developing and sustaining an ultrasound-guided …...april–june 2010 vol. 32, no. 2...

16
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 T HE utility of ultrasonography in the emergency department (ED) has been well 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 University Medical Center (Dr Lopez), and Duke University Hospi- tal Emergency Department (Mr Stone), Durham, North Carolina. Supplemental digital content is available for this arti- cle. Direct URL citations appear in the printed text and are 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 to evaluate multiple organ systems in different clinical scenarios. It is also used for central and peripheral venous catheter access. The use of EM ultrasonography that falls into the traditional practice of the emergency nurse is peripheral intravenous (IV) access. Even the most experienced emergency nurse may have difficulty obtaining IV access in patients with conditions such as injection drug use, obesity, chronic illness, hypovolemia, shock, vasculopathy, and extremes of age. These pa- tients lack easy access to peripheral venous sites using the traditional techniques of di- rect visualization, anatomic landmarks, pal- pation, and trial-and-error blind cannulation. 173

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Page 1: Developing and Sustaining an Ultrasound-Guided …...April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 175 Table 1. Incidence of complications from ultrasound-guided

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

Page 2: Developing and Sustaining an Ultrasound-Guided …...April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 175 Table 1. Incidence of complications from ultrasound-guided

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

Page 3: Developing and Sustaining an Ultrasound-Guided …...April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 175 Table 1. Incidence of complications from ultrasound-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

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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

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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

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

178 Advanced Emergency Nursing Journal

Tab

le2

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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

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(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

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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

)

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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

,&

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dy;

20

07

11

94

4%

No

tm

eas

ure

dN

ot

meas

ure

d4

.2%

arte

rial

;2

.5%

arm

nu

mb

ness

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.7%

seve

re

pai

n;al

lre

solv

ed

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rin

g

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stay

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=em

erg

en

cy

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trav

en

ou

s,U

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raso

un

d.

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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

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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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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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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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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

)

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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

)

Page 15: Developing and Sustaining an Ultrasound-Guided …...April–June 2010 Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 175 Table 1. Incidence of complications from ultrasound-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 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.

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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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