Developing and Sustaining an Ultrasound-Guided Peripheral

LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

Advanced Emergency Nursing Journal Vol. 32, No. 2, pp. 173–188 Copyright c 2010 Wolters Kluwer Health Lippincott Williams & Wilkins ! |

Developing and Sustaining an Ultrasound-Guided Peripheral Intravenous Access Program for Emergency Nurses Ann White, MSN, RN, CCNS, CEN, CPEN Fernando Lopez, MD Phillip Stone, RN

Abstract Ultrasonography use in the emergency department (ED) has been well established. The use of ultra- sonography that falls into the traditional practice of the emergency nurse is peripheral intravenous (IV) access. Benefits of using ultrasonography for peripheral IV access include decreasing patient throughput, cost reduction, decreasing complications, increased patient and emergency medicine physician satisfaction, and emergency nurse autonomy. Review of the literature demonstrates no discernable differences in ability and efficacy with ultrasound (US)-guided peripheral IV access when comparing data from studies about emergency medicine physicians, certified registered nurses anesthetists, emergency department technicians, physician assistants, and emergency registered nurses. In 2006, Duke University Hospital Emergency Department started a US-Guided Peripheral IV Access program for emergency nurses. Similar patient populations have been observed and the same types of complications have been encountered as described in the literature. Future goals include perfecting nurses’ vein selection, and to study skill mastery with US-guided peripheral IV ac- cess. Key words: emergency nurse, peripheral intravenous (IV) access, ultrasonography, ultrasound (US), US-guided peripheral IV

HE utility of ultrasonography in the ultrasonography for diagnostic purposes to emergency department (ED) has been evaluate multiple organ systems in different Twell established in the last decade. clinical scenarios. It is also used for central Emergency medicine (EM) physicians utilize and peripheral venous catheter access. The use of EM ultrasonography that falls into the Author Affiliations: Duke University Hospital Depart- traditional practice of the emergency nurse ment of Advanced Clinical Practice and Duke Univer- is peripheral intravenous (IV) access. Even sity School of Nursing (Ms White), Duke University Medical Center (Dr Lopez), and Duke University Hospi- the most experienced emergency nurse may tal Emergency Department (Mr Stone), Durham, North have difficulty obtaining IV access in patients Carolina. with conditions such as injection drug use, Supplemental digital content is available for this arti- obesity, chronic illness, hypovolemia, shock, cle. Direct URL citations appear in the printed text and vasculopathy, and extremes of age. These pa- are provided in the HTML and PDF versions of this ar- ticle on the journal’s Web site (www.AENJournal.com). tients lack easy access to peripheral venous sites using the traditional techniques of di- Corresponding Author: Ann White, MSN, RN, CCNS, CEN, CPEN, Duke University Hospital, DUMC 3677, rect visualization, anatomic landmarks, pal- Durham, NC 27710 ([email protected]). pation, and trial-and-error blind cannulation.

