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