Single-operator Ultrasound-guided Intravenous Line Placement by Emergency Nurses Reduces the Need for Physician Intervention in Patients with Difficult-to-establish Intravenous Access

Abstract

Background

Emergency physicians (EPs) have become facile with ultrasound-guided intravenous line (USIV) placement in patients for whom access is difficult to achieve, though the procedure can distract the EP from other patient care activities.

Objectives

We hypothesize that adequately trained Emergency Nurses (ENs) can effectively perform single-operator USIV placement with less physician intervention than is required with blind techniques.

Methods

This was a prospective multicenter pilot study. Interested ENs received a 2-h tutorial from an experienced EP. Patients were eligible for inclusion if they had either two failed blind peripheral intravenous (i.v.) attempts, or if they reported or had a known history of difficult i.v. placement. Consenting patients were assigned to have either EN USIV placement or standard of care (SOC).

Results

Fifty patients were enrolled, of which 29 were assigned to USIV and 21 to SOC. There were no significant differences in age, race, gender, or reason for inclusion. Physicians were called to assist in 11/21 (52.4%) of SOC cases and 7/29 (24.1%) of USIV cases (p = 0.04). Mean time to i.v. placement (USIV 27.6 vs. SOC 26.4 minutes, p = 0.88) and the number of skin punctures (USIV 2.0 vs. SOC 2.1, p = 0.70) were not significantly different. Patient satisfaction was higher in the USIV group, though the difference did not reach statistical significance (USIV 86.2% vs. SOC 63.2%, p = 0.06). Patient perception of pain on a 10-point scale was also similar (USIV 4.9 vs. SOC 5.5, p = 0.50).

Conclusions

ENs performing single-operator USIV placement in patients with difficult-to-establish i.v. access reduces the need for EP intervention.

Introduction

Establishing intravenous (i.v.) access is one of the more common tasks asked of Emergency Nurses (ENs), and the importance of this task—both for acquiring serum samples and for administering fluids and medications—is central to the care of patients with many emergent conditions. As a result, ENs are among the most experienced clinicians in the placement of peripheral i.v. lines.

Despite the frequency of i.v. line placement, sometimes this fundamental intervention is difficult to achieve. Past research has demonstrated that patients with obesity, sickle cell anemia, or a history of i.v. drug use, as well as those undergoing treatment with renal dialysis and general sufferers of chronic illness, are more likely to have difficult i.v. placement (1). One utilized model is that nurses will make several venopuncture attempts, and if unable to achieve access will then ask the physician to intervene, perhaps to place a central venous catheter (CVC). Unfortunately, CVC placement exposes patients to multiple possible complications, including greater risk of infection, large artery cannulation, and pneumothorax, as compared to peripheral lines 2, 3, 4. Placing a CVC is time-consuming and occupies the attention of an Emergency Physician who often has multiple patients to care for simultaneously.

Use of ultrasound guidance for the placement of CVCs is now widely recommended because it improves success and reduces complications 3, 5, 6. More recently, physicians have been using ultrasound to cannulate peripheral veins with greater frequency. The technique, first described by Keyes et al., was associated with a 91% success rate in patients who had two previously unsuccessful blind attempts in their study (7). Costantino et al. demonstrated that ultrasound-guided i.v. (USIV) placement by physicians, when compared with blind technique, was more successful, required less time, decreased the number of percutaneous punctures, and improved satisfaction in patients who had difficult-to-establish i.v. access (8). Regardless, even peripheral i.v. placement by the physician is time-consuming and may take the physician away from other activities in the Emergency Department (ED). However, if an EN, who routinely places i.v.s, can utilize the ultrasound when faced with difficult cannulation, it could save the physician from having to intervene. Previous works have described successful training and implementation programs for EN placement of USIV, as well as its associated positive effects on decreasing patient throughput times and reducing costs and complications, while increasing patient satisfaction and nurse autonomy 9, 10, 11, 12, 13.

This study aims to determine if placement of USIVs by ENs who undergo a brief training session can be performed with less physician intervention than standard i.v. line placement. As secondary endpoints, we also evaluated differences in the time it takes to achieve i.v. access, the number of skin punctures, and patient satisfaction and pain perception associated with USIV vs. standard of care.