173 LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

174 Advanced Emergency Nursing Journal

& Fernandez, 2003; Blaivas & Lyon, 2006; Bauman, Braude, & Crandall, 2009; Brannam, Blaivas, Lyon, & Flake, 2004; Witting, Schenkel, Lawner, & Euerle, in press). Additional benefits include increased patient comfort and satisfac- • tion, increased EM physician satisfaction due • to sustained productivity because of less interruptions to work flow to complete a routine procedure normally accom- plished by nurses, and increased emergency nurse autonomy Figure 1. DUH ED nurse, P. Stone, using ultra- • sonography to start IV. Reprinted with permission (Bauman et al., 2009; Blaivas, 2005; of Sonosite Inc. Costantino, Parikh, Satz, & Fojtik, 2005; Mills, Liebmann, Stone, & Frazee, 2007; Although these patients require timely pe- Stein, Cole, & Kramer, 2004). ripheral venous access, their condition may The use of ultrasonography is advantageous not be so acute as to require emergent cen- because there are no biological effects and no tral venous or intraosseous access. use of ionizing radiation; ultrasonography also An evolving option for peripheral IV ac- measures blood flow and can provide real- cess is the utilization of ultrasonography by time vascular imaging (Aponte et al., 2007). the emergency nurse (Figure 1). This option is employed after traditional techniques have REVIEW OF THE LITERATURE failed. This technique can also be used by the nurse for the initial IV attempt for patients The literature provides varied information who have a history or suspicion of difficult IV about formal research findings and clinical ex- access based on medical history. perience with the use of ultrasonography for peripheral IV access. Six studies published be- tween 1999 and 2009 describe the success BENEFITS rate in difficult peripheral IV access using ul- There are several benefits of using ultrasonog- trasonography by EM physicians (Costantino raphy: et al., 2005; Keyes, Franzee, Snoey, Simon, decreasing patient throughput time and & Christy, 1999; Mills et al., 2007; Stein • delays in diagnosis and treatment due to et al., 2004; Stein, George, River, Hebig, & less time spent in obtaining venous ac- McDermott, 2009; Witting et al., in press). cess, In ED patients with difficult peripheral IV ac- cost reduction by avoiding critical care cess, researchers from all studies except one • time and use of expensive equipment (Stein et al., 2009) concluded that US-guided for central catheter insertion, at the vein cannulation was safe and rapid and had a same time eliminating exposure to iatro- high success rate. In addition, the majority of genic complications such as pneumotho- cannulations were accomplished with one at- rax and bloodstream infection, which in- tempt (n 387; Costantino et al., 2005; Keyes crease mortality, hospital length of stay, et al., 1999;= Mills et al., 2007; Stein et al., and healthcare costs, and 2004; Witting et al., in press). Physicians re- decreasing complications of traditional ported untoward outcomes such as mechani- • insertion that include pain, arterial punc- cal, infectious, and thrombotic complications ture, nerve damage, and paresthesias (Table 1). In contrast to the five other studies, (Aponte et al., 2007; Blaivas, Brannam, Stein et al. (2009) concluded that US-guided LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 175 r , ess,” by L. 59) = N . George, G. River, A. us Access,” by C. Mills, 180) ( Annals of Emergency Medicine, 46 = N 2% other 25) ( doi:10.1016/j.jemermed.2009.01.003. “Ultrasonographically = N , pp. 711–714; “Ultrasonography-Guided Peripheral Intravenous Access 60) ( = N Costantino Mills Witting et al. Stein , pp. 68–72; “Effects of Vein Width and Depth on Ultrasound-Guided Peripheral IV Success The Journal of Emergency Medicine, , pp. 33–40. Annals of Emergency Medicine, 34 100) ( = N Keyes et al., 1999 et al., 2005 et al., 2007 in press et al., 2009 puncture contact with brachial nerve 2% Brachial arterial 1% Paresthesia due to Annals of Emergency Medicine, 50 Academic Emergency Medicine, 54 Incidence of complications from ultrasound-guided peripheral IV access by EM physicians ultrasound. Data from “Ultrasound-Guided Brachial and Basilica Vein Cannulation in Emergency Department Patients With Difficult Intravenous Acc = the catheter, US evidence of arterial puncture, hematoma formation, paresthesias, and venous infiltration consistent with catheter-associated cellulitis or phlebitis, or positive catheter-tip culture of upper-extremity venous thrombosis Arterial blood flow through Erythema, pain, edema Any clinical or US evidence US MechanicalInfectious 8% Infiltrated or fell outThrombotic 0 Not measured 4% Not measured Not measured 1% Paresthesias 0 0 Not measured Not measured 0 0 Not measured 0 Complication type ( Rates,” by M. Witting, S.Guided Schenkel, Peripheral B. Intravenous Lawner, and Cannulation B. inHebig, Euerle, Emergency and B, D. Department McDermott, in Patients 2009, press, With Difficult Intravenous Access: A Randomized Trial,” by J. Stein, B Table 1. Note: Keyes, B. Franzee, E.Versus Snoey, Traditional B. Approaches Simon, in Patients andpp. With D. 456–461; Difficult Christy, “Ultrasonographically Intravenous 1999, Guided Access,” by InsertionO. T. of Liebmann, Costantino, M. a A. Stone, 15-cm Parikh, and Catheter W. B. Into Satz, Frazee, the and 2007, Deep J. Fojtik, Brachial or 2005, Basilic Vein in Patients With Difficult Intraveno LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

