- Email: [email protected]
Peripheral Intravenous Access Using Ultrasound Guidance: Defining the Learning Curve
O R I G I N A L
A R T I C L E
Peripheral Intravenous Access Using Ultrasound Guidance: Defining the Learning Curve Mark J. Ault, MD Ryoko Tanabe, MSN, FNP-C Bradley T. Rosen, MD, MBA, FHM Cedars-Sinai Health System, Los Angeles, CA
Abstract Background: The need for peripheral intravenous (IV) access in anatomically challenging patients is becoming a more commonly encountered clinical problem. The significant investment devoted to physician training for ultrasound-guided vascular access has not yet been matched by a similar commitment to nursing. Nurses, paramedics, and physicians are becoming more enthusiastic about peripheral IV access with ultrasound (PIVUS); however, institutional and clinician support has not yet been forthcoming. The learning curve for PIVUS has never been rigorously studied, and may be flatter than previously assumed. Methods: Registered nurses were selected to participate as trainees. Training involved 1:1 sessions consisting of formal orientation to portable ultrasound, mentoring, and practice sessions with a nurse practitioner who has expertise in ultrasound-guided peripheral vascular access; hands-on, supervised practice cannulating vessels on a nonhuman tissue simulator; and supervised attempts on live patients. Results: Seven of 8 trainees completed the training. The average number of patient encounters required to achieve 10 successful IV placements was 25 (range ¼ 18-32). The average time required for successful vessel cannulation was 19.57 minutes (range ¼ 5-62 minutes). An average of 25 attempts was required to achieve proficiency, and average of 50 cases was required to maintain consistency. Conclusions: In today’s practice environment, PIVUS skills are increasingly important. The results of our study demonstrate that, with appropriate hands-on training and supervision, these skills can be effectively taught to registered nurses. Keywords: peripheral IV placement, procedure training, ultrasound guidance
Introduction he need for peripheral intravenous (IV) access in anatomically challenging patients is becoming a more commonly encountered clinical problem.1-3 The Agency for Healthcare Research and Quality declared the use of ultrasound a requisite adjunct for patient safety during all central line placements, and ultrasound use has been enthusiastically endorsed for this purpose for many years.4 Peripheral IV
T
Correspondence concerning this article should be addressed to [email protected] http://dx.doi.org/10.1016/j.java.2014.10.012 Copyright © 2015, ASSOCIATION FOR VASCULAR ACCESS. Published by Elsevier Inc. All rights reserved.
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access using ultrasound (PIVUS) has also been studied with no appreciable difference in ability or efficacy among emergency department physicians, physician assistants, registered nurses (RNs), or technicians.5 However, efforts to pursue training for PIVUS has generally not been forthcoming, and the learning curve for PIVUS skills appears to be the main barrier.6,7 Prior studies have demonstrated similar success rates for nurses compared with other practitioners: These studies reported a success rate at first attempt ranging from 56% to 97% for emergency department physicians, 74% for nurse anesthetists, 75% to 81% for emergency department technicians, and 44% to 87% for emergency department RNs.5,8-15 Time to successful cannulation on first attempt was variable among physicians, ranging from a few minutes to about an hour.6,8-11 The number of attempts before achieving successful
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cannulation for emergency department physicians ranged from 1.3 to 3, and for emergency department technicians the range was 1.3 to 2.3.5,8-12,14 However, neither time to successful cannulation nor the number of attempts to successful cannulation were measured for nurses.14,15 We report the results of implementing a standardized training curriculum for RNs on how to place peripheral IVs using ultrasound guidance. Methods RNs from Cedars-Sinai’s Procedure Center were selected as trainees for PIVUS based on the following criteria: documented proficiency in traditionally placed peripheral IV placement, a lack of prior experience with ultrasound for vascular access, and a desire to learn the techniques necessary for PIVUS. Participation was voluntary. The ultrasound machine used