Establishing Competency

• Learning curve expected: • Arnold dissertation intervention group (n = 70)

Inserter Progression 1.25 1.238 1.2 1.2

1.15 Mean

1.1 1.117

1.05 1-10 11-25 26-50 Category Arnold Findings – Descriptive data

• Participant collected data sample • Intervention group: n = 70 • PIV difficult? yes (n = 42, 60.9%) • Able to obtain access? yes (n = 68, 97.1%) • First attempt? yes (n = 54, 77.1%) • Number# of Attempts of attemptsn = 70 Percentage

1 55 78.6

2 14 20.3

3 1 1.4 Arnold Findings – Descriptive data

• Participant collected data sample • Control group: n = 68 • PIV difficult? yes (n = 29, 43.5%) • Able to obtain access? yes (n = 46, 67.6%) • First attempt? yes (n = 21, 30.9%) • Number# of Attempts of attemptsn = 68 Percentage 1 20 29.4 2 13 19.1 3 12 17.6 4 16 23.5 5 5 7.4 7 2 2.9 Arnold Findings - Data analysis

• Mann Whitney U test; Uses grouped medians. Not mean. There was a statistically significant grouped median decrease in the intervention group (1.22) as compared to the control group (2.60). U = 950.000, z = -6.587, p < 0.001 Challenges

• Time to acquire skill / turnover • Manager support in scheduling • Attrition • Over train to compensate • Supplies / equipment • Make convenient Going Forward

• What is the recipe for success? • Review the literature • Policy/Competency • Teaching methods/Didactic • Gain management support • Change management • Mentorship • Celebrate success • Collect data Conclusions/Implications

• UGPIVs are feasible with proven advantages and should be routinely used in practice in various settings by a number of disciplines. • Reduction of insertion attempts may directly improve nursing practice and patient outcomes. • Reduction in procedure time to completion may reduce hospital costs and speed up patient time to therapy. • Fewer complications and Increase in patient satisfaction. • Reduction in need for central lines. • Practice improvement further supports: Benner’s theory, training validation tool by Primdahl. References

1. Brannam, L., Blaivas, M., Lyon, M., & Flake, M. (2004). Emergency nurses’ utilization of ultrasound-guidance for placement of peripheral intravenous lines in difficult-access patients. Academic Emergency Medicine, 11(12), 1361-1363. doi: 10.1197/j.aem.2004.08.027

2. Gosselin, É, Lapré, J., Lavoie, S., & Rhein, S. (2017). Cost-effectiveness of introducing a nursing-based programme of ultrasound-guided peripheral venous access in a regional teaching hospital. Journal of Nursing Management, 25(5), 339-345. doi:10.1111/jonm.12470

3. Duran-Gehring, P., Bryant, L., Reynolds, J. A., Aldridge, P., Kalynych, C. J., & Guirgis, F. W. (2016). Ultrasound-guided peripheral intravenous catheter training results in physician- level success for emergency department technicians. Journal of Ultrasound in Medicine, 35(11), 2343-2352. doi:10.7863/ultra.15.11059

4. Adhikari, S., Blaivas, M., Morrison, D., & Lander, L. (2010). Comparison of infection rates among ultrasound-guided versus traditionally placed peripheral intravenous lines. Journal of Ultrasound in Medicine, 29(5), 741-747. doi:10.7863/jum.2010.29.5.741

5. Edwards, C., & Jones, J. (2018). Development and implementation of an ultrasound-guided peripheral intravenous catheter program for emergency nurses. Journal of Emergency Nursing, 44(1), 33-36. doi:10.1016/j.jen.2017.07.009

6. Feinsmith, S., Huebinger, R., Pitts, M., Baran, E., & Haas, S. (2018). Outcomes of a simplified ultrasound-guided intravenous training course for emergency nurses. Journal of Emergency Nursing, 44(2), 169-175. doi:10.1016/j.jen.2017.10.001