176 Advanced Emergency Nursing Journal

peripheral IV cannulation did not decrease physicians’ success with US-guided peripheral the number of attempts, time to successful IV access, there are no discernable differences catheterization, nor did it improve patient sat- in ability and efficacy (Table 2). isfaction and suggested that there is no supe- riority of this technique. The literature has also described other DUKE UNIVERSITY HOSPITAL EMERGENCY types of clinicians using ultrasonography to DEPARTMENT’S US-GUIDED start peripheral IVs. In 2007, Aponte et al. PERIPHERAL IV ACCESS described successful use of ultrasonography Program for Emergency Nurses by certified registered nurse anesthetists. Re- searchers randomized subjects to a traditional The motivation to develop emergency nurse group and a US-guided group and measured competency in US-guided peripheral IV ac- time to successful cannulation on first at- cess began as a grassroots effort in 2006 by tempt and number of attempts per subject. staff nurses. The nurses observed the utility White, Sturges, Barton, Battaglia, and Mc- of the technology when used by EM physi- Cowan (2007) and Bauman et al. (2009) de- cians after they were unsuccessful in obtain- scribed similar studies with ED technicians ing IV access with the traditional approach that also showed that the use of ultrasonog- and sought information about ultrasonogra- raphy increases the success rate of periph- phy for peripheral access from their EM physi- eral IV placement. In 2009, Witting et al. stud- cian colleagues. ied the effects of vein width and depth in A small number of nurses were instructed US-guided peripheral IV success rates. Three on the technique during actual application percent of the attempts studied were per- with a real patient by the EM physicians formed by physician assistants, and 1% of and requested to be able to use this new the attempts were performed by a registered knowledge independently when attempting nurse. to start IVs on patients. After consulting the Only three observational, descriptive stud- State Nursing Practice Act and securing sup- ies have been published about specific emer- port from ED and organizational leadership, gency nurse experience with US-guided pe- a program was developed to train the emer- ripheral IV access. Two are from the same gency nurses in US-guided venous cannu- healthcare institution, with analysis solely lation. Organizational experts who assisted from the EM physician’s perspective. These with the training included an ultrasonogra- two studies use the same sample of emer- phy fellowship-trained EM attending physi- gency nurses. The 2004 study (Brannam cian, clinicians from the IV therapy depart- et al.) actually measured the utility of nurses, ment who use bedside ultrasonography for using US in the clinical setting, and the peripherally inserted central catheters, and 2006 study (Blaivas & Lyon) measured the a representative from SonoSite Inc. (Both- perception of technical difficulty by the ell, WA, manufacturer of the portable US same nurses with the same patient sample. machine). In 2007, Chinnock, Thornton, and Hendey Senior staff nurses are selected to be trained studied predictors of success in emergency on this advanced skill. This approach is used nurse-performed US-guided cannulation. This as a retention strategy to recognize the nurse’s is the only study measuring complications experience and as an appeal to their request from cannulation by an emergency nurse. In for advanced education and responsibility. comparing the studies measuring certified The role is highlighted as an advanced clin- registered nurse anesthetists’, emergency ical role in the department and something technicians’, physician assistants’, and emer- that less-experienced nurses can strive for, gency nurses’ success with US-guided periph- as novice nurses, especially new graduate eral IV access with studies measuring EM nurses, need to remain focused on improving LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 177 r ) continues ( 0.7 See Table 1 1 See Table 1 ± ± 1.52 See Table 1 2 1.7 Not measured See Table 1 129 52 5.6 5 ± ± transducer placed on skin and vein cannulated; used two-person technique, time started after cleaning) puncture to vein cannulated) transducer placed on skin and vein cannulated; could useor one two-person technique and it was not reported which oneused) was enrollment to blood return; could use one- or two-person technique and it was not reported which one was used) ± ± (Measured in seconds when (Measured in minutes from needle (Measured in minutes when (Measured in minutes from Subjects with successful Time to successful US-guided IV Number of 39 97% 4 Comparison of ability with US-guided peripheral IV access by different clinicians (Aponte et al., 2007; Bauman et al., 2009; (2005) Stein et al. (2004)Costantino et al. 15Mills et al. (2007) 25 86% 61% Not measured 3 1.3 Not measured EM attending physician and residentKeyes physician et al. (1999) 100 73% 77 EM attending physician Stein et al. (2009) 28 Not reported separately 39 Type ofclinician/study subjects Number of US-guided cannulation on first attempt cannulation when successful attempts per Incidence of on first attempt subject complications Table 2. Brannam et al., 2004; CostantinoWitting et et al., al., 2005; in press) Keyes et al., 1999; Mills et al., 2007; Stein et al., 2004; Stein et al., 2009; White et al., 2007; LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

178 Advanced Emergency Nursing Journal no distal vascular compromise, bleeding stopped with 5-min compression; hematoma 29.3%; nerve pain 2.4% numbness; 6.7% severe pain; all resolved during ED stay 0.7 Not reported 0.56 0 0.7 9.8% arterial punctures with ± ± ± 1.4 1.6 228.3 ± transducer placed on skin and vein cannulated; used one-person technique, time started before cleaning) transducer placed on skin tocannulated; vein used one-person technique) (Measured in seconds when (Measured in minutes when ultrasound. = ) Subjects with successful Time to successful US-guided IV Number of intravenous, US = 180 56% Not measured321119 1.32 See 87% Table 1 44% Not measured Not measured Not measured 1.2%, all arterial punctures Not measured 4.2% arterial; 2.5% arm Continued Comparison of ability with US-guided peripheral IV access by different clinicians (Aponte et al., 2007; Bauman et al., 2009; emergency medicine, IV = EM press) (2004) Thornton, & Hendy; 2007 EM attending physician andattempts) resident physician (95% of attempts), physician assistant (3% of attempts), registered nurse (1% of Witting et al. in Certified registered nurse anesthetist Aponte et al. (2007) 19Emergency department technician (EM technician-paramedicWhite or et EM al. technician-intermediate) (2007)Bauman et al. (2009) 74% 45 75 187.3 Emergency nurse Brannam et al. 75.6% 80.5%Chinnock, Not measured 26.8 1.29 Type ofclinician/study subjects Number of US-guided cannulation on first attempt cannulation when successful attempts per Incidence of on first attempt subject complications Table 2. Brannam et al., 2004; CostantinoWitting et et al., al., 2005; in press) Keyes et ( al., 1999; Mills et al., 2007; Stein et al., 2004; Stein et al., 2009; White et al., 2007; Note: LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 179 r Table 3. Summary of ultrasound didactic training