for training was a Sonosite M Turbo (Sonosite Inc, Bothell, WA), with either an HFL 38 linear probe or an SLA 21 linear high frequency probe. All trainees practice PIVUS skills using either a 1.88-inch 20-gauge or an 18gauge BD Insyte Autoguard (Becton, Dickinson, and Company, Franklin Lakes, NJ). Institutional protocol for intravenous access was used, including wide sterile barriers and the use of buffered 1% lidocaine for local anesthesia. Institutional review board exemption for the study was obtained. Training consisted of 3 major phases. Phase 1 consisted of 1:1 mentoring sessions led by a nurse practitioner who had extensive expertise with ultrasound-guided peripherally inserted central catheter placement and peripheral vascular access. This initial training included a 2-hour didactic session on the principles of ultrasound and a review of vascular anatomy. Discussion and demonstration emphasized a review of basic ultrasound physics, the ultrasound probe, and knobology; how to differentiate vein from artery; how to differentiate local structures such as tendons and nerves from veins; how to select an appropriate site, vein, and angiocath (gauge and length) based on each patient’s medical history, indications for the procedure, and results of preliminary ultrasound mapping; how to select an optimal needle entry point and proper “angle of attack”; and the importance of localizing and tracking the needle tip on its way to cannulating the target vessel. The second phase of training required another 2-hour, 1:1 hands-on training session using a validated nonhuman tissue model for practice.16,17 Each trainee was required to demonstrate competency on the simulator before attempting PIVUS on patients. Competency was defined as being able to select the correct ultrasound probe, depth, and target vessel; properly positioning the target vessel in the center of ultrasound screen; correctly aligning the angiocath needle tip in the middle of the probe over the target vessel; tracking the needle tip through the skin and tissue to the vessel wall, including indenting the vessel under ultrasound guidance before cannulating; and cannulating the vessel and achieving a bull’s-eye image (Figure 1). Each trainee was required to successfully cannulate 2 large synthetic vessels (6 mm diameter) and 3 small synthetic vessels (3 mm diameter) before graduating to live patients. Once each trainee graduated from the practice environment, he or she was then permitted to attempt supervised PIVUS on patients.
Figure 1. Bulls-eye. Phase 3 involved live patients. Patients were selected for the study based on the following criteria: The presence of a physician’s order to place an ultrasound-guided IV line and either a lack of palpable or visible peripheral vessels or having a history of requiring ultrasound-guided peripheral or central venous access on prior encounters. Patients were excluded from the study if they had an allergy to lidocaine or were unwilling to consent to participate in the study. No trainee was allowed to attempt more than 3 cannulations of a single vessel or make attempts at more than 2 sites. All attempts were rated according to proficiency criteria outlined in Table 1. Proficiency was defined by the trainee achieving 10 supervised ultrasound-guided IV placements with a score of 4 or 5. Supervision was no longer required when the trainee both achieved proficiency and when IV placement was performed at the level of 4 or 5 for 3 consecutive attempts (ie, the criteria for achieving consistency). Premature termination
Table 1. Proficiency Score Definitions Proficiency score
Criteria
0
Unable to locate a suitable vessel
1
Suitable vessel located but vessel not accessed by trainee but ultimately accessed by supervisor
2
Suitable vessel located but vessel not accessed by trainee and ultimately not accessed by supervisor
3
Suitable vessel located but 3 attempts at 1 or 2 sites required
4
2 attempts at 1 or 2 sites required
5
1 successful attempt required
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Table 2. Baseline Characteristics of Trainees Trainee
Time in nursing (y)
Age group (y)
Gender
Time in proc ctr (y)
Baseline skill level
RN 1
11
35-40
F
5
Above average
RN 2
18
40-45
M
5
Above average
RN 3
11
30-35
F
3
Above average
RN 4
27
45-50
F
1
Above average
RN 5
10
35-40
F
1
Above average
RN 6
27
50-55
M
15
Above average
RN 7
15
35-40
F
2
Expert
RN 8
26
45-50
M
1
Expert
RN ¼ Registered nurse; Proc Ctr ¼ Cedars-Sinai Procedure Center.
