In the United States, at least 150–200 million intravascular/peripheral intravascular (IV/PIV) devices are inserted annually. Furthermore, approximately 80% of patients receive an IV when admitted to the hospital.1 Many factors may complicate IV access including obesity, IV drug abuse, and chronic medical problems such as kidney disease.1 More recently, ultrasound (US) has been used to assist with visualizing peripheral vasculature during the catheter insertion process, and this approach has gained significant popularity. However, many investigators report that formal training is necessary for successful cannulation with US-guided peripheral IVs (USGPIVs).2 Recent studies have shown that USGPIVs are equally as dependable and as safe as, if not superior to, the IVs inserted using standard of care.3–5
Successfully inserting an intravascular device is a fundamental skill for a clinical health care provider, particularly the practicing bedside nurse. Researchers have estimated that 60–90% of hospitalized health care consumers have benefited from IV catheters, and approximately 300 million IV catheters are used annually in the United States.6 Many of the initial IV catheters' health care providers insert on admission to the hospital will ultimately need replacement due to infiltration during the patient's hospital stay. Historically, provider attempts at vascular access using palpation of the veins and identification of landmarks while blindly inserting an IV device with a goal of successful cannulation of the appropriate vascular structure have been the norm. This blind technique often rendered multiple unsuccessful attempts, which may result in delayed medication administration, dissatisfied patients, and physician intervention likely ending with unnecessary central venous line (CVLs) insertions for difficult to access patients.7
Because of the need for vascular access in the hospitalized patient, the bedside nursing staff must be competent in this skill. In recent years, however, bedside nurses have seen a decline in utilization of the skills and competencies for placing IV devices. Numerous organizations have developed specialized teams for ensuring the efficient, effective, and safe placement of vascular devices. The paradigm shift from bedside nurse competency for IV placement to a specialized team or group of providers has resulted in a lack of the necessary skills and competencies for vascular access placement at the bedside. For bedside nurses, this lack of skill or competency in care may result in a lack of efficiency and negative patient outcomes. Treatment of patients through therapeutic intervention, such as medication administration or fluid volume replacement, may be delayed when IV access is not established in a timely fashion.
The purpose of this article is to describe a simulation and competency assessment intervention aimed at increasing the proficiency of the staff nurse in the emergency department (ED) for placing US-guided intravascular catheters, with a goal of reducing the number of inappropriate referrals to comprehensive vascular access team (CVAT).
In the organization for this study, the CVAT was created in 2017 to help reduce delays in medical treatment, specifically treatments involving fluid replacement and medication administration. The CVAT currently serves as a specialty consult team for IV access and other more advanced vascular access procedures. Comprehensive vascular access team provides access such as peripheral IVs, USGPIVs, modified Seldinger technique (MST) midlines, peripherally inserted central catheters (PICCs), and CVLs as appropriate for individual patient's medical treatments.
In 2018, the CVAT team received over 2,200 consults for peripheral IV access from staff of this specialty group. This figure represented approximately 25% percentage of all consults to the CVAT team. During this period, registered nurses (RN)/staff nurses, in the ED, were requesting a higher volume of CVAT consultations, not only for IVs but also for laboratory work on patients who were not considered difficult IV access opportunities, in turn, increasing the CVAT volume. This pattern of consults resulted in a higher volume of inappropriate consults, and an inefficient use of CVAT resources.
The ED nursing staff most often avoided attempts at peripheral IV placement in three specific patient populations, adults with a history of chronic kidney disease (CKD), end-stage renal failure, and morbidly obese patients. In an effort to improve staff confidence with peripheral IV placement, and to decrease inappropriate referrals to the CVAT team by 25%, the study team proposed an improvement intervention. The 6-week improvement intervention included establishing IV experts in the ED to specifically target US-guided placement of peripheral IVs in adults with a history of CKD, end-stage renal disease, and/or morbid obesity.
The health system setting for our improvement project was an academic medical center in the southeastern United States. The facility is designated as an urban, academic medical center with approximately 1,100 beds. The medical campus covers numerous city blocks with a central medical center and outlying hospitals, and a network of ambulatory clinics. In 2018, the organization treated over 360,000 outpatients and 41,000 inpatients.
The clinical setting for the improvement project was the ED of a 110-bed hospital located within the academic health system just adjacent to the main hospital campus. This smaller facility includes a dedicated 12-bed intensive care unit as well as a 15-bed ED.