Ultrasound physics—30 min Highlighting potential physiological effects affecting safety: ultrasonography enhances inflammatory response; and it can heat soft tissue Operation of US machine—30 min Screen settings, gain, field depth, and image optimization How to scan—1 hr Use of ultrasonographic gel, transducer probe selection, transverse or longitudinal beam, pressure of probe, needle tip location, and anatomy US-guided IV procedure—1 hr Preparation, transducer probe orientation, equipment positioning, scout scan, asepsis, needle angle, evaluation, pearls and pitfalls

Note: IV intravenous; US ultrasound. = =

their basic psychomotor skill with traditional chine screen as it enters the blood vessel allow- IV access techniques. Another benefit of lim- ing greater visualization of the needle-tip loca- iting the number of nurses who are trained to tion, whereas with the short-axis approach, this use ultrasonography is that their proficiency is not the case, because only a portion of the will develop and remain because their oppor- needle can be tracked as it passes through the tunity to use ultrasonography will not be di- US beam under the transducer probe (Blaivas et al., 2003). If the nurse prefers to gain IV access luted as it might if all nurses were trained. with the short-axis approach, we emphasize the This approach to prevent decay in skill level technique with the US transducer probe of fan- is also described in the literature (Chinnock, ning off the end of the needle tip to visualize the Thornton, & Hendey, 2007). bevel end. This deforms the target vessel prior The training consists of a 3-hour initial train- to cannulation and then upon insertion, position- ing session that includes didactic informa- ing the US transducer probe with the long-axis tion, simulation, and hands-on practice. Ta- view for definitive confirmation of location and ble 3 summarizes major concepts of the ini- effective function potential (Supplemental Digital tial training. Table 4 lists the behavioral ob- Content, Videos demonstrating this are available jectives used to evaluate competency with at http://links.lww.com/AENJ/A1 and http://links. the skill. The initial skill acquisition revolves lww.com/AENJ/A2, see videos 1 and 2). around the nurse being able to manipulate the After the initial session, nurses are required transducer probe to view the vessels from a to be observed starting peripheral IVs with longitudinal (long axis) or transverse (short ultrasonography by a core group of proctors. axis) approach (Figures 2–4). Although stud- At least 10 proctored attempts were selected ies demonstrate that novice ultrasonography as the benchmark for competency before users obtain vascular access faster with a the emergency nurse can perform ultrasonog- short-axis approach and it seems to be the raphy independently. This number was de- preferred approach for cannulation because termined by the ultrasonography fellowship- the blood vessel is easier to see and less trained EM attending physician who acts as alignment needs to be performed, we en- a medical director for the program, which is courage skill development, mainly hand–eye facilitated and coordinated by the ED clini- coordination, using both positions (Blaivas cal nurse specialist (CNS). The core proctors et al., 2003; Brannam, Fernandez, & Blaivas, are limited to the ultrasonography fellowship- 2003). trained EM attending physician, the ED CNS, In the long-axis approach, the entire length of and three other trained nurses selected by the the needle can be tracked on the ultra ma- ED CNS on the basis of their overall technical LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

180 Advanced Emergency Nursing Journal

Table 4. Performance criteria to evaluate competency for ultrasound-guided peripheral IV insertion

Competency Performance criteria Assessment of patient Assesses patient for need to utilize US-guided intravenous access Reviews most recent history and physical, medication history, and allergies Confirms patient identification armband Planning for procedure Collects necessary supplies, personal protective equipment, and sets up as needed Explains procedure to patient Teaches patient symptoms to report during procedure Patient safety Differentiates and identifies arteries versus veins using ultrasonography Utilizes appropriate infection-control measures to reduce risk of invasive line infection Determines the depth of the target vein utilizing depth scale on US device and selects the appropriate length IV catheter (1.16 in. for standard, 1.88 in. for deeper target veins) Removes tourniquet promptly when indicated Monitors line patency and infusion to detect signs and symptoms of infiltration Evaluation Confirms blood return, easy flush, and absence of swelling or tenderness at site Documents use of ultrasonography for IV placement, catheter size, length, location, and site condition Labels IV site with insertion date, catheter size, and whether deep brachial vein was used Reevaluates site frequently for signs of infiltration Evaluates patient’s response to procedure

