developing and sustaining an ultrasound-guided …...april–june 2010 vol. 32, no. 2...
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LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0
Advanced Emergency Nursing JournalVol. 32, No. 2, pp. 173–188
Copyright c© 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Developing and Sustaining anUltrasound-Guided PeripheralIntravenous Access Program forEmergency Nurses
Ann White, MSN, RN, CCNS, CEN, CPENFernando Lopez, MDPhillip Stone, RN
AbstractUltrasonography 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 patientthroughput, cost reduction, decreasing complications, increased patient and emergency medicinephysician satisfaction, and emergency nurse autonomy. Review of the literature demonstrates nodiscernable differences in ability and efficacy with ultrasound (US)-guided peripheral IV access whencomparing data from studies about emergency medicine physicians, certified registered nursesanesthetists, emergency department technicians, physician assistants, and emergency registerednurses. In 2006, Duke University Hospital Emergency Department started a US-Guided PeripheralIV Access program for emergency nurses. Similar patient populations have been observed and thesame types of complications have been encountered as described in the literature. Future goalsinclude 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
THE utility of ultrasonography in theemergency department (ED) has beenwell established in the last decade.
Emergency medicine (EM) physicians utilize
Author Affiliations: Duke University Hospital Depart-ment of Advanced Clinical Practice and Duke Univer-sity School of Nursing (Ms White), Duke UniversityMedical Center (Dr Lopez), and Duke University Hospi-tal Emergency Department (Mr Stone), Durham, NorthCarolina.
Supplemental digital content is available for this arti-cle. Direct URL citations appear in the printed text andare provided in the HTML and PDF versions of this ar-ticle on the journal’s Web site (www.AENJournal.com).
Corresponding Author: Ann White, MSN, RN, CCNS,CEN, CPEN, Duke University Hospital, DUMC 3677,Durham, NC 27710 ([email protected]).
ultrasonography for diagnostic purposes toevaluate multiple organ systems in differentclinical scenarios. It is also used for centraland peripheral venous catheter access. Theuse of EM ultrasonography that falls into thetraditional practice of the emergency nurseis peripheral intravenous (IV) access. Eventhe most experienced emergency nurse mayhave difficulty obtaining IV access in patientswith conditions such as injection drug use,obesity, chronic illness, hypovolemia, shock,vasculopathy, and extremes of age. These pa-tients lack easy access to peripheral venoussites using the traditional techniques of di-rect visualization, anatomic landmarks, pal-pation, and trial-and-error blind cannulation.
173
LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0
174 Advanced Emergency Nursing Journal
Figure 1. DUH ED nurse, P. Stone, using ultra-
sonography to start IV. Reprinted with permission
of Sonosite Inc.
Although these patients require timely pe-ripheral venous access, their condition maynot be so acute as to require emergent cen-tral venous or intraosseous access.
An evolving option for peripheral IV ac-cess is the utilization of ultrasonography bythe emergency nurse (Figure 1). This optionis employed after traditional techniques havefailed. This technique can also be used by thenurse for the initial IV attempt for patientswho have a history or suspicion of difficult IVaccess based on medical history.
BENEFITS
There are several benefits of using ultrasonog-raphy:
• decreasing patient throughput time anddelays in diagnosis and treatment due toless time spent in obtaining venous ac-cess,
• cost reduction by avoiding critical caretime and use of expensive equipmentfor central catheter insertion, at thesame time eliminating exposure to iatro-genic complications such as pneumotho-rax and bloodstream infection, which in-crease mortality, hospital length of stay,and healthcare costs, and
• decreasing complications of traditionalinsertion that include pain, arterial punc-ture, nerve damage, and paresthesias(Aponte et al., 2007; Blaivas, Brannam,
& Fernandez, 2003; Blaivas & Lyon,2006; Bauman, Braude, & Crandall, 2009;Brannam, Blaivas, Lyon, & Flake, 2004;Witting, Schenkel, Lawner, & Euerle, inpress).
Additional benefits include• increased patient comfort and satisfac-
tion,• increased EM physician satisfaction due
to sustained productivity because of lessinterruptions to work flow to completea routine procedure normally accom-plished by nurses, and
• increased emergency nurse autonomy(Bauman et al., 2009; Blaivas, 2005;Costantino, Parikh, Satz, & Fojtik, 2005;Mills, Liebmann, Stone, & Frazee, 2007;Stein, Cole, & Kramer, 2004).
The use of ultrasonography is advantageousbecause there are no biological effects and nouse of ionizing radiation; ultrasonography alsomeasures blood flow and can provide real-time vascular imaging (Aponte et al., 2007).
REVIEW OF THE LITERATURE
The literature provides varied informationabout formal research findings and clinical ex-perience with the use of ultrasonography forperipheral IV access. Six studies published be-tween 1999 and 2009 describe the successrate in difficult peripheral IV access using ul-trasonography by EM physicians (Costantinoet al., 2005; Keyes, Franzee, Snoey, Simon,& Christy, 1999; Mills et al., 2007; Steinet al., 2004; Stein, George, River, Hebig, &McDermott, 2009; Witting et al., in press).In ED patients with difficult peripheral IV ac-cess, researchers from all studies except one(Stein et al., 2009) concluded that US-guidedvein cannulation was safe and rapid and had ahigh success rate. In addition, the majority ofcannulations were accomplished with one at-tempt (n = 387; Costantino et al., 2005; Keyeset al., 1999; Mills et al., 2007; Stein et al.,2004; Witting et al., in press). Physicians re-ported untoward outcomes such as mechani-cal, infectious, and thrombotic complications(Table 1). In contrast to the five other studies,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
Tab
le1
.In
cid
en
ce
of
co
mp
licat
ion
sfr
om
ult
raso
un
d-g
uid
ed
peri
ph
era
lIV
access
by
EM
ph
ysic
ian
s
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stan
tin
oM
ills
Wit
tin
get
al.
