Evidence Based Practice: Ultrasound-Guided Peripheral Intravenous Access Bailey Fogt, Magda Garcia, Kenneth Molnar, Jarred Olson, Halie Wierenga California State University San Marcos, School of Nursing DIVA patients (no, not dramatic patients) ● The literature does not uniformly define what qualifies a patient as DIVA ● DIVA population is often ○ Obese ○ sickle cell disease ○ end-stage renal disease (ESRD) ○ a history of IV drug abuse (IVDA) ○ a chronic/complex disease ○ received chemotherapy (Bahl et al., 2016). ● Some studies use the number of insertion attempts during a hospital stay to classify patients as DIVA. ○ One study defined DIVA patients as patients who experienced ≥2 failed cannulation attempts during their hospital stay independent of whether they had any of the disorders mentioned previously (Davis et al., 2021). ● The DIVA population is a patient group wherein traditional methods of inserting IVs are often unsuccessful or require the use of a specialist. So how many DIVAs are out there? ● Department of Health and Human Services’ estimate of hospital admissions annually: 35.7 million (Freeman et al., 2018) ● If 60% of those visits require the use of an IV and 3.2% of those patients are DIVA (Shokoohi et al., 2020), then USGPIV could affect 685,440 patients annually ● If 90% of 35.7 million hospital admissions will require IV therapy and 13% of those patients are DIVA (Shokoohi et al., 2020), then 4,176,900 patients could be affected The Problem: why do we care if patients are DIVAs? ● DIVA is associated with significant delays in median time to care completion ○ +50 minutes for pain medication administration (p=<0.001) ○ +36 minutes for intravenous fluid administration (p=<0.001) ○ +29 minutes for laboratory results (p=<0.001) ○ +57 minutes for intravenous contrast administration (p=<0.001) ○ +37 minutes for admission orders (p=<0.001) ○ +87 minutes for discharge orders (p=<0.001) (Shokoohi et al., 2020) n=108,256 (Shokoohi et al., 2020) ( Shokoohi et al., 2020) The Solution? ultrasound-guided peripheral IV access (USGPIVA) More Background ● PIV insertion is one of the most common procedures performed in US hospitals with some studies indicating that between 60% and 90% of hospitalized patients will receive some kind of IV therapy during their stay (Helm et al., 2019). ● The rate of failure on first insertion attempt in patients with a normal vascular profile is estimated to be between 12% to 26% and 24% to 52% in patients with difficult venous access (McCarthy et al., 2016). ● Because of the increased complications, costs, and patient discomfort associated with failed PIV insertion attempts, especially with DIVA patients, researchers have been exploring methods to improve PIV insertion success rates, ways to reduce complications, and reduce patient discomfort (Shokoohi et al., 2013). Search Strategies ● Databases: CINAHL, PubMed, Google Scholar, Academic Premier, EbcsoHost, OVID and DeepDyve ● Search Terms: PIV, difficult intravenous access, ultrasound guided peripheral venous access, IV insertion, DIVA population data, intravenous delay in care ● Exclusions: Articles older than 2011, sample size n<10 participants, children ● At the end of our data collection period, our group identified 2 randomized control trials, 2 meta-analyses, 2 quasi-experimental observation studies, 1 observational retrospective cohort analysis, and 2 prospective observational studies ● We critiqued each publication’s methods section to ensure that any conclusions were supported by good study design PICOT Question In patients with difficult intravenous access (DIVA), does using ultrasound guided PIV result in higher successful first attempt placement, faster time to cannulation, or patient comfort compared to standard of care (SOC) methods? Well, sort of Let us explain... Literature Review ● USGPIV has a higher success rate on the first attempt, leading to less time spent on care, higher patient satisfaction, reduced patient pain levels and lowered costs (Van Loon & Colleagues, 2018). ● Ultrasonography showed to be more successful in those with difficult venous access and moderately difficult venous access (McCarthy & Colleagues, 2016). ● Implementing USGPIV, catheter failure rate after 72 hours fell from 75% to 34% as well as an overall 40% reduction in non essential PICC lines performed (Reeves, 2017). ● Nursing Surveys: 93% reported that the service prevented delays in patient care; 73% reported that if the service was not available, a central venous catheter would have been required for their patient; 80% reported that their patient preferred ultrasound guidance to the traditional technique; and 100% agreed that the service should be made permanently available (Galen & Southern, 2018). Synthesis of Research Findings Level 1 Le vel 1 Evidence: 2 meta-analyses were used. ● Findings in Stolz et al. (2015): USGPIVA was frequently more successful. ○ A meta-analysis of 6 peer-reviewed randomized control trials and 1 prospective systematically allocated ○ Studies analyzed included patients with DIVA, use of USGPIV as an intervention (retrospective cohort studies not included), and included success rate, cannulation time, and/or number of attempts as outcome measures. The weakness in this study is in the sample size of the studies analyzed. The authors acknowledged this and adjusted their statistical methods to reflect a more conservative approach. ○ Rating: moderate-high because of the sample size. ● Findings in Van Loon et al. (2018): USGPIV has a higher first attempt success rate which led to less time spent on care, higher patient satisfaction, reduced pain levels and lower costs. ○ A meta-analysis of 5 randomized control trials and 3 cohort studies Level 2 Level 2 Evidence: 2 randomized control trials were used. ● A prospective non-blinded randomized control trial identified that USGPIVA had higher success rates with ≤ 2 attempts and