of a given attempt (either due to trainee or patient comfort) was graded at the level of 1 or 2. The primary objective for the study was to determine the number of ultrasound-guided IV placements that needed to be performed under supervision before RN trainees achieved proficiency and consistency. Secondary outcomes included the number of minutes required for successful vessel cannulation (from initial anesthetic needle entry to bulls-eye), and the occurrence of any complications such as arterial puncture, hematoma, paresthesia, or excessive pain. Results A summary of the trainees’ baseline characteristics is summarized in Table 2. Trainees’ baseline skill was assessed by the study coordinator before training. Trainees were rated “above average” if they were able to place a traditional peripheral venous access line on their first attempt > 75% of the time and “expert” if they were able to place a traditional peripheral venous access line at first attempt > 90% of the time. Seven out of 8 trainees completed the training, and 1 trainee dropped out during Phase 2. Of the 7 trainees who completed the course, the average number of patient encounters required for 10 successful IV placements was 25, ranging from 18 to
30. For the entire study, the average time required for successful vessel cannulation was 19.57 minutes, ranging from 5 minutes to 62 minutes. For the entire study, the average time required for successful vessel cannulation was 19.57 minutes for 7 trainees (range ¼ 5-62 minutes), whereas the average time at the first attempt only (score ¼ 5) was 10.88 minutes, suggesting a clear improvement in efficiency as proficiency improves. Overall minor complication rate was 10.5% (30 out of 287 attempts), which consisted of 1 case of transient paresthesia, 1 near miss of a brachial artery, 18 hematomas, and 10 instances of significant pain. The rate of proficiency increased at a more rapid rate during the first 25 attempts, and continued to increase (albeit at a slower rate) after the second 25 attempts (Figure 2). Discussion Our study demonstrates that RNs with no prior ultrasound experience can achieve proficiency and consistency with PIVUS when given dedicated training, close supervision, and a fixed curriculum. Our study is notable for several significant findings. First, although the majority of trainees ultimately acquired expertise in ultrasound-guided IV access, there was wide variation in the number of attempts needed to attain
Figure 2. Average proficiency score.
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this skill. Second, trainees generally required a large clinical volume to achieve proficiency and consistency (25 and 50, respectively) that is greater than other documented ultrasound techniques (eg, Focused Assessment with Ultrasound in Trauma scan, abdominal aortic aneurysm screening, and central line placement). This is most likely explained by the fact that peripheral vessels represent a very small target and require a high degree of hand-eye coordination, technical dexterity, and precision to accurately localize and cannulate under ultrasound guidance. This need for greater volume should be taken into account when investing in, and setting expectations for, a PIVUS training curriculum for RNs. Third, despite traditional peripheral IV competency and a willingness to participate in the training process, not all trainees were able to successfully complete the training process. The 1 trainee who dropped out simply could not learn the ultrasound skills needed to move beyond Phase 2 of the curriculum. It is possible that technical adjuncts such as needle guide devices may be of assistance in this scenario. Additional study of devices that may affect the slope of the learning curve is warranted. Of note, our results were not calculated based on an intent-totreat analysis (ie, the dropout trainee’s preliminary results were not included in our calculations). Several factors had an influence on cannulation success. In the early part of Phase 3, trainees tended to revert toward selecting larger vessels as their target, although they had been taught in Phase 2 of the study that target size alone does not necessarily translate into successful vessel cannulation. Other vessel characteristics such as depth, location, tortuosity, and spasticity are equally important considerations. Although vessels with diameters > 0.5 cm were more likely to result in success, vessel depth > 1.6 cm decreased likelihood of success; in fact, veins at moderate depth (0.3-1.5 cm) seem to portend the greatest likelihood of successful cannulation.12,18 In addition to the technical aspects of utilizing ultrasound in vessel cannulation, it was also observed by the