developing and sustaining an ultrasound-guided peripheral ... · lww/aenj tme200073 april 29, 2010...

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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


174 Advanced Emergency Nursing Journal

Figure 1. DUH ED nurse, P. Stone, using ultra-sonography to start IV. Reprinted with permissionof 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


April–June 2010 ! Vol. 32, No. 2 Ultrasound-Guided Peripheral IV Access Program 175

Tab

le1.

Inci

denc

eof

com

plic

atio

nsfr

omul

tras

ound

-gui

ded

per

iphe

ralI

Vac

cess

byEM

phy

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ans

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stan

tin

oM

ills

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tin

get

al.

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nK

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etal

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al.,

2005

etal

.,20

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pre

sset

al.,

2009

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mp

lica

tio

nty

pe

(N=

100)

(N=

60)

(N=

25)

(N=

180)

(N=

59)

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hani

cal

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filtr

ated

orfe

llou

t0

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sthe

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eter

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ure,

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ion

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ial

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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 EMERGENCYDEPARTMENT’S US-GUIDEDPERIPHERAL 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



Tab

le2.

Com

par

ison

ofab

ility

wit

hU

S-gu

ided

per

iphe

ral

IVac

cess

bydi

ffer

ent

clin

icia

ns(A

pon

teet

al.,

2007

;B

aum

anet

al.,

2009

;B

rann

amet

al.,

2004

;Cos

tant

ino

etal

.,20

05;K

eyes

etal

.,19

99;M

ills

etal

.,20

07;S

tein

etal

.,20

04;S

tein

etal

.,20

09;W

hite

etal

.,20

07;

Wit

ting

etal

.,in

pre

ss)

Sub

ject

sw

ith

succ

essf

ul

Tim

eto

succ

essf

ul

US-

guid

edIV

Nu

mb

ero

fTy

pe

of

Nu

mb

ero

fU

S-gu

ided

can

nu

lati

on

on

can

nu

lati

on

wh

ensu

cces

sfu

lat

tem

pts

per

Inci

den

ceo

fcl

inic

ian

/stu

dy

sub

ject

sfi

rst

atte

mp

to

nfi

rst

atte

mp

tsu

bje

ctco

mp

lica

tio

ns

EM

atte

nd

ing

ph

ysic

ian

Stei

net

al.(

2009

)28

Not

rep

orte

dse

par

atel

y39

±52

(Mea

sure

din

min

utes

from

enro

llmen

tto

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dre

turn

;co

uld

use

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ortw

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chni

que

and

itw

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tre

por

ted

whi

chon

ew

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ed)

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1Se

eTa

ble

1

EM

atte

nd

ing

ph

ysic

ian

and

resi

den

tp

hys

icia

nK

eyes

etal

.(19

99)

100

73%

77±

129

(Mea

sure

din

seco

nds

whe

ntr

ansd

ucer

pla

ced

onsk

inan

dve

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ated

;use

dtw

o-p

erso

nte

chni

que,

tim

est

arte

daf

ter

clea

ning

)

Not

mea

sure

dSe

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ble

1

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net

al.(

2004

)15

86%

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mea

sure

d1.

3N

otm

easu

red

Cos

tant

ino

etal

.(2

005)

3997

%4

±5.

6(M

easu

red

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inut

esfr

omne

edle

pun

ctur

eto

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cann

ulat

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1.7

±0.

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eTa

ble

1

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set

al.(

2007

)25

61%

3±

5(M

easu

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inm

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hen

tran

sduc

erp

lace

don

skin

and

vein

cann

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ould

use

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ortw

o-p

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chni

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and

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asno

tre

por

ted

whi

chon

ew

asus

ed)

1.52

See

Tabl

e1

(con

tin

ues

)



Tab

le2.

Com

par

ison

ofab

ility

wit

hU

S-gu

ided

per

iphe

ral

IVac

cess

bydi

ffer

ent

clin

icia

ns(A

pon

teet

al.,

2007

;B

aum

anet

al.,

2009

;B

rann

amet

al.,

2004

;Cos

tant

ino

etal

.,20

05;K

eyes

etal

.,19

99;M

ills

etal

.,20

07;S

tein

etal

.,20

04;S

tein

etal

.,20

09;W

hite

etal

.,20

07;

Wit

ting

etal

.,in

pre

ss)

(Con

tin

ued

)