The CVAT within the hospital is composed of six advanced practice providers (APPs), including nurse practitioners and physician assistants who cover the hospital 24 hours a day and 7 days a week and are based outside of the ED. This ED sees approximately 35,000 patients per year, with IV access necessary in over 80% of all patients. There are total of 16 staff nurses in the ED (8 on days/8 on nights).
Using the Plan-Do-Study-Act8,9 small test of change improvement model as the methodological framework for the improvement project, two advanced practice RNs (APRNs) with ED and CVAT experience developed an improvement intervention to target staff nurse training and competency assessment for using US-guided peripheral IV placement. The protocol for this project was approved by the organization's institutional review board (IRB) with exempt status.
The improvement team defined success of the project as a 25% decrease in total CVAT consultation and placement volume for peripheral IV access in the ED. Percentage measurement was derived before project implementation and at the end of a 6-week observation period after training and competency assessment of the ED nursing staff.
A total of 13 (81% of ED staff) ED RNs, 9 dayshift and 4 nightshift, volunteered to be trained using the USGPIV technique. Participants consisted of assistant nurse managers, charge nurses, and staff nurses. Each participant was required to have at least 2 years of ED experience.
Participants were provided training sessions for validation of competency, and these sessions took place within the organization's simulation laboratory located on the main hospital campus. The project team APRNs led the sessions, which included a refresher on IV insertion skills, overview of basic US functions, and a combination of implementing the two skills simultaneously. Training consisted of a blended, simulation-based approach involving the following steps:
- Learn/see experiences including prelearning and in class participation with video and faculty-led instruction.
- Practice simulation–based deliberate practice in the simulation laboratory with the APPs.
- Prove-learner demonstration in the simulation laboratory (Table 1 checklist).
- Do-direct patient care with supervision (Table 1 checklist).
Participants used the US system to obtain appropriate veins on a phantom arm task trainer for peripheral IV access. Each participant used the US as a guide while inserting the catheter into the vessel on the phantom arm and tracking the bevel throughout the entire procedure. This approach ensured that once a vein was identified in the mock phantom arm, the participant would be able to access vasculature without any difficulty. The participants were instructed to use their nondominant hand to control the US probe and to use their dominant hand for needle insertion. Once the needle punctured through the surface of the skin on the mock arm, participants were instructed to watch the US monitor as they no longer needed to look down at the phantom arm for confirmation. When the bevel was in the middle of the vessel, participants were directed to put down the US probe, advance the catheter over the needle, and dress the phantom arm normally as they would for a traditional IV.
Participants were required to demonstrate competency in the clinical setting after completing steps 1–3 within the simulation laboratory. Step 4 required that the participants start USGPIV insertions on live patients under direct supervision of the APP. Each participant was required to successfully attempt and achieve five unassisted but supervised USGPIVs to be deemed competent. Emergency department RNs participating in the intervention began using this technique independently in their unit once the defined measure of competency was achieved.
Data Collection and Analysis
Descriptive statistics (frequency and percentage) were used to analyze the project outcomes. Chi-square10 and Fisher's exact10 tests were also used to compare the proportions of USGPIVs inserted by ED RNs compared with the CVAT team. All analyses were performed using QI Macros statistical software in Excel.11–13
Using April and May 2019 as a baseline, the CVAT inserted 438 USGPIV during the 2-month period, averaging about 219 PIV placements per month. During the intervention period between June 1 and July 15, 2019, the CVAT and the ED RNs placed a total of 430 USGPIV. The CVAT placed 341 of the 430, 79% of the USGPIVs. Of the total 430 USGPIVs placed during the intervention timeframe, the ED RNs placed a total of 89 PIV catheters, which resulted in a 21% decrease in CVAT consults and placements.
The CVAT and ED staff placed a total of 212 USGPIVs on dayshift, and a total of 218 USGPIVs on nightshift. In the ED, dayshift RNs placed significantly fewer USGPIVS (12%) relying more heavily on CVAT compared with ED nightshift RNs who placed 29% of the USGPIVs (p < .001) using chi-square analysis (Table 2). A control chart analysis depicts only common cause variation in the volume trends for CVAT consultation and placement of PIVs. The USGPIV placement by the ED RN staff did not result in a statistically significant or process control change in the CVAT volume of consult and placement of PIVs after intervention (Figure 1). A decrease in USGPIV consults and placements by the CVAT at the beginning of June 2019 is displayed on the control chart; at the time, the intervention was initially implemented (Figure 1).