supervisors that patients who were agitated, combative, highly anxious, or overly skeptical appeared to have an adverse effect on trainees’ confidence, focus, and success. Limitations The greatest limitations of our study are the small number of trainees studied, and the fact that all patients who participated were enrolled in an outpatient, nonemergent setting. A larger series of trainees in more varied patient-care settings may be needed to validate the findings. Conclusions RN training to the level of proficiency and consistency in ultrasound-guided peripheral IV placement is achievable with appropriate time and training. The learning curve relative to other ultrasound applications is flat, with a high degree of individual variability in skill acquisition and retention amongst the trainees. Not every staff member can or should be expected to attain expertise in this technique. We believe that ultrasound-guided placement of peripheral IVs is becoming an increasingly important skill set for the provision
of optimal patient care and comfort, and it may be worthwhile to incorporate this into the existing skill set of IV teams. Ongoing development of training techniques and curriculum elements would help to further this important educational field. Disclosures The authors have no conflicts of interest to disclose. References 1. Dychter SS, Gold DA, Carson D, Haller M. Intravenous therapy: a review of complications and economic considerations of peripheral access. J Infus Nurs. 2012;35(2):84-91. 2. Egan G, Healy D, O’Neill H, Clarke-Moloney M, Grace PA, Walsh SR. Ultrasound guidance for difficult peripheral venous access: systematic review and metaanalysis. Emerg Med J. 2013;30(7):521-526. 3. Kerforne T, Petitpas F, Frasca D, Goudet V, Robert R, Mimoz O. Ultrasound-guided peripheral venous access in severely ill patients with suspected difficult vascular puncture. Chest. 2012;141(1):279-280. 4. Rothschild J. Chapter 21: ultrasound guidance of central vein catheterization. http://archive.ahrq.gov/clinic/ptsafety/ chap21.htm. Accessed December 13, 2014. 5. White A, Lopez F, Stone P. Developing and sustaining an ultrasound-guided peripheral intravenous access program for emergency nurses. Adv Emerg Nur J. 2010;32(2):173-188. 6. Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med. 2005;46(5):456-461. 7. Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med. 1999;34(6):711-714. 8. Mills CN, Liebmann O, Stone MB, Frazee BW. Ultrasonographically guided insertion of a 15-cm catheter into the deep brachial or basilic vein in patients with difficult intravenous access. Ann Emerg Med. 2007;50(1):68-72. 9. Stein J, Cole W, Kramer N. Ultrasound-guided peripheral intravenous cannulation emergency department patients with difficult IV access. Acad Emerg Med. 2004;11:581-582. 10. Witting M, Schenkel S, Lawner B, Euerle B. Effects of vein width and depth on ultrasound-guided peripheral IV success rates. J Emerg Med. 2010;39(1):70-75. 11. Aponte H, Acosta S, Rigamonti D, Sylvia B, Austin P, Samolitis T. The use of ultrasound for placement of intravenous catheters. AANA J. 2007;75(3):212-216. 12. Bauman M, Braude D, Crandall C. Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians. Am J Emerg Med. 2009;27(2):135-140. 13. Brannam L, Blaivas M, Lyon M, Flake M. Emergency nurses’ utilization of ultrasound guidance for placement of peripheral intravenous lines in difficult-access patients. Acad Emerg Med. 2004;11(12):1361-1363. 14. Stein J, George B, River G, Hebig A, McDermott D. Ultrasonographically guided peripheral intravenous cannulation in emergency department patients with difficult
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intravenous access: a randomized trial. Ann Emerg Med. 2009;54(1):33-40. 15. Chinnock B, Thornton S, Hendey GW. Predictors of success in nurse-performed ultrasound-guided cannulation. J Emerg Med. 2007;33(4):401-415. 16. Ault MJ, Rosen BT, Ault B. The use of tissue models for vascular access training. Phase I of the procedural patient safety initiative. J Gen Intern Med. 2006;21(5):514-517. 17. Rosen BT, Uddin PQ, Harrington AR, Ault BW, Ault MJ. Does personalized vascular access training on
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a nonhuman tissue model allow for learning and retention of central line placement skills? Phase II of the procedural patient safety initiative (PPSI-II). J Hosp Med. 2009;4(7): 423-429. 18. Panebianco NL, Fredette JM, Szyld D, Sagalyn EB, Pines JM, Dean AJ. What you see (sonographically) is what you get: vein and patient characteristics associated with successful ultrasound-guided peripheral intravenous placement in patients with difficult access. Acad Emerg Med. 2009;16(12):1298-1303.