Sub

ject

sw

ith

succ

essf

ul

Tim

eto

succ

essf

ul

US-

guid

edIV

Nu

mb

ero

fTy

pe

of

Nu

mb

ero

fU

S-gu

ided

can

nu

lati

on

on

can

nu

lati

on

wh

ensu

cces

sfu

lat

tem

pts

per

Inci

den

ceo

fcl

inic

ian

/stu

dy

sub

ject

sfi

rst

atte

mp

to

nfi

rst

atte

mp

tsu

bje

ctco

mp

lica

tio

ns

EM

atte

nd

ing

ph

ysic

ian

and

resi

den

tp

hys

icia

n(9

5%o

fat

tem

pts

),p

hys

icia

nas

sist

ant

(3%

of

atte

mp

ts),

regi

ster

edn

urs

e(1

%o

fat

tem

pts

)W

itti

nget

al.i

np

ress

)18

056

%N

otm

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red

1.32

See

Tabl

e1

Cer

tifi

edre

gist

ered

nu

rse

anes

thet

ist

Ap

onte

etal

.(20

07)

1974

%18

7.3

±22

8.3

(Mea

sure

din

seco

nds

whe

ntr

ansd

ucer

pla

ced

onsk

inan

dve

inca

nnul

ated

;use

don

e-p

erso

nte

chni

que,

tim

est

arte

dbe

fore

clea

ning

)

1.4

±0.

7N

otre

por

ted

Em

erge

ncy

dep

artm

ent

tech

nic

ian

(EM

tech

nic

ian

-par

amed

ico

rE

Mte

chn

icia

n-i

nte

rmed

iate

)W

hite

etal

.(20

07)

4575

.6%

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mea

sure

d1.

29±

0.56

0B

aum

anet

al.(

2009

)75

80.5

%26

.8(M

easu

red

inm

inut

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hen

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tove

inca

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±0.

79.

8%ar

teri

alp

unct

ures

wit

hno

dist

alva

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arco

mp

rom

ise,

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ding

stop

ped

wit

h5-

min

com

pre

ssio

n;he

mat

oma

29.3

%;n

erve

pai

n2.

4%E

mer

gen

cyn

urs

eB

rann

amet

al.

(200

4)32

187

%N

otm

easu

red

Not

mea

sure

d1.

2%,a

llar

teri

alp

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ures

Chi

nnoc

k,T

horn

ton,

&H

endy

;200

7

119

44%

Not

mea

sure

dN

otm

easu

red

4.2%

arte

rial

;2.5

%ar

mnu

mbn

ess;

6.7%

seve

rep

ain;

allr

esol

ved

duri

ngED

stay

Not

e:EM

=em

erge

ncy

med

icin

e,IV

=in

trav

enou

s,U

S=

ultr

asou

nd.



Table 3. Summary of ultrasound didactic training

Ultrasound physics—30 min Highlighting potential physiological effects affecting safety:ultrasonography enhances inflammatory response; and itcan heat soft tissue

Operation of US machine—30 min Screen settings, gain, field depth, and image optimizationHow to scan—1 hr Use of ultrasonographic gel, transducer probe selection,

transverse or longitudinal beam, pressure of probe, needletip location, and anatomy

US-guided IV procedure—1 hr Preparation, transducer probe orientation, equipmentpositioning, 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 ofthe 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, thisis not the case, because only a portion of theneedle can be tracked as it passes through theUS beam under the transducer probe (Blaivas etal., 2003). If the nurse prefers to gain IV accesswith the short-axis approach, we emphasize thetechnique with the US transducer probe of fan-ning off the end of the needle tip to visualize thebevel end. This deforms the target vessel priorto cannulation and then upon insertion, position-ing the US transducer probe with the long-axisview for definitive confirmation of location andeffective function potential (Supplemental DigitalContent, Videos demonstrating this are availableat 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



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 accessReviews most recent history and physical, medication history, and

allergiesConfirms patient identification armband

Planning for procedure Collects necessary supplies, personal protective equipment, and sets upas needed

Explains procedure to patientTeaches patient symptoms to report during procedure

Patient safety Differentiates and identifies arteries versus veins using ultrasonographyUtilizes appropriate infection-control measures to reduce risk of invasive

line infectionDetermines the depth of the target vein utilizing depth scale on US

device and selects the appropriate length IV catheter (1.16 in. forstandard, 1.88 in. for deeper target veins)

Removes tourniquet promptly when indicatedMonitors line patency and infusion to detect signs and symptoms of

infiltrationEvaluation Confirms blood return, easy flush, and absence of swelling or tenderness

at siteDocuments use of ultrasonography for IV placement, catheter size,

length, location, and site conditionLabels IV site with insertion date, catheter size, and whether deep

brachial vein was usedReevaluates site frequently for signs of infiltrationEvaluates 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



Figure 2. First two images show transducer place-ment for short-axis (transverse) view includinghow image appears on ultrasound machine screen.Last two images show transducer placement forlong-axis (longitudinal) view including how imageappears on ultrasound machine screen. Used withpermission 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, whitepoint in center of vein at a depth of approxi-mately 1 cm. Bright white dots are depth indicatorsspaced at 1 cm increments.