Ste
in
Key
es
et
al.
,1
99
9et
al.
,2
00
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al.
,2
00
7in
press
et
al.
,2
00
9
Co
mp
licati
on
typ
e(N
=1
00
)(N
=6
0)
(N=
25
)(N
=1
80
)(N
=5
9)
Mech
anic
al8
%In
filt
rate
do
rfe
llo
ut
04
%1
%Par
est
hesi
as0
Art
eri
alb
loo
dfl
ow
thro
ugh
the
cat
hete
r,U
Sevid
en
ce
of
arte
rial
pu
nctu
re,
hem
ato
ma
form
atio
n,
par
est
hesi
as,an
dve
no
us
infi
ltra
tio
n
2%
Bra
chia
lar
teri
al
pu
nctu
re
1%
Par
est
hesi
ad
ue
to
co
nta
ct
wit
hb
rach
ial
nerv
e
2%
oth
er
Infe
cti
ou
sN
ot
meas
ure
dN
ot
meas
ure
d0
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tm
eas
ure
d0
Ery
them
a,p
ain
,ed
em
a
co
nsi
sten
tw
ith
cat
hete
r-as
socia
ted
cellu
liti
so
rp
hle
bit
is,o
r
po
siti
vecat
hete
r-ti
p
cu
ltu
re
Th
rom
bo
tic
No
tm
eas
ure
dN
ot
meas
ure
d0
No
tm
eas
ure
d0
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yclin
ical
or
US
evid
en
ce
of
up
per-
extr
em
ity
ven
ou
s
thro
mb
osi
s
Note
:U
S=
ult
raso
un
d.
Dat
afr
om
“Ult
raso
un
d-G
uid
ed
Bra
chia
lan
dB
asilic
aV
ein
Can
nu
lati
on
inEm
erg
en
cy
Dep
artm
en
tPat
ien
tsW
ith
Dif
ficu
ltIn
trav
en
ou
sA
ccess
,”b
yL.
Keye
s,B
.Fra
nze
e,
E.
Sno
ey,
B.
Sim
on
,an
dD
.C
hri
sty,
19
99
,A
nn
als
of
Em
erge
ncy
Med
icin
e,3
4,
pp
.711–714;
“Ult
raso
no
gra
ph
y-G
uid
ed
Peri
ph
era
lIn
trav
en
ou
sA
ccess
Vers
us
Tra
dit
ion
alA
pp
roac
hes
inPat
ien
tsW
ith
Dif
ficu
ltIn
trav
en
ou
sA
ccess
,”b
yT.
Co
stan
tin
o,
A.
Par
ikh
,W
.Sa
tz,
and
J.Fo
jtik
,2005,
An
na
lsof
Em
erge
ncy
Med
icin
e,4
6,
pp
.456–461;
“Ult
raso
no
gra
ph
ical
lyG
uid
ed
Inse
rtio
no
fa
15-c
mC
ath
ete
rIn
toth
eD
eep
Bra
chia
lo
rB
asilic
Vein
inPat
ien
tsW
ith
Dif
ficu
ltIn
trav
en
ou
sA
ccess
,”b
yC
.M
ills
,
O.
Lie
bm
ann
,M
.St
on
e,
and
B.
Fra
zee,
20
07
,A
nn
als
of
Em
erge
ncy
Med
icin
e,5
0,
pp
.6
8–7
2;
“Eff
ects
of
Vein
Wid
than
dD
ep
tho
nU
ltra
sou
nd
-Gu
ided
Peri
ph
era
lIV
Success
Rat
es,
”b
yM
.W
itti
ng,
S.Sc
hen
kel,
B.
Law
ner,
and
B.
Eu
erl
e,
B,
inp
ress
,Th
eJo
urn
al
of
Em
erge
ncy
Med
icin
e,d
oi:1
0.1
01
6/j
.jem
erm
ed
.20
09
.01
.00
3.
“Ult
raso
no
gra
ph
ical
ly
Gu
ided
Peri
ph
era
lIn
trav
en
ou
sC
ann
ula
tio
nin
Em
erg
en
cy
Dep
artm
en
tPat
ien
tsW
ith
Dif
ficu
ltIn
trav
en
ou
sA
ccess
:A
Ran
do
miz
ed
Tri
al,”
by
J.St
ein
,B
.G
eo
rge,
G.
Riv
er,
A.
Heb
ig,an
dD
.M
cD
erm
ott
,2
00
9,A
cadem
icE
mer
gen
cyM
edic
ine,
54
,p
p.3
3–4
0.
LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0
176 Advanced Emergency Nursing Journal
peripheral IV cannulation did not decreasethe number of attempts, time to successfulcatheterization, nor did it improve patient sat-isfaction and suggested that there is no supe-riority of this technique.
The literature has also described othertypes of clinicians using ultrasonography tostart peripheral IVs. In 2007, Aponte et al.described successful use of ultrasonographyby certified registered nurse anesthetists. Re-searchers randomized subjects to a traditionalgroup and a US-guided group and measuredtime to successful cannulation on first at-tempt and number of attempts per subject.White, Sturges, Barton, Battaglia, and Mc-Cowan (2007) and Bauman et al. (2009) de-scribed similar studies with ED techniciansthat also showed that the use of ultrasonog-raphy increases the success rate of periph-eral IV placement. In 2009, Witting et al. stud-ied the effects of vein width and depth inUS-guided peripheral IV success rates. Threepercent of the attempts studied were per-formed by physician assistants, and 1% ofthe attempts were performed by a registerednurse.