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A R T I C L E
Peripheral Intravenous Access Using Ultrasound Guidance: Defining the Learning Curve Mark J. Ault, MD Ryoko Tanabe, MSN, FNP-C Bradley T. Rosen, MD, MBA, FHM Cedars-Sinai Health System, Los Angeles, CA
Abstract Background: The need for peripheral intravenous (IV) access in anatomically challenging patients is becoming a more commonly encountered clinical problem. The significant investment devoted to physician training for ultrasound-guided vascular access has not yet been matched by a similar commitment to nursing. Nurses, paramedics, and physicians are becoming more enthusiastic about peripheral IV access with ultrasound (PIVUS); however, institutional and clinician support has not yet been forthcoming. The learning curve for PIVUS has never been rigorously studied, and may be flatter than previously assumed. Methods: Registered nurses were selected to participate as trainees. Training involved 1:1 sessions consisting of formal orientation to portable ultrasound, mentoring, and practice sessions with a nurse practitioner who has expertise in ultrasound-guided peripheral vascular access; hands-on, supervised practice cannulating vessels on a nonhuman tissue simulator; and supervised attempts on live patients. Results: Seven of 8 trainees completed the training. The average number of patient encounters required to achieve 10 successful IV placements was 25 (range ¼ 18-32). The average time required for successful vessel cannulation was 19.57 minutes (range ¼ 5-62 minutes). An average of 25 attempts was required to achieve proficiency, and average of 50 cases was required to maintain consistency. Conclusions: In today’s practice environment, PIVUS skills are increasingly important. The results of our study demonstrate that, with appropriate hands-on training and supervision, these skills can be effectively taught to registered nurses. Keywords: peripheral IV placement, procedure training, ultrasound guidance
Introduction he need for peripheral intravenous (IV) access in anatomically challenging patients is becoming a more commonly encountered clinical problem.1-3 The Agency for Healthcare Research and Quality declared the use of ultrasound a requisite adjunct for patient safety during all central line placements, and ultrasound use has been enthusiastically endorsed for this purpose for many years.4 Peripheral IV
T
Correspondence concerning this article should be addressed to [email protected] http://dx.doi.org/10.1016/j.java.2014.10.012 Copyright © 2015, ASSOCIATION FOR VASCULAR ACCESS. Published by Elsevier Inc. All rights reserved.