Figure 4. A cannulated vein using the long-axis(longitudinal) view, cannula appears as long whiteline in middle of vein at a depth of approximately 1cm. Bright white dots are depth indicators spacedat 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



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 thevessel at a partially compressed positionand look for subtle pulsations. This mayrequire observation for several seconds.

If cannulation has already occurred, confirmabsence of pulsations by aspirating bloodhalfway or less into the extension tubingand observe for pulsatory fluctuations inthe column of blood, possibly very subtle,similar to those observed in a sphygmomanometer.

Following cannulation of the vessel, tryconfirming the position in the vessel byusing a longitudinal view. Apply mildcompression in that view to confirm thatthere are no pulsations. Pulsations wouldindicate arterial cannulation.

The color Doppler signal feature can be usedto discern catheter location and is definedas red representing blood flow toward thetransducer (arterial) and bluerepresenting blood flow away from thetransducer (venous).

An arterial blood gas can be analyzed toevaluate 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



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



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



Tab

le6.

Skill

acqu

isit

ion

stat

emen

tsin

the

liter

atur

e(A

pon

teet

al.,

2007

;B

aum

anet

al.,

2009

;B

laiv

aset

al.,

2003

;B

laiv

aset

al.,

2006

;B

rann

amet

al.,

2003

;Bra

nnam

etal

.,20

04;C

osta

ntin

oet

al.,

2005

;Key

eset

al.,

1999

;Ste

inet

al.,

2004

;Ste

inet

al.,

2009

;Wit

ting

etal

.,in

pre

ss)

Ref

eren

ceSa

mp

lety

pe

Stat

emen

tab

ou

tU

SIV

-sk

ill

acq

uis

itio

n

Key

eset

al.(

1999

)EM

atte

ndin

gp

hysi

cian

and

resi

dent

phy

sici

an

EDp

atie

nts

EMat

tend

ing

phy

sici

anor

seni

orre

side

nts

who

had

US

exp

erie

nce

and

unde

rwen

tbr

ief

trai

ning

inid

enti

ficat

ion

ofde

epbr

achi

alan

dba

silic

vein

Bla

ivas

etal

.(20

03)

Sim

ulat

edin

anim

ate

arm

mod

elSt

udie

dno

vice

US

user

sEM

resi

dent

phy

sici

ans

30-m

inut

edi

dact

icse

ssio

n,th

enim

med

iate

lyat

tem

pte

dU

SIV

acce

ssw

ith

100%

succ

ess

rate

Litt

lein

vest

igat

ion

rega

rdin

gte

achi

ngm

odel

sfo

rU

SIV

acce

ssha

vebe

enre

por

ted

Ifef

fici

ency

isth

ego

al,t

each

shor

t-axi

sap

pro

ach

first

beca

use

ityi

elds

fast

est

acce

ssB

rann

amet

al.(

2003

)Si

mul

ated

inan

imat

ear

mm

odel

Stud

ied

novi

ceU

Sus

ers

EMre

side

ntp

hysi

cian

s30

-min

ute

dida

ctic

sess

ion,

then

imm

edia

tely

atte

mp

ted

US

IVac

cess

eith

erus

ing

SAor

LAap

pro

ach.

Mea

nti

me

toSA

was

2.36

min

and

LAw

as5.

02m

indi

ffer

ence

stat

isti

cally

sign

ifica

nt(p

=0.

03).