Only three observational, descriptive stud-ies have been published about specific emer-gency nurse experience with US-guided pe-ripheral IV access. Two are from the samehealthcare institution, with analysis solelyfrom the EM physician’s perspective. Thesetwo studies use the same sample of emer-gency nurses. The 2004 study (Brannamet al.) actually measured the utility of nurses,using US in the clinical setting, and the2006 study (Blaivas & Lyon) measured theperception of technical difficulty by thesame nurses with the same patient sample.In 2007, Chinnock, Thornton, and Hendeystudied predictors of success in emergencynurse-performed US-guided cannulation. Thisis the only study measuring complicationsfrom cannulation by an emergency nurse. Incomparing the studies measuring certifiedregistered nurse anesthetists’, emergencytechnicians’, physician assistants’, and emer-gency nurses’ success with US-guided periph-eral IV access with studies measuring EM
physicians’ success with US-guided peripheralIV access, there are no discernable differencesin ability and efficacy (Table 2).
DUKE UNIVERSITY HOSPITAL EMERGENCY
DEPARTMENT’S US-GUIDED
PERIPHERAL IV ACCESS
Program for Emergency Nurses
The motivation to develop emergency nursecompetency in US-guided peripheral IV ac-cess began as a grassroots effort in 2006 bystaff nurses. The nurses observed the utilityof the technology when used by EM physi-cians after they were unsuccessful in obtain-ing IV access with the traditional approachand sought information about ultrasonogra-phy for peripheral access from their EM physi-cian colleagues.
A small number of nurses were instructedon the technique during actual applicationwith a real patient by the EM physiciansand requested to be able to use this newknowledge independently when attemptingto start IVs on patients. After consulting theState Nursing Practice Act and securing sup-port from ED and organizational leadership,a program was developed to train the emer-gency nurses in US-guided venous cannu-lation. Organizational experts who assistedwith the training included an ultrasonogra-phy fellowship-trained EM attending physi-cian, clinicians from the IV therapy depart-ment who use bedside ultrasonography forperipherally inserted central catheters, anda representative from SonoSite Inc. (Both-ell, WA, manufacturer of the portable USmachine).
Senior staff nurses are selected to be trainedon this advanced skill. This approach is usedas a retention strategy to recognize the nurse’sexperience and as an appeal to their requestfor advanced education and responsibility.The role is highlighted as an advanced clin-ical role in the department and somethingthat less-experienced nurses can strive for,as novice nurses, especially new graduatenurses, 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
Tab
le2
.C
om
par
iso
no
fab
ilit
yw
ith
US-
gu
ided
peri
ph
era
lIV
access
by
dif
fere
nt
clin
icia
ns
(Ap
on
teet
al.,
20
07
;B
aum
anet
al.,
20
09
;B
ran
nam
et
al.,
20
04
;C
ost
anti
no
et
al.,
20
05
;K
eye
set
al.,
19
99
;M
ills
et
al.,
20
07
;St
ein
et
al.,
20
04
;St
ein
et
al.,
20
09
;W
hit
eet
al.,
20
07
;W
itti
ng
et
al.,
inp
ress
)
Su
bje
cts
wit
hsu
ccess
ful
Tim
eto
success
ful
US-g
uid
ed
IVN
um
ber
of
Ty
pe
of
Nu
mb
er
of
US-g
uid
ed
can
nu
lati
on
on
can
nu
lati
on
wh
en
success
ful
att
em
pts
per
Incid
en
ce
of
cli
nic
ian
/stu
dy
sub
jects
firs
tatt
em
pt
on
firs
tatt
em
pt
sub
ject
co
mp
licati
on
s
EM
att
en
din
gp
hy
sicia
n
Stein
et
al.(2
00
9)
28
No
tre
po
rted
sep
arat
ely
39
±5
2
(Meas
ure
din
min
ute
sfr
om
en
rollm
en
tto
blo
od
retu
rn;
co
uld
use
on
e-o
rtw
o-p
ers
on
tech
niq
ue
and
itw
asn
ot
rep
ort
ed
wh
ich
on
ew
asu
sed
)
2±
1Se
eTab
le1
EM
att
en
din
gp
hy
sicia
nan
dresi
den
tp
hy
sicia
n
Keye
set
al.(1
99
9)
10
07
3%
77
±1
29
(Meas
ure
din
seco
nd
sw
hen
tran
sdu
cer
pla
ced
on
skin
and
vein
can
nu
late
d;u
sed
two
-pers
on
tech
niq
ue,ti
me
star
ted
afte
rcle
anin
g)
No
tm
eas
ure
dSe
eTab
le1
Stein
et
al.(2
00
4)
15
86
%N
ot
meas
ure
d1
.3N
ot
meas
ure
d
Co
stan
tin
oet
al.