7. Kantor, D. B., Su, E., Milliren, C. E., & Conlon, T. W. (2016). Ultrasound-guidance and other determinants of successful peripheral artery catheterization in critically ill children. Pediatric Critical Care Medicine, 17(12), 1124-1130. doi:10.1097/PCC.0000000000000936

8. Moore, C. (2013). An emergency department nurse-driven ultrasound-guided peripheral intravenous line program. Journal of the Association for Vascular Access, 18(1), 45-51. doi:10.1016/j.java.2012.12.001

9. Scoppettuolo, G., Pittiruti, M., Pitoni, S., Dolcetti, L., Emoli, A., Mitidieri, A., … Annetta, M. G. (2016). Ultrasound-guided “short” midline catheters for difficult venous access in the emergency department: A retrospective analysis. International Journal of Emergency Medicine, 9(3). doi:10.1186/s12245-016-0100-0

10. Seto, A. H., Roberts, J. S., Abu-Fadel, M. S., Czak, S. J., Latif, F., Jain, S. P., … Lasic, Z. (2015). Real-time ultrasound guidance facilitates transradial access: RAUST (Radial artery access with ultrasound trial). JACC: Cardiovascular Interventions, 8(2), 283-291. doi:10.1016/j.jcin.2014.05.036

11. Tan, J., Liu, L., Xie, J., Hu, L., Yang, Q., & Wang, H. (2016). Cost-effectiveness analysis of ultrasound-guided Seldinger peripherally inserted central catheters (PICC). Springer Plus, 5(1), 2051. doi:10.1186/s40064-016-3698-8

12. Vitto, M. J., Myers, M., Vitto, C. M., & Evans, D. P. (2016). Perceived difficulty and success rate of standard versus ultrasound-guided peripheral intravenous cannulation in a novice study group. Journal of Ultrasound in Medicine, 35(5), 895-898. doi:10.7863/ultra.15.06057

13. Dargin, J. M., Rebholz, C. M., Lowenstein, R. A., Mitchell, P. M., & Feldman, J. A. (2010). Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access. American Journal of Emergency Medicine, 28(1), 1-7. doi:10.1016/j.ajem.2008.09.001 References

14. Keyes, L. E., Frazee, B. W., Snoey, E. R., Simon, B. C., & Christy, D. (1999). Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Annals of Emergency Medicine, 34(6), 711-714. doi:10.1016/s0196-0644(99)70095-8

15. Rose, J. S., & Norbutas, C. M. (2008). A randomized controlled trial comparing one-operator versus two-operator technique in ultrasound-guided basilic vein cannulation. Journal of Emergency Medicine, 35(4), 431-435. doi:10.1016/j.jemermed.2007.11.009

16. Schoenfeld, E., Boniface, K., & Shokoohi, H. (2011a). ED technicians can successfully place ultrasound-guided intravenous catheters in patients with poor vascular access. American Journal of Emergency Medicine, 29(5), 496-501. doi:10.1016/j.ajem.2009.11.021

17. Moore, C. L. (2014). Ultrasound first, second, and last for vascular access. Journal of Ultrasound in Medicine, 33(7), 1135-1142. doi:10.7863/ultra.33.7.1135

18. Bauman, M., Braude, D., & Crandall, C. (2009). Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians. American Journal of Emergency Medicine, 27(2), 135-140. doi:10.1016/j.ajem.2008.02.005

19. Au, A. K., Rotte, M. J., Grzybowski, R. J., Ku, B. S., & Fields, J. M. (2012). Decrease in central venous catheter placement due to use of ultrasound-guidance for peripheral intravenous catheters. The American Journal of Emergency Medicine,30(9), 1950-1954. doi:10.1016/j.ajem.2012.04.016

20. Weiner, M. M., Geldard, P., & Mittnacht, A. J. (2013a). Ultrasound-guided vascular access: A comprehensive review. Journal of Cardiothoracic & Vascular Anesthesia, 27(2), 345-360. doi:10.1053/j.jvca.2012.07.007