The project team found that as a result of the simulation training and competency validation, ED RNs using the USGPIV technique decreased the total volume CVAT consults for peripheral IV placement. Although the project goal of a 25% reduction in the referrals and use of the CVAT for PIV placement was not met, the team did observe a 21% decrease in CVAT referral and placement for PIV over 6 weeks. The study team believed that while the 21% decrease in consults and placement of PIVs to the CVAT failed to be statistically significant, the outcome was clinically significant. The ED RNs were able to place 89 USGPIVs from the time of project initiation on June 1, 2019, until project completion on July 15, 2019, which allowed CVAT to assist patients with other more complicated and advanced IV devices such as MST midlines, PICC lines, and CVLs.
Although there were nine ED RNs trained on day shift in comparison with four trained ED RNs on nightshift, the nightshift RNs outperformed the day shift with 29% of the total volume of USGPIV placements compared with the 12% from dayshift during the allotted timeframe. This finding may suggest that the nightshift RNs were more quickly able to achieve comfort with the technical aspects of the US technique than their dayshift peers. Several factors could have contributed to this nightshift success such as the individual RN, the RN's initiative or drive, years of experience, patient factors such as vasculature, difficult anatomy, patient arrival time, and decreased availability of CVAT members at night. RNs who were not able to place as many IVs using the US as their peers may have possibly benefitted from another simulation laboratory training or additional supervised practice.
The CVAT USGPIV control chart (Figure 1) displayed common cause variation with no shift in the process control for the CVAT PIV consultation and placement volume from baseline to postimplementation of the intervention. The CVAT volume of USGPIV consult and placement decreases during the first month of the intervention; however, the volume returned to baseline during the following weeks of the intervention. Although the CVAT continued to receive similar numbers PIV access consults during the intervention timeframe, the consults appeared to be reflective of a shift in the type and complexity of the device required. The CVAT team performed a larger volume of placements of advanced devices such as PICC lines. For example, the CVAT inserted 64 PICCs in the month of June 2019 compared with 45 PICCs in April 2019 and 52 PICCs in May 2019, a 33% and 23% difference, respectively. This described shift in the type of devices placed by the CVAT aligns with the team's project goal of allowing the CVAT to be readily available for more advanced device placement.
When comparing the outcomes of this project to similar research,7 the project team determined that formal training was vital to the successful cannulation of vessels using the ED RN nurse-directed US-guided approach. Similar methods were used for training in the organization of study as those reported in the published literature, including participant requirement of 2 years of ED experience, completion of didactic education, and competency assessment after a designated number of supervised, successful USGPIVs placements.
There are limitations for this improvement project. First, the study was limited to a 6-week timeframe, which may have been insufficient to observe statistically significant process changes. The project was implemented at a single institution in the ED, so generalizability or spread capacity is unknown and likely will vary by location. The ED for this organization has a dedicated US machine, which was readily available for the RNs to use for their patients. Smaller institutions may not have similar resources for US equipment. Finally, the project team did not collect patient characteristics on patients requiring CVAT consult versus those that could successfully be placed the ED RN staff. It is possible that patients with certain conditions or chief complaints regularly require more advanced care comparable with that which CVAT providers deliver.
The project team plans to spread this evidence-based intervention on a larger scale throughout the health system. The spread process will begin with training for all ED RNs, and then the process will be expanded to targeted inpatient nursing units with high-volume CVAT consults for PIV placement. A longer observation period beyond 6 weeks is recommended to better test and refine the training and simulation program. Spreading the described US-guided PIV placement simulation and training intervention on a broader scale throughout the organization of study has the potential to ensure and maintain RN competency for peripheral IV placement, decrease delays in IV medication therapy, length of stay, and health care costs; and increase patient satisfaction.
As more people are diagnosed with obesity and chronic illnesses such as CKD, our institution is experiencing increasing difficulty with obtaining successful IV access during and after admission. The study team demonstrated through this project that formally training RNs to use an US-guided approach to PIV placement may decrease inappropriate consults to a CVAT. Furthermore, ED RNs with competency in USGPIV placement allowed a CVAT more dedicated time to placement of advanced devices such as midline catheters, PICC lines, and CVLs.