(20
05
)
39
97
%4
±5
.6
(Meas
ure
din
min
ute
sfr
om
need
le
pu
nctu
reto
vein
can
nu
late
d)
1.7
±0
.7Se
eTab
le1
Mills
et
al.(2
00
7)
25
61
%3
±5
(Meas
ure
din
min
ute
sw
hen
tran
sdu
cer
pla
ced
on
skin
and
vein
can
nu
late
d;co
uld
use
on
e
or
two
-pers
on
tech
niq
ue
and
it
was
no
tre
po
rted
wh
ich
on
ew
as
use
d)
1.5
2Se
eTab
le1
(con
tin
ues
)
LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0
178 Advanced Emergency Nursing Journal
Tab
le2
.C
om
par
iso
no
fab
ilit
yw
ith
US-
gu
ided
peri
ph
era
lIV
access
by
dif
fere
nt
clin
icia
ns
(Ap
on
teet
al.,
20
07
;B
aum
anet
al.,
20
09
;B
ran
nam
et
al.,
20
04
;C
ost
anti
no
et
al.,
20
05
;K
eye
set
al.,
19
99
;M
ills
et
al.,
20
07
;St
ein
et
al.,
20
04
;St
ein
et
al.,
20
09
;W
hit
eet
al.,
20
07
;W
itti
ng
et
al.,
inp
ress
)(C
on
tin
ued
)
Su
bje
cts
wit
hsu
ccess
ful
Tim
eto
success
ful
US-g
uid
ed
IVN
um
ber
of
Ty
pe
of
Nu
mb
er
of
US-g
uid
ed
can
nu
lati
on
on
can
nu
lati
on
wh
en
success
ful
att
em
pts
per
Incid
en
ce
of
cli
nic
ian
/stu
dy
sub
jects
firs
tatt
em
pt
on
firs
tatt
em
pt
sub
ject
co
mp
licati
on
s
EM
att
en
din
gp
hy
sicia
nan
dresi
den
tp
hy
sicia
n(9
5%
of
att
em
pts
),p
hy
sicia
nass
ista
nt
(3%
of
att
em
pts
),regis
tered
nu
rse
(1%
of
att
em
pts
)
Wit
tin
get
al.in
pre
ss)
18
05
6%
No
tm
eas
ure
d1
.32
See
Tab
le1
Cert
ifie
dregis
tered
nu
rse
an
est
heti
st
Ap
on
teet
al.(2
00
7)
19
74
%1
87
.3±
22
8.3
(Meas
ure
din
seco
nd
sw
hen
tran
sdu
cer
pla
ced
on
skin
and
vein
can
nu
late
d;u
sed
on
e-p
ers
on
tech
niq
ue,ti
me
star
ted
befo
recle
anin
g)
1.4
±0
.7N
ot
rep
ort
ed
Em
erg
en
cy
dep
art
men
tte
ch
nic
ian
(EM
tech
nic
ian
-para
med
ico
rE
Mte
ch
nic
ian
-in
term
ed
iate
)
Wh
ite
et
al.(2
00
7)
45
75
.6%
No
tm
eas
ure
d1
.29
±0
.56
0
Bau
man
et
al.(2
00
9)
75
80
.5%
26
.8
(Meas
ure
din
min
ute
sw
hen
tran
sdu
cer
pla
ced
on
skin
tove
in
can
nu
late
d;u
sed
on
e-p
ers
on
tech
niq
ue)
1.6
±0
.79
.8%
arte
rial
pu
nctu
res
wit
h
no
dis
talva
scu
lar
co
mp
rom
ise,b
leed
ing
sto
pp
ed
wit
h5
-min
co
mp
ress
ion
;h
em
ato
ma
29
.3%
;n
erv
ep
ain
2.4
%
Em
erg
en
cy
nu
rse
Bra
nn
amet
al.
(20
04
)
32
18
7%
No
tm
eas
ure
dN
ot
meas
ure
d1
.2%
,al
lar
teri
alp
un
ctu
res
Ch
inn
ock,
Th
orn
ton
,&
Hen
dy;
20
07
11
94
4%
No
tm
eas
ure
dN
ot
meas
ure
d4
.2%
arte
rial
;2
.5%
arm
nu
mb
ness
;6
.7%
seve
re
pai
n;al
lre
solv
ed
du
rin
g
ED
stay
Note
:EM
=em
erg
en
cy
med
icin
e,IV
=in
trav
en
ou
s,U
S=
ult
raso
un
d.
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
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 traditionalIV access techniques. Another benefit of lim-iting the number of nurses who are trained touse ultrasonography is that their proficiencywill develop and remain because their oppor-tunity to use ultrasonography will not be di-luted as it might if all nurses were trained.This approach to prevent decay in skill levelis also described in the literature (Chinnock,Thornton, & Hendey, 2007).
The training consists of a 3-hour initial train-ing session that includes didactic informa-tion, simulation, and hands-on practice. Ta-ble 3 summarizes major concepts of the ini-tial training. Table 4 lists the behavioral ob-jectives used to evaluate competency withthe skill. The initial skill acquisition revolvesaround the nurse being able to manipulate thetransducer probe to view the vessels from alongitudinal (long axis) or transverse (shortaxis) approach (Figures 2–4). Although stud-ies demonstrate that novice ultrasonographyusers obtain vascular access faster with ashort-axis approach and it seems to be thepreferred approach for cannulation becausethe blood vessel is easier to see and lessalignment needs to be performed, we en-courage skill development, mainly hand–eyecoordination, using both positions (Blaivaset al., 2003; Brannam, Fernandez, & Blaivas,2003).
In the long-axis approach, the entire length of
the needle can be tracked on the ultra ma-
chine screen as it enters the blood vessel allow-
ing greater visualization of the needle-tip loca-
tion, whereas with the short-axis approach, this
is not the case, because only a portion of the
needle can be tracked as it passes through the
US beam under the transducer probe (Blaivas et
al., 2003). If the nurse prefers to gain IV access
with the short-axis approach, we emphasize the
technique with the US transducer probe of fan-
ning off the end of the needle tip to visualize the
bevel end. This deforms the target vessel prior
to cannulation and then upon insertion, position-
ing the US transducer probe with the long-axis
view for definitive confirmation of location and
effective function potential (Supplemental Digital
Content, Videos demonstrating this are available
at http://links.lww.com/AENJ/A1 and http://links.
lww.com/AENJ/A2, see videos 1 and 2).