21. McKay, G. F. M., & Weerasinghe, A. (2018). Can we successfully teach novice junior doctors basic interventional ultrasound in a single focused training session? Post Graduate Medical Journal, 94(1111), 259-262. doi:10.1136/postgradmedj-2018-135590

22. Oliveira, L., & Lawrence, M. (2016). Ultrasound-guided peripheral intravenous access program for emergency physicians, nurses, and corpsmen (technicians) at a military hospital. Military Medicine, 181(3), 272-276. doi:10.7205/MILMED-D-15-00056

23. Reusz, G., & Csomos, A. (2015). The role of ultrasound guidance for vascular access. Current Opinion in Anesthesiology, 28(6), 710-716. doi:10.1097/aco.0000000000000245

24. Schoenfeld, E., Shokoohi, H., & Boniface, K. (2011b). Ultrasound-guided peripheral intravenous access in the emergency department: Patient-centered survey. Western Journal of Emergency Medicine, 12(4), 475-477.

25. Baddoo, H., Djagbletey, R., & Owoo, C. (2014). A simple tissue model for practicing ultrasound guided vascular cannulation. Ghana Medical Journal, 48(1), 47-49. doi:10.4314/gmj.v48i1.8

26. Erickson, C. S., Liao, M. M., Haukoos, J. S., Douglass, E., DiGeronimo, M., Christensen, E., … Kendall, J. L. (2014). Ultrasound-guided small vessel cannulation: Long-axis approach is equivalent to short-axis in novice sonographers experienced with landmark-based cannulation. Western Journal of Emergency Medicine, 15(7), 824–830. doi:10.5811/westjem.2014.9.22404

27. Gottlieb, M., Sundaram, T., Holladay, D., & Nakitende, D. (2017). Ultrasound-guided peripheral intravenous line placement: A narrative review of evidence-based best practices. Western Journal of Emergency Medicine, 18(6), 1047-1054. doi:10.5811/westjem.2017.7.34610 References

28. Griffiths, J., Carnegie, A., Kendall, R., & Madan, R. (2017). A randomised crossover study to compare the cross-sectional and longitudinal approaches to ultrasound-guided peripheral venepuncture in a model. Critical Ultrasound Journal, 9(1), 9. doi:10.1186/s13089-017-0064-1

29. Jaffer, U., Normahani, P., Singh, P., Aslam, M., & Standfield, N. J. (2015), Randomized study of teaching ultrasound-guided vascular cannulation using a phantom and the freehand versus needle guide–assisted puncture techniques. Journal Clinical Ultrasound, 43, (8), 469-477. doi:10.1002/jcu.22263

30. Primdahl, S. C., Weile, J., Clemmesen, L., Madsen, K. R., Subhi, Y., Petersen, P., & Graumann, O. (2018). Validation of the peripheral ultrasound-guided vascular access rating scale. Medicine, 97(2), e9576. doi:10.1097/md.0000000000009576

31. Rice, J., Crichlow, A., Baker, M., Regan, L., Dodson, A., Hsieh, Y.H., & Omron, R. (2016). An assessment tool for the placement of ultrasound-guided peripheral intravenous access. Journal of Graduate Medical Education, 8(2), 202-207. doi:10.4300/JGME-D-15-00298.1

32. Rippey, J. C., Blanco, P., & Carr, P. J. (2015). An affordable and easily constructed model for training in ultrasound-guided vascular access. The Journal of Vascular Access, 16(5), 422- 427. doi:10.5301/jva.5000384

33. Thomas, S., & Moore, C. L. (2013). The vanishing target sign: Confirmation of intraluminal needle position for ultrasound guided vascular access. Academic Emergency Medicine, 20(10), e17-e18. doi:10.1111/acem.12228

34. White, A., Lopez, F., & Stone, P. (2010). Developing and sustaining an ultrasound-guided peripheral intravenous access program for emergency nurses. Advanced Emergency Nursing Journal, 32(2), 173-188. doi:10.1097/tme.0b013e3181dbca70