most attempts with USGPIVA took less PIV insertion time compared to SOC methods (Bahl et al., 2016) ○ study included 10 nurses and 124 DIVA subjects, each randomized into a USGPIVA or a SOC group ○ data analysis section is clear in its analysis of success rate, but lacks clarity in its description of the analysis of time to establish PIV access ○ Rating: moderate-high for success rate evidence & low-moderate for time to cannulation ● The second study found USGPIV to be more successful in DIVA patients (McCarthy et al., 2016) ○ The study’s sample included 36 ED technicians trained in USGPIVA, 73 DIVA patients, 260 moderately difficult IV access patients, and 141 easy IV access patients. ○ showed an 81.6% success rate with ultrasonography on the first attempt in DIVA patients compared to a 35.1% success rate first attempt success rate with the landmark technique. Sample sizes consisted of (n=98) and (n=94) respectively. Level 3 Level 3 evidence: 2 prospective observational cohort study, a retrospective cohort study, and quasi-experimental observation study ● These nurses averaged 1.5 attempts for success rate in IV insertion vs prior clinical nurse average of 5.5 attempts until success. After the program, the catheter failure rate after 72 hours fell from 75% to 34% as well as an overall 40% reduction in non essential PICC lines performed (Reeves, 2017) ○ The hospital saved over $250,000 in the 20 months USGPIVA devices program was implemented (Reeves et al., 2017) ○ Sample size: 20 nurses ● It was identified that patients with DIVA experienced significant delays in diagnosis, diagnostic test and therapeutic treatments, extending their ED stay (Shokoohi et al., 2020) ● Implementation of USGPIVA training may reduce need for central line placement (Shokoohi et al., 2016). ○ The study showed that central line placement was reduced by 80% during a 6-year period at an urban ED wherein the only significant operational change was the implementation of USGPIVA training for staff. Level 3 (continued) ● Longitudinal approach had the highest success rate and the program was successful in training ED providers with US-guided PIV (Oliveira & Lawrence, 2016) ○ success rate improved from 55.2% attempting on 1 to 5 patients, to 88.5% after attempting access on 16 or more patients ○ physicians had the highest success rate with 79.4%, nurses 63.2%, and corpsmen 50.0% ● Initial failure to obtain peripheral intravenous catheter access lead to an increase in central venous line placement, which has a high associated risk of infection and complications (Galen & Southern, 2018). ○ a 30% decrease in average new central venous line placement per day from .67 to .47 between the two group ○ Nurses were strongly in favor of the service: 93% reported that the service prevented delays in patient care ■ 80% of nurses prefer USGPIV over the traditional technique Summing it all up Success rate ● USGPIVA had a higher success rates on establishing a functioning IV in DIVA patients compared to SOC methods. (Bahl et al., 2016) (McCarthy et al., 2016) (Stolz et al., 2015) (Van Loon et al., 2018), (Reeves et al., 2017) (Oliveira & Lawrence, 2016) Central lines ● Implementation of USGPIVA caused a 40% reduction in nonessential PICC insertions. The average cost of a PICC line through their interventional radiology suite costs $1200-2000 vs $50 for USGPIVA insertions. With the 40% reduction in nonessential PICC, the hospital saved over $250,000 in the 20 months (Reeves & Colleagues, 2017). Recommendations & Practice Change ● One of the health care priorities stated by the US Department of Health and Human Services is to reduce the number of bloodstream infections caused by central venous line placement in acute care settings and one of the ways to achieve that goal is to reduce the use of non essential PICC line placements (Reeves, 2017). ○ We think use of USGPIVA can help accomplish this goal ● Based on our evaluation, we recommend that hospitals implement USGPIVA training for nurses in their ED to increase successful attempts and reduce that amount of central lines placed in DIVA patients ● Pocket sized and portable ultrasound devices with vascular imaging abilities can be a low cost alternative to implement for lower socioeconomic medical centers and communities (Galen & Southern, 2018). ● We recommend that more research be done that focuses on patient satisfaction and time to cannulation specifically and in a sound methodological way Methods of Implementation ● We predict that the USGPIVA method will become more accepted and may become SOC when dealing with DIVA patients as ultrasound technology improves, costs decrease, and more research is done on the topic. ● Just like our nursing school, simulation-based mastery learning techniques have begun to be used. Teaching nurses to reduce the utilization of peripherally inserted central catheters and midline catheters for patients with DIVA. “During the SBML intervention period, an expanded project funding enabled training of nurses across the institution, with a goal of having at least 1 trained nurse per unit” (Amick and colleagues, 2021). ● In person training: “complete a one-hour online module on the technical aspects of the device before participating in eight hours of face-to-face instruction. In the first four hours, we reviewed VAPP principles, including anatomy and physiology concepts, aseptic no-touch technique (used to hold instruments without contaminating the sterile components or insertion site), insertion site selection, mitigation of complications, and appropriate treatment interventions should complications occur. In the second four hours, we focused on manufacturer-provided instructional materials for operating the device and developing psychomotor skills” (Reeves, 2017). ● Create an Ultrasound guided certification similar to regular IV certification, or have it built into future IV certification programs.