Note: IV intravenous, US ultrasound. = =

skill and ability to teach and mentor others. ing on aseptic technique and how to avoid Once the proctored insertions are completed, arterial puncture when venous cannulation a signed document confirming the compe- is the goal. The cited literature inconsis- tencies that were observed is placed in the tently mentions in a detailed fashion infection nurse’s personnel file and an announcement prevention technique used while inserting recognizing the nurse’s accomplishment is US-guided venous catheters. For example, sent out electronically to all ED staff. Also, the Mills et al. (2007) state that the catheter nurse’s name is added to a reference that is was inserted by EM physicians with unster- posted in the clinical area that lists the names ile ultrasonographic gel and unsterile gloves of the nurses that ED staff can consult when and Bauman et al. (2009) mention using a IV access using the traditional approach has semisterile technique with a nonsterile trans- failed. The process of consulting one of these ducer probe. With a major focus on reduc- nurses first, before involving an EM physician ing bloodstream infections, and also because to start the IV, is stressed. blood cultures are frequently obtained with The objective in using a small core group the IV insertion, Duke’s procedure includes of proctors is to allow a greater chance the use of sterile ultrasonographic gel and for consistency in technique, mainly focus- covering the probe with a sterile transparent LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 181 r

Figure 4. Acannulatedveinusingthelong-axis (longitudinal) view, cannula appears as long white line in middle of vein at a depth of approximately 1 cm. Bright white dots are depth indicators spaced Figure 2. First two images show transducer place- at 1 cm increments. ment for short-axis (transverse) view including how image appears on ultrasound machine screen. nurses are taught how to use this same tech- Last two images show transducer placement for nology for arterial puncture to obtain blood long-axis (longitudinal) view including how image sampling for blood gas analysis. Another appli- appears on ultrasound machine screen. Used with cation of ultrasonography is fetal heart rate vi- permission from SonoSite® Inc. sualization. Nurses are taught how to visualize fetal heart rate after hand-held Doppler assess- dressing before placing it on the cleansed skin ment is unsuccessful. These two applications over the preselected puncture site. are infrequently used compared with the use Along with instruction on peripheral ve- for establishing IV access. However, anecdo- nous access, which includes recognizing the tally, nurses seem to grasp the technique and difference between a vein and an artery, concept quite readily. Since 2006, the training class has been of- fered four times. At present, 13 nurses (ap- proximately 10% of registered nurse full-time equivalents with an equal distribution on the day and night shift are trained to perform US-guided peripheral IV access independently and approximately 10 nurses are currently in the process of being proctored. We have observed similar patient popu- lations described in two studies that high- lighted poor peripheral vasculature with scle- rosis and scar tissue from chronic injection drug use followed by chemotherapy, obesity, and hypotension (Keyes et al., 1999; Mills et al., 2007) as the most prevalent patient Figure 3. Acannulatedveinusingtheshort-axis types who present with difficult peripheral (transverse) view, needle appears as bright, white IV access. Two chronic conditions also men- point in center of vein at a depth of approxi- tioned in the literature that we found in our mately 1 cm. Bright white dots are depth indicators clinical setting who are common candidates spaced at 1 cm increments. for ultrasonography as the initial modality LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