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access using ultrasound (PIVUS) has also been studied with no appreciable difference in ability or efficacy among emergency department physicians, physician assistants, registered nurses (RNs), or technicians.5 However, efforts to pursue training for PIVUS has generally not been forthcoming, and the learning curve for PIVUS skills appears to be the main barrier.6,7 Prior studies have demonstrated similar success rates for nurses compared with other practitioners: These studies reported a success rate at first attempt ranging from 56% to 97% for emergency department physicians, 74% for nurse anesthetists, 75% to 81% for emergency department technicians, and 44% to 87% for emergency department RNs.5,8-15 Time to successful cannulation on first attempt was variable among physicians, ranging from a few minutes to about an hour.6,8-11 The number of attempts before achieving successful
2015
cannulation for emergency department physicians ranged from 1.3 to 3, and for emergency department technicians the range was 1.3 to 2.3.5,8-12,14 However, neither time to successful cannulation nor the number of attempts to successful cannulation were measured for nurses.14,15 We report the results of implementing a standardized training curriculum for RNs on how to place peripheral IVs using ultrasound guidance. Methods RNs from Cedars-Sinai’s Procedure Center were selected as trainees for PIVUS based on the following criteria: documented proficiency in traditionally placed peripheral IV placement, a lack of prior experience with ultrasound for vascular access, and a desire to learn the techniques necessary for PIVUS. Participation was voluntary. The ultrasound machine used for training was a Sonosite M Turbo (Sonosite Inc, Bothell, WA), with either an HFL 38 linear probe or an SLA 21 linear high frequency probe. All trainees practice PIVUS skills using either a 1.88-inch 20-gauge or an 18gauge BD Insyte Autoguard (Becton, Dickinson, and Company, Franklin Lakes, NJ). Institutional protocol for intravenous access was used, including wide sterile barriers and the use of buffered 1% lidocaine for local anesthesia. Institutional review board exemption for the study was obtained. Training consisted of 3 major phases. Phase 1 consisted of 1:1 mentoring sessions led by a nurse practitioner who had extensive expertise with ultrasound-guided peripherally inserted central catheter placement and peripheral vascular access. This initial training included a 2-hour didactic session on the principles of ultrasound and a review of vascular anatomy. Discussion and demonstration emphasized a review of basic ultrasound physics, the ultrasound probe, and knobology; how to differentiate vein from artery; how to differentiate local structures such as tendons and nerves from veins; how to select an appropriate site, vein, and angiocath (gauge and length) based on each patient’s medical history, indications for the procedure, and results of preliminary ultrasound mapping; how to select an optimal needle entry point and proper “angle of attack”; and the importance of localizing and tracking the needle tip on its way to cannulating the target vessel. The second phase of training required another 2-hour, 1:1 hands-on training session using a validated nonhuman tissue model for practice.16,17 Each trainee was required to demonstrate competency on the simulator before attempting PIVUS on patients. Competency was defined as being able to select the correct ultrasound probe, depth, and target vessel; properly positioning the target vessel in the center of ultrasound screen; correctly aligning the angiocath needle tip in the middle of the probe over the target vessel; tracking the needle tip through the skin and tissue to the vessel wall, including indenting the vessel under ultrasound guidance before cannulating; and cannulating the vessel and achieving a bull’s-eye image (Figure 1). Each trainee was required to successfully cannulate 2 large synthetic vessels (6 mm diameter) and 3 small synthetic vessels (3 mm diameter) before graduating to live patients. Once each trainee graduated from the practice environment, he or she was then permitted to attempt supervised PIVUS on patients.
Figure 1. Bulls-eye. Phase 3 involved live patients. Patients were selected for the study based on the following criteria: The presence of a physician’s order to place an ultrasound-guided IV line and either a lack of palpable or visible peripheral vessels or having a history of requiring ultrasound-guided peripheral or central venous access on prior encounters. Patients were excluded from the study if they had an allergy to lidocaine or were unwilling to consent to participate in the study. No trainee was allowed to attempt more than 3 cannulations of a single vessel or make attempts at more than 2 sites. All attempts were rated according to proficiency criteria outlined in Table 1. Proficiency was defined by the trainee achieving 10 supervised ultrasound-guided IV placements with a score of 4 or 5. Supervision was no longer required when the trainee both achieved proficiency and when IV placement was performed at the level of 4 or 5 for 3 consecutive attempts (ie, the criteria for achieving consistency). Premature termination
Table 1. Proficiency Score Definitions Proficiency score
Criteria
0
Unable to locate a suitable vessel
1
Suitable vessel located but vessel not accessed by trainee but ultimately accessed by supervisor
2
Suitable vessel located but vessel not accessed by trainee and ultimately not accessed by supervisor
3
Suitable vessel located but 3 attempts at 1 or 2 sites required
4
2 attempts at 1 or 2 sites required
5
1 successful attempt required
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Table 2. Baseline Characteristics of Trainees Trainee
Time in nursing (y)
Age group (y)
Gender
Time in proc ctr (y)
Baseline skill level
RN 1
11
35-40
F
5
Above average
RN 2
18
40-45
M
5
Above average
RN 3
11
30-35
F
3
Above average
RN 4
27
45-50
F
1
Above average
RN 5
10
35-40
F
1
Above average
RN 6
27
50-55
M
15
Above average
RN 7
15
35-40
F
2
Expert
RN 8
26
45-50
M
1
Expert
RN ¼ Registered nurse; Proc Ctr ¼ Cedars-Sinai Procedure Center.