Mea

ndi

ffic

ulty

scor

esfo

rSA

and

LAw

ere

3.99

and

5.86

(dif

fere

nce

not

stat

isti

cally

sign

ifica

nt)

Nov

ice

US

user

sob

tain

vasc

ular

acce

ssm

uch

fast

erus

ing

SAap

pro

ach

Bra

nnam

etal

.(20

04)

EDp

atie

nts

Non

eof

the

nurs

esha

dus

edU

Sp

revi

ousl

yfo

ran

yap

plic

atio

nB

laiv

aset

al.(

2006

)B

oth

stud

ies

used

sam

esa

mp

leof

emer

genc

ynu

rses

Perf

orm

edU

Saf

ter

45-m

inut

edi

dact

icse

ssio

nw

ith

hand

s-on

pra

ctic

ew

ith

sim

ulat

edin

anim

ate

arm

mod

el89

%su

cces

sra

tew

ith

SAte

chni

que,

85%

succ

ess

rate

wit

hLA

tech

niqu

e(d

iffe

renc

eno

tst

atis

tica

llysi

gnifi

cant

)N

urse

sre

por

ted

decr

ease

inp

erce

ived

diff

icul

tyin

obta

inin

gIV

acce

ssby

US

desp

ite

the

use

ofte

chno

logy

bein

gne

w—

fam

iliar

izat

ion

wit

heq

uip

men

tan

dte

chni

que

for

both

visu

aliz

atio

nan

dca

nnul

atio

noc

curr

edqu

ickl

yan

dea

sily

(con

tin

ues

)



Tab

le6.

Skill

acqu

isit

ion

stat

emen

tsin

the

liter

atur

e(A

pon

teet

al.,

2007

;B

aum

anet

al.,

2009

;B

laiv

aset

al.,

2003

;B

laiv

aset

al.,

2006

;B

rann

amet

al.,

2003

;Bra

nnam

etal

.,20

04;C

osta

ntin

oet

al.,

2005

;Key

eset

al.,

1999

;Ste

inet

al.,

2004

;Ste

inet

al.,

2009

;Wit

ting

etal

.,in

pre

ss)

(Con

tin

ued

)

Ref

eren

ceSa

mp

lety

pe

Stat

emen

tab

ou

tU

SIV

-sk

ill

acq

uis

itio

n

The

mos

tdi

ffic

ult

skill

was

dep

ende

nce

oney

e–ha

ndco

ordi

nati

on(v

isua

lizin

gth

eve

inon

the

US

mac

hine

scre

enan

dm

aint

aini

ngp

rop

ertr

ansd

ucer

pro

bep

lace

men

tw

ith

one

hand

and

cann

ulat

ion

wit

hth

eot

her)

Stei

net

al.(

2004

)EM

Att

endi

ngPh

ysic

ians

EDp

atie

nts

The

nurs

ew

ould

seek

the

assi

stan

ceof

ap

hysi

cian

com

fort

able

wit

hU

S-gu

ided

per

iphe

ralI

Vca

nnul

atio

n.C

osta

ntin

oet

al.(

2005

)EM

atte

ndin

gp

hysi

cian

and

resi

dent

phy

sici

an

EDp

atie

nts

Phys

icia

nsw

ere

fam

iliar

wit

hU

Sfr

omre

side

ncy

trai

ning

—3-

wee

kED

rota

tion

wit

hso

lefo

cus

ondo

ing

US,

15hr

ofdi

dact

icle

ctur

ean

d10

0em

erge

ncy

US

scan

sp

erfo

rmed

Mor

eex

peri

ence

dw

asde

fined

asp

hysi

cian

who

pla

ced

mor

eth

an10

pre

viou

sU

S-gu

ided

IVca

thet

ers

wit

hex

per

ienc

era

ngin

gfr

omno

pre

viou

sU

S-gu

ided

IVac

cess

exp

erie

nce

to50

orm

ore

pla

cem

ents

Ap

onte

etal

.(20

07)

Cer

tifie

dre

gist

ered

nurs

ean

esth

etis

ts

Peri

oper

ativ

ep

atie

nts

Cer

tifie

dre

gist

ered

nurs

ean

esth

etis

tsp

laci

ngth

eca

thet

ers

wer

ew

ell

exp

erie

nced

inth

eus

eof

US

(3ye

ars’

exp

erie

nce)

.Op

erat

ors

wit

ha

rang

eof

exp

erie

nce

inU

Ssh

ould

bein

clud

edin

futu

rein

vest

igat

ions

Chi

nnoc

k,T

horn

ton,

&H

ende

y;20

07Em

erge

ncy

Nur

ses

EDp

atie

nts

Perf

orm

edU

Saf

ter

90m

inut

edi

dact

icse

ssio

nw

ith

hand

son

pra

ctic

ew

ith

sim

ulat

edin

anim

ate

arm

mod

el.T

rain

edon

lyin

shor

t-axi

sap

pro

ach.