After the initial session, nurses are requiredto be observed starting peripheral IVs withultrasonography by a core group of proctors.At least 10 proctored attempts were selectedas the benchmark for competency beforethe emergency nurse can perform ultrasonog-raphy independently. This number was de-termined by the ultrasonography fellowship-trained EM attending physician who acts asa medical director for the program, which isfacilitated and coordinated by the ED clini-cal nurse specialist (CNS). The core proctorsare limited to the ultrasonography fellowship-trained EM attending physician, the ED CNS,and three other trained nurses selected by theED 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 IVinsertion
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.Once the proctored insertions are completed,a signed document confirming the compe-tencies that were observed is placed in thenurse’s personnel file and an announcementrecognizing the nurse’s accomplishment issent out electronically to all ED staff. Also, thenurse’s name is added to a reference that isposted in the clinical area that lists the namesof the nurses that ED staff can consult whenIV access using the traditional approach hasfailed. The process of consulting one of thesenurses first, before involving an EM physicianto start the IV, is stressed.
The objective in using a small core groupof proctors is to allow a greater chancefor consistency in technique, mainly focus-
ing on aseptic technique and how to avoidarterial puncture when venous cannulationis the goal. The cited literature inconsis-tently mentions in a detailed fashion infectionprevention technique used while insertingUS-guided venous catheters. For example,Mills et al. (2007) state that the catheterwas inserted by EM physicians with unster-ile ultrasonographic gel and unsterile glovesand Bauman et al. (2009) mention using asemisterile technique with a nonsterile trans-ducer probe. With a major focus on reduc-ing bloodstream infections, and also becauseblood cultures are frequently obtained withthe IV insertion, Duke’s procedure includesthe use of sterile ultrasonographic gel andcovering the probe with a sterile transparent
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April–June 2010 � Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 181
Figure 2. First two images show transducer place-
ment for short-axis (transverse) view including
how image appears on ultrasound machine screen.
Last two images show transducer placement for
long-axis (longitudinal) view including how image
appears on ultrasound machine screen. Used with
permission from SonoSite® Inc.
dressing before placing it on the cleansed skinover the preselected puncture site.
Along with instruction on peripheral ve-nous access, which includes recognizing thedifference between a vein and an artery,
Figure 3. A cannulated vein using the short-axis
(transverse) view, needle appears as bright, white
point in center of vein at a depth of approxi-
mately 1 cm. Bright white dots are depth indicators
spaced at 1 cm increments.
Figure 4. A cannulated vein using the long-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
at 1 cm increments.
nurses are taught how to use this same tech-nology for arterial puncture to obtain bloodsampling for blood gas analysis. Another appli-cation of ultrasonography is fetal heart rate vi-sualization. Nurses are taught how to visualizefetal heart rate after hand-held Doppler assess-ment is unsuccessful. These two applicationsare infrequently used compared with the usefor establishing IV access. However, anecdo-tally, nurses seem to grasp the technique andconcept quite readily.
Since 2006, the training class has been of-fered four times. At present, 13 nurses (ap-proximately 10% of registered nurse full-timeequivalents with an equal distribution on theday and night shift are trained to performUS-guided peripheral IV access independentlyand approximately 10 nurses are currently inthe 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 injectiondrug use followed by chemotherapy, obesity,and hypotension (Keyes et al., 1999; Millset al., 2007) as the most prevalent patienttypes who present with difficult peripheralIV access. Two chronic conditions also men-tioned in the literature that we found in ourclinical setting who are common candidatesfor ultrasonography as the initial modality
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182 Advanced Emergency Nursing Journal
for IV insertions are patients with sickle celldisease and chronic renal failure (Aponteet al., 2007; Brannam et al., 2004; Costantinoet al., 2005; Witting et al., in press).
Blaivas and Lyon (2006) also noted many pa-tients with chronic medical conditions whoexperience acute exacerbations and frequentvisits to the ED, attempt to avoid blind IV at-tempts and request immediate use of ultra-sonography when blood sampling or IV ther-apy is required. It has become common sincethe start of our ultrasonography program thatpatients with chronic conditions, who visitthe ED frequently, ask for their IV to be startedinitially with the US technique. The ability toprovide this US-guided service has resultedin increased patient comfort, satisfaction, andimproved rapport with the healthcare team.
We have also encountered the same typesof complications described in the literatureabout ED technicians by Bauman et al. (2009)and emergency nurses by Brannam et al.(2004) and Chinnock, Thornton, and Hendey(2007). These authors cited the occurrenceof arterial puncture during cannulation. Thiscomplication was also noted in the stud-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.This can be due to low systolic pressure orpoor arterial wall tone. We have outlined forthe US-trained nurses a decision-making pro-cess (Table 5) to confirm whether the IV iswhere they want it to be.
First, the tendency is to compress vesselsquickly and completely flat. Sometimes, pul-sations can be obscured by complete com-pression. Try slowing the compression rateand hold the vessel at a partially com-pressed position and look for subtle pulsa-tions. This may require observation for sev-eral seconds (a video of this is available athttp://links.lww.com/AENJ/A3, see video 3).Second, if cannulation has already occurred,confirm the absence of pulsations by aspi-rating blood halfway or less into the exten-sion tubing and observe for pulsatory fluc-tuations in the column of blood, possibly
Table 5. Decision-making process to confirmIV location
Slow the compression rate and hold the
vessel at a partially compressed position
and look for subtle pulsations. This may
require observation for several seconds.
If cannulation has already occurred, confirm
absence of pulsations by aspirating blood
halfway or less into the extension tubing
and observe for pulsatory fluctuations inthe column of blood, possibly very subtle,
similar to those observed in a sphygmo
manometer.
Following cannulation of the vessel, try
confirming the position in the vessel by
using a longitudinal view. Apply mild
compression in that view to confirm that
there are no pulsations. Pulsations would
indicate arterial cannulation.
The color Doppler signal feature can be used
to discern catheter location and is defined
as red representing blood flow toward thetransducer (arterial) and bluerepresenting blood flow away from thetransducer (venous).