182 Advanced Emergency Nursing Journal

for IV insertions are patients with sickle cell Table 5. Decision-making process to confirm disease and chronic renal failure (Aponte IV location et al., 2007; Brannam et al., 2004; Costantino et al., 2005; Witting et al., in press). Slow the compression rate and hold the Blaivas and Lyon (2006) also noted many pa- vessel at a partially compressed position tients with chronic medical conditions who and look for subtle pulsations. This may experience acute exacerbations and frequent require observation for several seconds. visits to the ED, attempt to avoid blind IV at- If cannulation has already occurred, confirm tempts and request immediate use of ultra- absence of pulsations by aspirating blood sonography when blood sampling or IV ther- halfway or less into the extension tubing apy is required. It has become common since and observe for pulsatory fluctuations in the start of our ultrasonography program that the column of blood, possibly very subtle, patients with chronic conditions, who visit similar to those observed in a sphygmo the ED frequently, ask for their IV to be started manometer. Following cannulation of the vessel, try initially with the US technique. The ability to confirming the position in the vessel by provide this US-guided service has resulted using a longitudinal view. Apply mild in increased patient comfort, satisfaction, and compression in that view to confirm that improved rapport with the healthcare team. there are no pulsations. Pulsations would We have also encountered the same types indicate arterial cannulation. of complications described in the literature The color Doppler signal feature can be used about ED technicians by Bauman et al. (2009) to discern catheter location and is defined and emergency nurses by Brannam et al. as red representing blood flow toward the (2004) and Chinnock, Thornton, and Hendey transducer (arterial) and blue (2007). These authors cited the occurrence representing blood flow away from the of arterial puncture during cannulation. This transducer (venous). An arterial blood gas can be analyzed to complication was also noted in the stud- evaluate the values for arterial blood. ies with EM physicians (Costantino et al., 2005; Keyes et al., 1999; Mills et al., 2007; Witting et al., in press). Arteries may be dif- ficult to identify and differentiate from veins. very subtle, similar to those observed in a This can be due to low systolic pressure or sphygmomanometer. Following cannulation poor arterial wall tone. We have outlined for of the vessel, try confirming the catheter po- the US-trained nurses a decision-making pro- sition in the vessel by using a longitudinal cess (Table 5) to confirm whether the IV is view. Apply mild compression in that view where they want it to be. to confirm that there are no pulsations. Pul- First, the tendency is to compress vessels sations would indicate arterial cannulation. quickly and completely flat. Sometimes, pul- The color Doppler signal feature can also sations can be obscured by complete com- be used to discern catheter location and is pression. Try slowing the compression rate defined as red representing blood flow to- and hold the vessel at a partially com- ward the transducer (arterial) and blue repre- pressed position and look for subtle pulsa- senting blood flow away from the transducer tions. This may require observation for sev- (venous; video available at http://links.lww. eral seconds (a video of this is available at com/AENJ/A4, see video 4). Also, an arterial http://links.lww.com/AENJ/A3, see video 3). blood gas can be analyzed to evaluate the val- Second, if cannulation has already occurred, ues for arterial blood. confirm the absence of pulsations by aspi- Anecdotal reports of inconsistent longevity rating blood halfway or less into the exten- of the catheter function after insertion have sion tubing and observe for pulsatory fluc- been common. This phenomenon seems to tuations in the column of blood, possibly be correlated with experience and skill of the LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 183 r

Figure 5. Nurse-provided venous access using ultrasonography data collection form, Duke University Hos- pital emergency department.

US-trained nurse. Failed cutaneous punctures width and depth on the probability of suc- are cited as common in the literature (Bauman cess in US-guided IV insertion. The results et al., 2009; Mills et al., 2007; Witting et al., of this study showed that success rates are in press). In 2009, Witting et al. studied vein higher in larger veins ( 0.4 cm) and veins at ≥ LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