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3. Saltarelli NA, VanHouten J, Boyd J, Rupp J, Ferre RM. 377 Infiltration rates are similar in ultrasound-guided and traditionally placed peripheral IVs in admitted emergency department patients with difficult IV access. Ann Emerg Med. 2015;66:S137.
4. Warrington WG, Aragon Penoyer D, Kamps TA, Van Hoeck EH. Outcomes of using a modified seldinger technique for long term intravenous therapy in hospitalized patients with difficult venous access. J Assoc Vasc Access. 2012;17(1):24–30.
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Somali Nguyen, DNP, AGACNP-BC, is the lead nurse practitioner for the CVAT and medical emergency team at the University of Alabama at Birmingham (UAB) Highlands Medical Center, Birmingham, Alabama. He received his Bachelor's degree of Science in Nursing (2010), Master's degree of Science in Nursing (2014), and Doctor of Nursing Practice (2019) degree all from the UAB. Before his role as lead nurse practitioner, he practiced emergency medicine for 2 years. Nguyen is board certified as an adult and gerontology acute care nurse practitioner and specializes in emergency medicine. He may be contacted at firstname.lastname@example.org.
Allison Jones, PhD, RN, is an assistant professor at the University of Alabama at Birmingham (UAB) School of Nursing and serves as Co-Director of the School's BSN Honors Program. She received her Bachelor's degree in Nursing (2006), Master's degree in Nursing (2012), and Doctor of Philosophy in Nursing (2015) all from the University of Kentucky. Her research focuses on outcomes associated with use of older stored blood in patients with major trauma and patient blood management across the care spectrum. She is certified as a Clinical Nurse Specialist in Adult Acute Care and also in Patient Blood Management. Dr. Jones is trained in Clinical and Translational Sciences as well as Minority Health and Health Disparities research.
Shea Polancich, PhD, RN, is column editor for the Journal of Healthcare Quality Department titled: Translation of Research into Healthcare Quality Practice. Dr. Polancich has been practicing in quality and patient safety for over 15 years. She is currently an associate professor and assistant dean at the University of Alabama at Birmingham (UAB) School of Nursing with a primary practice at the UAB Medical Center, Birmingham, Alabama, as a director specializing in nursing improvement, innovation, and analytics. Formerly, her roles included the Director for Quality and Patient Safety at Vanderbilt University Medical Center, Director of Data Analysis and Measurement at Texas Health Resources, NIH/NINR research intern, and health policy fellow at George Mason University. She served on an NQF advisory group specific to patient safety and adverse events.
Terri Poe, DNP, RN, NE-BC, is the senior associate vice president and chief nursing officer (CNO) for the University of Alabama Hospital (Birmingham). She received her Bachelor's degree of Nursing (1986), Master's degree of Public Administration (1993), and Doctorate degree of Nursing Practice (2013) all from the University of Alabama at Birmingham (UAB). Before her role as the CNO, she was the Administrative Director for Emergency Services and has served as a nursing leader for over 3 decades. She is 2015 graduate from the America's Essential Hospital fellowship program.
April Garrigan, DNP, MSN, FNP-BC, is the advanced practice provider (APP) manager for the EDs at the University of Alabama at Birmingham (UAB) Medical center including UAB Highlands in Birmingham, Alabama, and UAB freestanding ED in Gardendale, Alabama. She also manages the CVAT and medical emergency team at UAB Highlands. She received her Bachelor's degree of Science in Nursing (2009) from Jacksonville State University, Master's degree of Science in Nursing (2013) from Auburn University, and her Doctor of Nursing Practice (2019) degree at the UAB. Before her role as the APP manager, she was the UAB's ED lead nurse practitioner for 5 years. Garrigan is board certified as a family nurse practitioner and specialized in emergency medicine.
Michele Talley, PhD, ACNP-BC, FAANP, is associate professor and assistant dean for Graduate Clinical Education: MSN Program and NP Pathways at the UAB School of Nursing. She received her Bachelor's degree of Nursing (1996) from the University of Alabama, and her Master's of Science in Nursing (2005) degree as well as Doctor of Philosophy from UAB. She joined the UAB School of Nursing as faculty and brings with her extensive experience in cardiac, thoracic, and vascular surgery as well as diabetes. Talley is board certified as an adult acute care nurse practitioner.