An arterial blood gas can be analyzed to
evaluate the values for arterial blood.
very subtle, similar to those observed in asphygmomanometer. Following cannulationof the vessel, try confirming the catheter po-sition in the vessel by using a longitudinalview. Apply mild compression in that viewto confirm that there are no pulsations. Pul-sations would indicate arterial cannulation.The color Doppler signal feature can alsobe used to discern catheter location and isdefined as red representing blood flow to-ward the transducer (arterial) and blue repre-senting blood flow away from the transducer(venous; video available at http://links.lww.com/AENJ/A4, see video 4). Also, an arterialblood gas can be analyzed to evaluate the val-ues for arterial blood.
Anecdotal reports of inconsistent longevityof the catheter function after insertion havebeen common. This phenomenon seems tobe correlated with experience and skill of the
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April–June 2010 � Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 183
Figure 5. Nurse-provided venous access using ultrasonography data collection form, Duke University Hos-
pital emergency department.
US-trained nurse. Failed cutaneous puncturesare cited as common in the literature (Baumanet al., 2009; Mills et al., 2007; Witting et al.,in press). In 2009, Witting et al. studied vein
width and depth on the probability of suc-cess in US-guided IV insertion. The resultsof this study showed that success rates arehigher in larger veins (≥0.4 cm) and veins at
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184 Advanced Emergency Nursing Journal
moderate depth (0.3–1.5 cm; Witting et al., inpress). The researchers suggested that mod-erate depth is more successful because moreshallow veins do not allow enough distance tovisualize the needle approaching the target re-quiring a shallower needle angle and veins atgreater depths have inadequate needle lengthto pass into the vein (Witting et al., in press).
A problem frequently cited in the literatureis the proximity of the US-guided IV site to thebiceps muscle and tendon and the occasionalpractice of securing the IV tubing across theantecubital fossa when that site is used, re-sulting in more tip movement during arm ma-nipulation, movement of the catheter in andout of the vessel, and extravasation when ashorter catheter is used (Bauman et al., 2009;Blaivas, 2005; Keyes et al., 1999; Wittinget al., in press). To mitigate these problems,this information was shared with the currentUS-trained nurses. The use of longer catheters(1.88 in.) exclusively for US-guided IV accessis taught. We will be periodically validatingthat the US-trained nurses are adept at mea-suring width and depth and we will be stress-ing avoidance of veins with unfavorable char-acteristics (too small, shallow, or deep) moreprominently in future training for nurses newto the skill to ensure greater longevity of IVfunction.
Data collection for performance-improvement purposes has recently started.The US-trained nurses complete the formafter each patient encounter, documentingpatient characteristics, degree of patient satis-faction, and information about the access andpatient outcomes elucidating the potentialbenefits and complications of US guidance inIV access (Figure 5). The choice was made notto approach this data collection as researchbut rather as quality improvement becausea research process would have requiredobtaining informed consent from the patientbefore using ultrasonography. It was felt thatconsenting the patient as a research subjectwould delay IV access and patients mightthink that the use of ultrasonography wasexperimental as opposed to an establishedtool to accomplish a standard procedure.
FUTURE RESEARCH
The literature already clearly identifies the pa-tient characteristics that support ultrasonog-raphy use and the benefits and risks. Whatis not identified clearly in the literature istime and number of patient encounters re-quired by the ultrasonographer to feel profi-cient. The literature provides anecdotal infor-mation about how different clinician types ac-quired their skill with starting IVs with ultra-sonography (Table 6).
The research question that needs to be an-swered is: How does the ultrasonographer de-velop skill mastery with US-guided peripheralIV access? Are the 10 proctored insertionsan adequate number to measure skill mas-tery? Plans are under way to study emergencynurses’ skill mastery with the technique byanalyzing how many cannulations it takes fora nurse to feel proficient with US-guided pe-ripheral IV access and what other types of re-sources contributed to that perception of skillmastery.
CONCLUSION
Developing a program to train emergencynurses in US-guided venous cannulation isviable, easy, and safe. Future goals includeincreasing the number of nurses trained toperform US-guided venous cannulation, per-fecting the nurses’ vein selection decisionsto increase longevity of the IV, and to studyhow nurses develop their skill mastery withUS-guided peripheral IV access. We are alsoconsidering exploring training nurses to useultrasonography for bladder scanning to im-pact incidence of urinary tract infections fromunwarranted urinary catheter insertion in theED.
Overall, senior nurses are acknowledgedfor the benefit their skills add to the effi-ciency of the care team and patient through-put. The EM physicians appreciate the con-tribution these nurses’ independent ability tomanage this technology provides to patientlength of stay and the physicians’ produc-tivity due to less interruptions for what is
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April–June 2010 � Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 185
Tab
le6
.Sk
ill
acq
uis
itio
nst
atem
en
tsin
the
lite
ratu
re(A
po
nte
et
al.,
20
07
;B
aum
anet
al.,
20
09
;B
laiv
aset
al.,
20
03
;B
laiv
aset
al.,
20
06
;B
ran
nam
et
al.,
20
03
;B
ran
nam
et
al.,
20
04
;C
ost
anti
no
et
al.,
20
05
;K
eye
set
al.,
19
99
;St
ein
et
al.,
20
04
;St
ein
et
al.,
20
09
;W
itti
ng
et
al.,
inp
ress
)
Refe
ren
ce
Sam
ple
typ
eSta
tem
en
tab
ou
tU
SIV
-sk
ill
acq
uis
itio
n
Keye
set
al.(1
99
9)
EM
atte
nd
ing
ph
ysic
ian
and
resi
den
tp
hys
icia
n
ED
pat
ien
tsEM
atte
nd
ing
ph
ysic
ian
or
sen
ior
resi
den
tsw
ho
had
US
exp
eri
en
ce
and
un
derw
en
tb
rief
trai
nin
gin
iden
tifi
cat
ion
of
deep
bra
chia
lan
db
asilic
vein
Bla
ivas
et
al.(2
003)
Sim
ula
ted
inan
imat
ear
mm
od
el
Stu
die
dn
ovic
eU
Su
sers
EM
resi
den
tp
hys
icia
ns
30-m
inu
ted
idac
tic
sess
ion
,th
en
imm
ed
iate
lyat
tem
pte
dU
SIV
access
wit
h1
00
%su
ccess
rate
Lit
tle
inve
stig
atio
nre
gar
din
gte
ach
ing
mo
dels
for
US
IVac
cess
hav
eb
een
rep
ort
ed
Ifeff
icie
ncy
isth
ego
al,te
ach
sho
rt-a
xis
app
roac
hfi
rst
becau
seit
yield
s
fast
est
access
Bra
nn
amet
al.(2
003)
Sim
ula
ted
inan
imat
ear
mm
od
el
Stu
die
dn
ovic
eU
Su
sers
EM
resi
den
tp
hys
icia
ns
30-m
inu
ted
idac
tic
sess
ion
,th
en
imm
ed
iate
lyat
tem
pte
dU
SIV
access
eit
her
usi
ng
SAo
rLA
app
roac
h.M
ean
tim
eto
SAw
as2
.36
min
and
LA
was
5.0
2m
ind
iffe
ren
ce
stat
isti
cal
lysi
gn
ific
ant
(p=
0.0
3).