Wor

k-sh

ifts

wit

hle

ssU

S-tr

aine

dnu

rses

had

mor

eca

nnul

atio

nop

por

tuni

ties

wit

hm

odes

tim

pro

vem

ent

insk

ill.I

nclu

sion

crit

eria

limit

edp

atie

ntse

lect

ion

tow

orst

acce

ssp

atie

nts

mak

ing

nurs

esw

ait

mon

ths

inbe

twee

nat

tem

pts

lead

ing

tola

ckof

conf

iden

cean

dde

cay

insk

ill.P

ossi

ble

solu

tion

wou

ldbe

totr

ain

alln

urse

san

dto

dooc

casi

onal

refr

eshe

rsto

mai

ntai

nsk

ill.

Wit

ting

etal

.(in

pre

ss)

EMat

tend

ing

and

resi

dent

phy

sici

ans

(95%

ofat

tem

pts

),p

hysi

cian

assi

stan

ts(3

%of

atte

mp

ts),

and

regi

ster

ednu

rses

(1%

ofat

tem

pts

)

EDp

atie

nts

Succ

ess

rate

low

est

ingr

oup

wit

hle

ssth

an20

pri

orat

tem

pts

and

pla

teau

saf

ter

20at

tem

pts

(con

tin

ues

)



Tab

le6.

Skill

acqu

isit

ion

stat

emen

tsin

the

liter

atur

e(A

pon

teet

al.,

2007

;B

aum

anet

al.,

2009

;B

laiv

aset

al.,

2003

;B

laiv

aset

al.,

2006

;B

rann

amet

al.,

2003

;Bra

nnam

etal

.,20

04;C

osta

ntin

oet

al.,

2005

;Key

eset

al.,

1999

;Ste

inet

al.,

2004

;Ste

inet

al.,

2009

;Wit

ting

etal

.,in

pre

ss)

(Con

tin

ued

)

Ref

eren

ceSa

mp

lety

pe

Stat

emen

tab

ou

tU

SIV

-sk

ill

acq

uis

itio

n

Bau

man

etal

.(20

09)

EDte

chni

cian

sED

pat

ient

sPe

rfor

med

US

afte

r1-

hour

dida

ctic

sess

ion

wit

hha

nds-

onp

ract

ice

wit

hsi

mul

ated

inan

imat

ear

mm

odel

Del

ayin

tim

eto

acce

ssm

ayha

vebe

ena

resu

ltof

EDte

chni

cian

s’in

exp

erie

nce

wit

hth

eU

Sm

achi

nean

dth

ete

chni

que

orlo

cati

nga

suit

able

site

.Pre

viou

sst

udie

sus

edre

side

nts

and

EMat

tend

ing

phy

sici

ans

wit

hco

nsid

erab

leU

Sex

per

ienc

e.St

ein

etal

.(20

09)

EDp

atie

nts

12cr

eden

tial

edin

US

acco

rdin

gto

Am

eric

anC

olle

geof

Emer

genc

yPh

ysic

ians

guid

elin

es,8

inp

roce

ssof

cred

enti

alin

gan

dha

dre

ceiv

eda

16-h

our

intr

oduc

tory

cour

se.A

llp

hysi

cian

sp

ract

iced

per

form

ing

US-

guid

edIV

sfo

r6

mon

ths

trai

ning

per

iod

pri

orto

stud

y.G

oalw

asno

tto

asse

ssw

heth

era

subg

roup

ofhi

ghly

trai

ned

phy

sici

ans

coul

dp

erfo

rmth

iste

chni

que

bett

er.F

urth

erst

udy

isre

com

men

ded

tode

term

ine

whe

ther

ther

eis

ap

hysi

cian

trai

ning

thre

shol

dat

whi

chp

atie

nts

are

likel

yto

bene

fitm

ore

cons

iste

ntly

Not

e:ED

=em

erge

ncy

dep

artm

ent,

EM=

emer

genc

ym

edic

ine,

IV=

intr

aven

ous,

LA=

long

axis

,SA

=sh

ort

axis

,US

=ul

tras

ound

.



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.

REFERENCES

Aponte, H., Acosta, S., Rigamonti, D., Sylvia, B., Austin, P.,& Samolitis, T. (2007). The use of ultrasound for place-ment of intravenous catheters. American Associationof Nurse Anesthetists Journal, 75, 212–216.

Bauman, M., Braude, D., & Crandall, C. (2009).Ultrasound-guidance vs. standard technique indifficult vascular access patients by ED technicians.American Journal of Emergency Medicine, 27,135–140.

Blaivas, M. (2005). Ultrasound-guided peripheral IV inser-tion in the ED. American Journal of Nursing, 105,54–57.

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