of a given attempt (either due to trainee or patient comfort) was graded at the level of 1 or 2. The primary objective for the study was to determine the number of ultrasound-guided IV placements that needed to be performed under supervision before RN trainees achieved proficiency and consistency. Secondary outcomes included the number of minutes required for successful vessel cannulation (from initial anesthetic needle entry to bulls-eye), and the occurrence of any complications such as arterial puncture, hematoma, paresthesia, or excessive pain. Results A summary of the trainees’ baseline characteristics is summarized in Table 2. Trainees’ baseline skill was assessed by the study coordinator before training. Trainees were rated “above average” if they were able to place a traditional peripheral venous access line on their first attempt > 75% of the time and “expert” if they were able to place a traditional peripheral venous access line at first attempt > 90% of the time. Seven out of 8 trainees completed the training, and 1 trainee dropped out during Phase 2. Of the 7 trainees who completed the course, the average number of patient encounters required for 10 successful IV placements was 25, ranging from 18 to
30. For the entire study, the average time required for successful vessel cannulation was 19.57 minutes, ranging from 5 minutes to 62 minutes. For the entire study, the average time required for successful vessel cannulation was 19.57 minutes for 7 trainees (range ¼ 5-62 minutes), whereas the average time at the first attempt only (score ¼ 5) was 10.88 minutes, suggesting a clear improvement in efficiency as proficiency improves. Overall minor complication rate was 10.5% (30 out of 287 attempts), which consisted of 1 case of transient paresthesia, 1 near miss of a brachial artery, 18 hematomas, and 10 instances of significant pain. The rate of proficiency increased at a more rapid rate during the first 25 attempts, and continued to increase (albeit at a slower rate) after the second 25 attempts (Figure 2). Discussion Our study demonstrates that RNs with no prior ultrasound experience can achieve proficiency and consistency with PIVUS when given dedicated training, close supervision, and a fixed curriculum. Our study is notable for several significant findings. First, although the majority of trainees ultimately acquired expertise in ultrasound-guided IV access, there was wide variation in the number of attempts needed to attain
Figure 2. Average proficiency score.
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this skill. Second, trainees generally required a large clinical volume to achieve proficiency and consistency (25 and 50, respectively) that is greater than other documented ultrasound techniques (eg, Focused Assessment with Ultrasound in Trauma scan, abdominal aortic aneurysm screening, and central line placement). This is most likely explained by the fact that peripheral vessels represent a very small target and require a high degree of hand-eye coordination, technical dexterity, and precision to accurately localize and cannulate under ultrasound guidance. This need for greater volume should be taken into account when investing in, and setting expectations for, a PIVUS training curriculum for RNs. Third, despite traditional peripheral IV competency and a willingness to participate in the training process, not all trainees were able to successfully complete the training process. The 1 trainee who dropped out simply could not learn the ultrasound skills needed to move beyond Phase 2 of the curriculum. It is possible that technical adjuncts such as needle guide devices may be of assistance in this scenario. Additional study of devices that may affect the slope of the learning curve is warranted. Of note, our results were not calculated based on an intent-totreat analysis (ie, the dropout trainee’s preliminary results were not included in our calculations). Several factors had an influence on cannulation success. In the early part of Phase 3, trainees tended to revert toward selecting larger vessels as their target, although they had been taught in Phase 2 of the study that target size alone does not necessarily translate into successful vessel cannulation. Other vessel characteristics such as