Mean
dif
ficu
lty
sco
res
for
SAan
dLA
were
3.9
9an
d5.8
6(d
iffe
ren
ce
no
t
stat
isti
cal
lysi
gn
ific
ant)
No
vic
eU
Su
sers
ob
tain
vasc
ula
rac
cess
mu
chfa
ster
usi
ng
SAap
pro
ach
Bra
nn
amet
al.(2
00
4)
ED
pat
ien
tsN
on
eo
fth
en
urs
es
had
use
dU
Sp
revio
usl
yfo
ran
yap
plicat
ion
Bla
ivas
et
al.(2
00
6)
Bo
thst
ud
ies
use
dsa
me
sam
ple
of
em
erg
en
cy
nu
rses
Perf
orm
ed
US
afte
r45-m
inu
ted
idac
tic
sess
ion
wit
hh
and
s-o
np
racti
ce
wit
hsi
mu
late
din
anim
ate
arm
mo
del
89
%su
ccess
rate
wit
hSA
tech
niq
ue,8
5%
success
rate
wit
hLA
tech
niq
ue
(dif
fere
nce
no
tst
atis
tical
lysi
gn
ific
ant)
Nu
rses
rep
ort
ed
decre
ase
inp
erc
eiv
ed
dif
ficu
lty
ino
bta
inin
gIV
access
by
US
desp
ite
the
use
of
tech
no
logy
bein
gn
ew
—fa
milia
riza
tio
nw
ith
eq
uip
men
tan
dte
chn
iqu
efo
rb
oth
vis
ual
izat
ion
and
can
nu
lati
on
occu
rred
qu
ickly
and
eas
ily
(con
tin
ues
)
LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0
186 Advanced Emergency Nursing Journal
Tab
le6
.Sk
ill
acq
uis
itio
nst
atem
en
tsin
the
lite
ratu
re(A
po
nte
et
al.,
20
07
;B
aum
anet
al.,
20
09
;B
laiv
aset
al.,
20
03
;B
laiv
aset
al.,
20
06
;B
ran
nam
et
al.,
20
03
;B
ran
nam
et
al.,
20
04
;C
ost
anti
no
et
al.,
20
05
;K
eye
set
al.,
19
99
;St
ein
et
al.,
20
04
;St
ein
et
al.,
20
09
;W
itti
ng
et
al.,
inp
ress
)(C
on
tin
ued
)
Refe
ren
ce
Sam
ple
typ
eSta
tem
en
tab
ou
tU
SIV
-sk
ill
acq
uis
itio
n
Th
em
ost
dif
ficu
ltsk
illw
asd
ep
en
den
ce
on
eye
–h
and
co
ord
inat
ion
(vis
ual
izin
gth
eve
ino
nth
eU
Sm
ach
ine
scre
en
and
mai
nta
inin
gp
rop
er
tran
sdu
cer
pro
be
pla
cem
en
tw
ith
on
eh
and
and
can
nu
lati
on
wit
hth
e
oth
er)
Stein
et
al.(2
00
4)
EM
Att
en
din
gP
hys
icia
ns
ED
pat
ien
tsT
he
nu
rse
wo
uld
seek
the
assi
stan
ce
of
ap
hys
icia
nco
mfo
rtab
lew
ith
US-
gu
ided
peri
ph
era
lIV
can
nu
lati
on
.
Co
stan
tin
oet
al.(2
00
5)
EM
atte
nd
ing
ph
ysic
ian
and
resi
den
tp
hys
icia
n
ED
pat
ien
tsP
hys
icia
ns
were
fam
ilia
rw
ith
US
fro
mre
sid
en
cy
trai
nin
g—
3-w
eek
ED
rota
tio
nw
ith
sole
focu
so
nd
oin
gU
S,1
5h
ro
fd
idac
tic
lectu
rean
d1
00
em
erg
en
cy
US
scan
sp
erf
orm
ed
More
exper
ien
ced
was
defi
ned
asp
hys
icia
nw
ho
pla
ced
mo
reth
an1
0
pre
vio
us
US-
gu
ided
IVcat
hete
rsw
ith
exp
eri
en
ce
ran
gin
gfr
om
no
pre
vio
us
US-
gu
ided
IVac
cess
exp
eri
en
ce
to5
0o
rm
ore
pla
cem
en
ts
Ap
on
teet
al.(2
00
7)
Cert
ifie
dre
gis
tere
dn
urs
e
anest
heti
sts
Peri
op
era
tive
pat
ien
tsC
ert
ifie
dre
gis
tere
dn
urs
ean
est
heti
sts
pla
cin
gth
ecat
hete
rsw
ere
well
exp
eri
en
ced
inth
eu
seo
fU
S(3
year
s’ex
peri
en
ce).