35. Stolz, L. A., Stolz, U., Howe, C., Farrell, I. J., & Adhikari, S. (2015). Ultrasound-guided peripheral venous access: A meta-analysis and systematic review. The Journal of Vascular Access, 16(4), 321-326. doi:10.5301/jva.5000346

36. 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). doi:10.1186/s12912-017-0261-z

37. Vezzani, A., Manca, T., Vercelli, A., Braghieri, A., & Magnacavallo, A. (2013). Ultrasonography as a guide during vascular access procedures and in the diagnosis of complications. Journal of Ultrasound, 16(4), 161–170. doi:10.1007/s40477-013-0046-5

38. Weiner, S. G., Sarff, A. R., Esener, D. E., Shroff, S. D., Budhram, G. R., Switkowski, K. M., & … Darvish, A. H. (2013b). Single-operator ultrasound-guided intravenous line placement by emergency nurses reduces the need for physician intervention in patients with difficult-to-establish intravenous access. Journal of Emergency Medicine, 44(3), 653-660. doi:10.1016/j.jemermed.2012.08.021

39. Cappa, A. R., Minckler, M. R., Wyatt, R. G., Binger, C.W., Stolz, U., Amini, R., ... Stolz, L. (2015). Research forum abstract: 291 effect of ultrasound-guided peripheral intravenous catheter placement by nurses and paramedics on central line placement in the emergency department. Annals of Emergency Medicine, 66(4 Supplement), S105. doi:10.1016/j.annemergmed.2015.07.325 References

40. Galen, B. T., & Southern, W. N. (2018). Ultrasound-guided peripheral intravenous catheters to reduce central venous catheter use on the inpatient medical ward. Quality Management in Health Care, 27(1), 30-32. doi:10.1097/qmh.0000000000000156

41. Gregg, S. C., Murthi, S. B., Sisley, A. C., Stein, D. M., & Scalea, T. M. (2010). Ultrasound-guided peripheral intravenous access in the intensive care unit. Journal of Critical Care, 25(3), 514. doi:10.1016/j.jcrc.2009.09.003

42. Ozakin, E., Can, R., Acar, N., Baloglu Kaya, F., & Cevik, A. A. (2014). An evaluation of complications in ultrasound-guided central venous catheter insertion in the emergency department. Turkish Journal of Emergency Medicine, 14(2), 53–58. doi:10.5505/1304.7361.2014.93275

43. Morata, L., Ogilvie, C., Yon, J., & Johnson, A. (2017). Decreasing peripherally inserted central catheter use with ultrasound-guided peripheral intravenous lines. JONA: The Journal of Nursing Administration, 47(6), 338-344. doi:10.1097/nna.0000000000000489

44. Shokoohi, H., Boniface, K., Mccarthy, M., Al-Tiae, T. K., Sattarian, M., Ding, R., … Yadav, K. (2013). Ultrasound-guided peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncritically ill emergency department patients. Annals of Emergency Medicine, 61(2), 198-203. doi:10.1016/j.annemergmed.2012.09.016

45. Pandurangadu, A. V., Tucker, J., Bagan, M., & Bahl, A. (2016). Patient satisfaction with nurse placed ultrasound guided peripheral IV. Emergency Medicine: Open Access, 6(3), 325. doi:10.4172/2165-7548.1000325

46. Dwyer, V. (2016). Improving patient satisfaction by using ultrasound for IV insertion. Journal of the Association for Vascular Access, 21(4), 252. doi:10.1016/j.java.2016.10.035

47. Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall.

48. McEwen, M., & Wills, E. M. (2014). Theoretical basis for nursing (4th ed.). Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins.

49. Arnold, K. (2011). Ultrasound guided peripheral IV insertion. Ivy League Nurse Retrieved from https://www.ivyleaguenurse.com/courses/Ultrasound_Guided_PIVs.pdf