depth, location, tortuosity, and spasticity are equally important considerations. Although vessels with diameters > 0.5 cm were more likely to result in success, vessel depth > 1.6 cm decreased likelihood of success; in fact, veins at moderate depth (0.3-1.5 cm) seem to portend the greatest likelihood of successful cannulation.12,18 In addition to the technical aspects of utilizing ultrasound in vessel cannulation, it was also observed by the supervisors that patients who were agitated, combative, highly anxious, or overly skeptical appeared to have an adverse effect on trainees’ confidence, focus, and success. Limitations The greatest limitations of our study are the small number of trainees studied, and the fact that all patients who participated were enrolled in an outpatient, nonemergent setting. A larger series of trainees in more varied patient-care settings may be needed to validate the findings. Conclusions RN training to the level of proficiency and consistency in ultrasound-guided peripheral IV placement is achievable with appropriate time and training. The learning curve relative to other ultrasound applications is flat, with a high degree of individual variability in skill acquisition and retention amongst the trainees. Not every staff member can or should be expected to attain expertise in this technique. We believe that ultrasound-guided placement of peripheral IVs is becoming an increasingly important skill set for the provision
of optimal patient care and comfort, and it may be worthwhile to incorporate this into the existing skill set of IV teams. Ongoing development of training techniques and curriculum elements would help to further this important educational field. Disclosures The authors have no conflicts of interest to disclose. References 1. Dychter SS, Gold DA, Carson D, Haller M. Intravenous therapy: a review of complications and economic considerations of peripheral access. J Infus Nurs. 2012;35(2):84-91. 2. Egan G, Healy D, O’Neill H, Clarke-Moloney M, Grace PA, Walsh SR. Ultrasound guidance for difficult peripheral venous access: systematic review and metaanalysis. Emerg Med J. 2013;30(7):521-526. 3. Kerforne T, Petitpas F, Frasca D, Goudet V, Robert R, Mimoz O. Ultrasound-guided peripheral venous access in severely ill patients with suspected difficult vascular puncture. Chest. 2012;141(1):279-280. 4. Rothschild J. Chapter 21: ultrasound guidance of central vein catheterization. http://archive.ahrq.gov/clinic/ptsafety/ chap21.htm. Accessed December 13, 2014. 5. White A, Lopez F, Stone P. Developing and sustaining an ultrasound-guided peripheral intravenous access program for emergency nurses. Adv Emerg Nur J. 2010;32(2):173-188. 6. Costantino TG, Parikh AK, Satz WA, Fojtik JP. Ultrasonography-guided peripheral intravenous access versus traditional approaches in patients with difficult intravenous access. Ann Emerg Med. 2005;46(5):456-461. 7. Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med. 1999;34(6):711-714. 8. Mills CN, Liebmann O, Stone MB, Frazee BW. Ultrasonographically guided insertion of a 15-cm catheter into the deep brachial or basilic vein in patients with difficult intravenous access. Ann Emerg Med. 2007;50(1):68-72. 9. Stein J, Cole W, Kramer N. Ultrasound-guided peripheral intravenous cannulation emergency department patients with difficult IV access. Acad Emerg Med. 2004;11:581-582. 10. Witting M, Schenkel S, Lawner B, Euerle B. Effects of vein width and depth on ultrasound-guided peripheral IV success rates. J Emerg Med. 2010;39(1):70-75. 11. Aponte H, Acosta S, Rigamonti D, Sylvia B, Austin P, Samolitis T. The use of ultrasound for placement of intravenous catheters. AANA J. 2007;75(3):212-216. 12. Bauman M, Braude D, Crandall C. Ultrasound-guidance vs. standard technique in difficult vascular access patients by ED technicians. Am J Emerg Med. 2009;27(2):135-140. 13. Brannam L, Blaivas M, Lyon M, Flake M. Emergency nurses’ utilization of ultrasound guidance for placement of peripheral intravenous lines in difficult-access patients. Acad Emerg Med. 2004;11(12):1361-1363. 14. Stein J, George B, River G, Hebig A, McDermott D. Ultrasonographically guided peripheral intravenous cannulation in emergency department patients with difficult
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