184 Advanced Emergency Nursing Journal

moderate depth (0.3–1.5 cm; Witting et al., in FUTURE RESEARCH press). The researchers suggested that mod- The literature already clearly identifies the pa- erate depth is more successful because more tient characteristics that support ultrasonog- shallow veins do not allow enough distance to raphy use and the benefits and risks. What visualize the needle approaching the target re- is not identified clearly in the literature is quiring a shallower needle angle and veins at time and number of patient encounters re- greater depths have inadequate needle length quired by the ultrasonographer to feel profi- to pass into the vein (Witting et al., in press). cient. The literature provides anecdotal infor- A problem frequently cited in the literature mation about how different clinician types ac- is the proximity of the US-guided IV site to the quired their skill with starting IVs with ultra- biceps muscle and tendon and the occasional sonography (Table 6). practice of securing the IV tubing across the The research question that needs to be an- antecubital fossa when that site is used, re- swered is: How does the ultrasonographer de- sulting in more tip movement during arm ma- velop skill mastery with US-guided peripheral nipulation, movement of the catheter in and IV access? Are the 10 proctored insertions out of the vessel, and extravasation when a an adequate number to measure skill mas- shorter catheter is used (Bauman et al., 2009; tery? Plans are under way to study emergency Blaivas, 2005; Keyes et al., 1999; Witting nurses’ skill mastery with the technique by et al., in press). To mitigate these problems, analyzing how many cannulations it takes for this information was shared with the current a nurse to feel proficient with US-guided pe- US-trained nurses. The use of longer catheters ripheral IV access and what other types of re- (1.88 in.) exclusively for US-guided IV access sources contributed to that perception of skill is taught. We will be periodically validating mastery. that the US-trained nurses are adept at mea- suring width and depth and we will be stress- ing avoidance of veins with unfavorable char- CONCLUSION acteristics (too small, shallow, or deep) more prominently in future training for nurses new Developing a program to train emergency to the skill to ensure greater longevity of IV nurses in US-guided venous cannulation is function. viable, easy, and safe. Future goals include Data collection for performance- increasing the number of nurses trained to improvement purposes has recently started. perform US-guided venous cannulation, per- The US-trained nurses complete the form fecting the nurses’ vein selection decisions after each patient encounter, documenting to increase longevity of the IV, and to study patient characteristics, degree of patient satis- how nurses develop their skill mastery with faction, and information about the access and US-guided peripheral IV access. We are also patient outcomes elucidating the potential considering exploring training nurses to use benefits and complications of US guidance in ultrasonography for bladder scanning to im- IV access (Figure 5). The choice was made not pact incidence of urinary tract infections from to approach this data collection as research unwarranted urinary catheter insertion in the but rather as quality improvement because ED. aresearchprocesswouldhaverequired Overall, senior nurses are acknowledged obtaining informed consent from the patient for the benefit their skills add to the effi- before using ultrasonography. It was felt that ciency of the care team and patient through- consenting the patient as a research subject put. The EM physicians appreciate the con- would delay IV access and patients might tribution these nurses’ independent ability to think that the use of ultrasonography was manage this technology provides to patient experimental as opposed to an established length of stay and the physicians’ produc- tool to accomplish a standard procedure. tivity due to less interruptions for what is LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 185 r ) continues ( 0.03). Mean = p with simulated inanimate arm model (difference not statistically significant) by US despite the useequipment of and technology technique being for new—familiarization both with occurred visualization quickly and and cannulation easily underwent brief training in identificationvein of deep brachial and basilic with 100% success rate reported fastest access either using SA or LAwas approach. 5.02 Mean min time difference to statistically SAdifficulty significant was scores ( 2.36 for min SA and andstatistically LA LA significant) were 3.99 and 5.86 (difference not Performed US after 45-minute didactic session89% with success rate hands-on with SA practice technique, 85% success rate withNurses LA reported technique decrease in perceived difficulty in obtaining IV access Little investigation regarding teaching models for US IV access haveIf been efficiency is the goal, teach short-axis approach first because it yields Novice US users obtain vascular access much faster using SA approach ED patients EM attending physician or senior residents who had US experience and Skill acquisition statements in the literature (Aponte et al., 2007; Bauman et al., 2009; Blaivas et al., 2003; Blaivas et al., 2006; resident physician emergency nurses EM resident physiciansEM resident physicians 30-minute didactic session, then immediately attempted US IV access 30-minute didactic session, then immediately attempted US IV access EM attending physician and Both studies used same sample of ReferenceKeyes et al. (1999) Blaivas et al. (2003)Brannam Simulated et inanimate al. arm (2003) model Sample type Studied novice US users Simulated inanimate armBrannam model et al. (2004)Blaivas et Studied al. novice (2006) US users Statement about US IV -skill acquisition ED patients None of the nurses had used US previously for any application Table 6. Brannam et al., 2003; Brannamin et press) al., 2004; Costantino et al., 2005; Keyes et al., 1999; Stein et al., 2004; Stein et al., 2009; Witting et al., LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

186 Advanced Emergency Nursing Journal ) continues ( was defined as physician who placed more than 10 (visualizing the vein on thetransducer US probe machine placement screen with and one maintainingother) hand proper and cannulation with the US-guided peripheral IV cannulation. rotation with sole focus onemergency doing US US, scans 15 performed hr of didactic lecture and 100 previous US-guided IV catheters withprevious experience US-guided ranging IV from access no experience to 50 or more placements experienced in the use ofrange US of (3 experience years’ in experience). US Operators should with be a included in futurewith investigations simulated inanimate arm model.approach. Trained Work-shifts only with in less short-axis US-trained nursescannulation had opportunities more with modest improvementcriteria in limited skill. patient Inclusion selection tonurses worst wait access months patients in making betweenand attempts decay leading in to skill. lack Possible ofdo solution confidence occasional would refreshers be to to maintain train skill. all nurses and to plateaus after 20 attempts The most difficult skill was dependence on eye–hand coordination More experienced ED patientsED patientsPerioperative patients The nurse would seek the assistance Physicians of were a familiarED physician with patients comfortable US with from residency training—3-week ED Certified registered nurse anesthetists placing the catheters were well ED patients Performed US after 90 minute didactic session with hands on practice Success rate lowest in group with less than 20 prior attempts and ) Continued Skill acquisition statements in the literature (Aponte et al., 2007; Bauman et al., 2009; Blaivas et al., 2003; Blaivas et al., 2006; resident physician anesthetists 2007 physicians (95% of attempts), physician assistants (3% of attempts), and registered nurses (1% of attempts) EM Attending Physicians EM attending physician and Certified registered nurse Emergency Nurses EM attending and resident Reference Sample type Statement about US IV -skill acquisition Stein et al. (2004) Costantino et al. (2005) Aponte et al. (2007) Chinnock, Thornton, & Hendey; Witting et al. (in press) Table 6. Brannam et al., 2003; Brannamin et press) ( al., 2004; Costantino et al., 2005; Keyes et al., 1999; Stein et al., 2004; Stein et al., 2009; Witting et al., LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 187 r ultrasound. = short axis, US = long axis, SA simulated inanimate arm model inexperience with the US machinesuitable and site. the Previous technique studies or used locatingphysicians residents a with and considerable EM US attending experience. Physicians guidelines, 8 in process16-hour of introductory credentialing course. and All had physicians receivedUS-guided practiced a IVs performing for 6 monthsto training assess period whether prior a to subgroup study.perform Goal of this was highly technique not trained better. physicians Further could determine study is whether recommended there to is apatients physician are training likely threshold to at benefit which more consistently = Delay in time to access may have been a result of ED technicians’ intravenous, LA = ED patients Performed US after 1-hour didactic session with hands-on practice with emergency medicine, IV = ) Continued Skill acquisition statements in the literature (Aponte et al., 2007; Bauman et al., 2009; Blaivas et al., 2003; Blaivas et al., 2006; emergency department, EM = ED ED technicians ReferenceBauman et al. (2009) Stein et al. (2009) Sample type ED patients Statement about US IV -skill acquisition 12 credentialed in US according to American College of Emergency Table 6. Brannam et al., 2003; Brannamin et press) ( al., 2004; Costantino et al., 2005; Keyes et al., 1999; Stein et al., 2004; Stein et al., 2009; Witting et al., Note: LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0