Op
era
tors
wit
ha
ran
geo
fex
peri
en
ce
inU
Ssh
ou
ldb
ein
clu
ded
infu
ture
inve
stig
atio
ns
Ch
inn
ock,T
ho
rnto
n,&
Hen
dey;
20
07
Em
erg
en
cy
Nu
rses
ED
pat
ien
tsPerf
orm
ed
US
afte
r9
0m
inu
ted
idac
tic
sess
ion
wit
hh
and
so
np
racti
ce
wit
hsi
mu
late
din
anim
ate
arm
mo
del.
Tra
ined
on
lyin
sho
rt-a
xis
app
roac
h.W
ork
-sh
ifts
wit
hle
ssU
S-tr
ain
ed
nu
rses
had
mo
re
can
nu
lati
on
op
po
rtu
nit
ies
wit
hm
od
est
imp
rove
men
tin
skill.
Inclu
sio
n
cri
teri
alim
ited
pat
ien
tse
lecti
on
tow
ors
tac
cess
pat
ien
tsm
akin
g
nu
rses
wai
tm
on
ths
inb
etw
een
atte
mp
tsle
adin
gto
lack
of
co
nfi
den
ce
and
decay
insk
ill.
Po
ssib
leso
luti
on
wo
uld
be
totr
ain
alln
urs
es
and
to
do
occas
ion
alre
fresh
ers
tom
ain
tain
skill.
Wit
tin
get
al.(i
np
ress
)
EM
atte
nd
ing
and
resi
den
t
ph
ysic
ian
s(9
5%
of
atte
mp
ts),
ph
ysic
ian
assi
stan
ts(3
%o
f
atte
mp
ts),
and
regis
tere
dn
urs
es
(1%
of
atte
mp
ts)
ED
pat
ien
tsSu
ccess
rate
low
est
ingro
up
wit
hle
ssth
an2
0p
rio
rat
tem
pts
and
pla
teau
saf
ter
20
atte
mp
ts
(con
tin
ues
)
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
Tab
le6
.Sk
ill
acq
uis
itio
nst
atem
en
tsin
the
lite
ratu
re(A
po
nte
et
al.,
20
07
;B
aum
anet
al.,
20
09
;B
laiv
aset
al.,
20
03
;B
laiv
aset
al.,
20
06
;B
ran
nam
et
al.,
20
03
;B
ran
nam
et
al.,
20
04
;C
ost
anti
no
et
al.,
20
05
;K
eye
set
al.,
19
99
;St
ein
et
al.,
20
04
;St
ein
et
al.,
20
09
;W
itti
ng
et
al.,
inp
ress
)(C
on
tin
ued
)
Refe
ren
ce
Sam
ple
typ
eSta
tem
en
tab
ou
tU
SIV
-sk
ill
acq
uis
itio
n
Bau
man
et
al.(2
00
9)
ED
tech
nic
ian
s
ED
pat
ien
tsPerf
orm
ed
US
afte
r1
-ho
ur
did
acti
cse
ssio
nw
ith
han
ds-
on
pra
cti
ce
wit
h
sim
ula
ted
inan
imat
ear
mm
od
el
Dela
yin
tim
eto
access
may
hav
eb
een
are
sult
of
ED
tech
nic
ian
s’
inex
peri
en
ce
wit
hth
eU
Sm
ach
ine
and
the
tech
niq
ue
or
locat
ing
a
suit
able
site
.P
revio
us
stu
die
su
sed
resi
den
tsan
dEM
atte
nd
ing
ph
ysic
ian
sw
ith
co
nsi
dera
ble
US
exp
eri
en
ce.
Stein
et
al.(2
00
9)
ED
pat
ien
ts1
2cre
den
tial
ed
inU
Sac
co
rdin
gto
Am
eri
can
Co
llege
of
Em
erg
en
cy
Ph
ysic
ian
sgu
idelin
es,
8in
pro
cess
of
cre
den
tial
ing
and
had
receiv
ed
a
16
-ho
ur
intr
od
ucto
ryco
urs
e.A
llp
hys
icia
ns
pra
cti
ced
perf
orm
ing
US-
gu
ided
IVs
for
6m
on
ths
trai
nin
gp
eri
od
pri
or
tost
ud
y.G
oal
was
no
t
toas
sess
wh
eth
er
asu
bgro
up
of
hig
hly
trai
ned
ph
ysic
ian
sco
uld
perf
orm
this
tech
niq
ue
bett
er.
Fu
rth
er
stu
dy
isre
co
mm
en
ded
to
dete
rmin
ew
heth
er
there
isa
ph
ysic
ian
trai
nin
gth
resh
old
atw
hic
h
pat
ien
tsar
elikely
tob
en
efi
tm
ore
co
nsi
sten
tly
Note
:ED
=em
erg
en
cy
dep
artm
en
t,EM
=em
erg
en
cy
med
icin
e,IV
=in
trav
en
ou
s,LA
=lo
ng
axis
,SA
=sh
ort
axis
,U
S=
ult
raso
un
d.
LWW/AENJ TME200073 April 29, 2010 19:10 Char Count= 0
188 Advanced Emergency Nursing Journal
perceived as a nurse’s procedure. Patientsbenefit from decreased exposure to risk fromcentral venous access and, as cited in the liter-ature, experience satisfaction during their EDvisit with this nurse-provided intervention.
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