188 Advanced Emergency Nursing Journal

perceived as a nurse’s procedure. Patients Chinnock, B., Thornton, S., & Hendey, G. (2007). Predic- benefit from decreased exposure to risk from tors of success in nurse–performed ultrasound–guided central venous access and, as cited in the liter- cannulation. The Journal of Emergency Medicine, 33, 401–405. ature, experience satisfaction during their ED Costantino, T., Parikh, A., Satz, W., & Fojtik, J. (2005). visit with this nurse-provided intervention. Ultrasonography-guided peripheral intravenous ac- cess versus traditional approaches in patients with REFERENCES difficult intravenous access. Annals of Emergency Medicine, 46,456–461. Aponte, H., Acosta, S., Rigamonti, D., Sylvia, B., Austin, P., Keyes, L., Franzee, B., Snoey, E., Simon, B., & Christy, D. & Samolitis, T. (2007). The use of ultrasound for place- (1999). Ultrasound-guided brachial and basilica vein ment of intravenous catheters. American Association cannulation in emergency department patients with of Nurse Anesthetists Journal, 75,212–216. difficult intravenous access. Annals of Emergency Bauman, M., Braude, D., & Crandall, C. (2009). Medicine, 34,711–714. Ultrasound-guidance vs. standard technique in Mills, C., Liebmann, O., Stone, M., & Frazee, B. (2007). difficult vascular access patients by ED technicians. Ultrasonographically guided insertion of a 15-cm American Journal of Emergency Medicine, 27, catheter into the deep brachial or basilic vein in pa- 135–140. tients with difficult intravenous access. Annals of Blaivas, M. (2005). Ultrasound-guided peripheral IV inser- Emergency Medicine, 50, 68–72. tion in the ED. American Journal of Nursing, 105, Stein, J., Cole, W., & Kramer, N. (2004). Ultrasound- 54–57. guided peripheral intravenous cannulation in emer- Blaivas, M., Brannam, L., & Fernandez, E. (2003). gency department patients with difficult IV access Short-axis versus long-axis approaches for teaching [Abstract]. Academic Emergency Medicine, 11,581– ultrasound-guided vascular access on a new inanimate 582. model. Academic Emergency Medicine, 10,1307– Stein, J., George, B., River, G., Hebig, A., & McDermott, 1311. D. (2009). Ultrasonographically guided peripheral in- Blaivas, M., & Lyon, M. (2006). The effect of ultrasound travenous cannulation in emergency department pa- guidance on the perceived difficulty of emergency tients with difficult intravenous access: A randomized nurse-obtained peripheral IV access. The Journal of trial. Annals of Emergency Medicine, 54, 33–40. Emergency Medicine, 31,407–410. White, S., Sturges, Z., Barton, E., Battaglia, D., & Mc- Brannam, L., Blaivas, M., Lyon, M., & Flake, M. (2004). Cowan C. (2007). Ultrasound-guided peripheral ve- Emergency nurses’ utilization of ultrasound guid- nous access by emergency medical technicians in pa- ance for placement of peripheral intravenous lines tients with difficult access [Abstract]. Annals of Emer- in difficult-access patients. Academic Emergency gency Medicine (Suppl.) 50, S85. Medicine, 11,1361–1363. Witting, M., Schenkel, S., Lawner, B., & Euerle, B. (in Brannam, L., Fernandez, E., & Blaivas, M. (2003). Short press). Effects of vein width and depth on ultrasound- axis versus long axis approaches for teaching ultra- guided peripheral IV success rates. The Journal of sound guided vascular access [Abstract]. Academic Emergency Medicine. doi:10.1016/j.jemermed.2009. Emergency Medicine, 10,572–573. 01.003.