Patient Experience With Vascular Access Management Informs Satisfaction With Overall Hospitalization Experience

Operation STICK Improves Vascular Access Outcomes in a Specialty Team: A Quasi-Experimental Study

BACKGROUND

Education and training may improve outcomes within an experienced vascular access team.

PURPOSE

The purpose of this study was to measure the impact of a standardized peripheral intravenous catheter insertion educational program (Operation STICK) on vascular access outcomes.

METHODS

A quasi-experimental study design was used. Adult inpatients with difficult intravenous access (DIVA) requiring ultrasound-guided insertion by a vascular access specialty team were eligible. Data were collected before and 7 months after the educational training program.

RESULTS

A total of 54 subjects were included (24 pre- and 30 post-implementation). Significant improvements were found for mean peripheral intravenous catheter dwell time (3.62 to 14.97 days, P < .001), completion of therapy (58.3% to 96.7%, P = .001), and first-stick success rate (79.2% to 100%, P = .013). Catheter-to-vein ratio significantly decreased (P = .007).

CONCLUSIONS

Standardized education/training in vascular access focusing on best practices yields favorable outcomes for DIVA patients within an established specialty team.

Best practice in the use of peripheral venous catheters: A consensus from French experts

BACKGROUND

Peripheral intravenous catheters (PIVCs) are the most commonly used invasive medical devices in healthcare. While they are often perceived as innocuous because they are common, this perception does not match their risk factors. In France, 16% of intravenous device-associated bacteremia are due to PIVCs. This consensus document reports the French experience in PIVC management, issues arising from their complications, and a proposed path toward improved PIVC care.

METHODS

A panel of five French experts discussed this topic based on evidence and personal experience. A consensus process was applied to highlight the issues in need of increased awareness and to suggest possible improvements. PIVC topics were organized as General Statements, Indication, Preparation, Insertion, Maintenance, and Removal. An electronic survey was used to record agreement or disagreement; to expand the dataset, five additional French experts also answered the questions.

RESULTS

Out of 67 statements, 62 reached a consensus (the 80% agreement threshold was exceeded). Experts are increasingly aware that PIVCs are a significant source of complications, including local and bloodstream infections. Practices need to progress to improve patient outcomes, which will require better education for all personnel involved with the insertion and maintenance of PIVCs.

CONCLUSIONS

Current practice around PIVCs does not always comply with the recommendations issued. A new surveillance network targeting catheter-related healthcare-associated infections is now in place in France. Simplified, standardized, bundled solutions are needed to reduce avoidable harm from PIVCs. Healthcare practice has changed over time and new educational tools are needed to adapt to increased workload and time constraints.

Operation STICK: A vascular access specialty program for the generalist emergency medicine clinician

OBJECTIVE

Comprehensive education and training programs are urgently needed to improve vascular access outcomes in the emergency department (ED). This study aimed to demonstrate the success of a formalized vascular access program in developing competent ED clinicians in traditional and ultrasound-guided insertion methods.

METHODS

This was a retrospective observational study exploring the success of trainees in obtaining competency in peripheral vascular access at an academic suburban ED with 120,000 annual visits. Eligible participants included healthcare workers that enrolled in the Operation STICK vascular access program and perform vascular access procedures as an aspect of their clinical practice. Competency in vascular access included both traditional and ultrasound-guided (US) peripheral intravenous catheter (PIVC) insertions. Competency was defined as demonstration of successful insertion of one traditional and one US PIVC in compliance with checklist. The primary objective was competency. Secondary objectives included trainee time to competency, trainee number of line encounters, and changes in program competency achievements over time.

RESULTS

From October 15, 2021, to April 15, 2023, 141 clinicians participated in peripheral vascular access training via the Operation STICK model, which included 72 (51.1%) nurses, 52 (36.9%) ED technicians, and 17 (12.0%) healthcare personnel with other medical training. Clinicians overall reported an average of 5.6 years of experience inserting peripheral intravenous catheters (PIVCs) and 23 (16.3%) had experience with using ultrasound. About 122 (86.5%) clinicians successfully completed the program and demonstrated competency in traditional and ultrasound-guided techniques. Time to competency varied over time, with a median of 124 days in the early phase, 32.5 days middle phase, and 10.6 h over 9.5 days in the later phase of the program (p < 0.001).

CONCLUSIONS

Achieving competency in PIVC insertion necessitates a focused effort on refining and systematizing education and training approaches. Recognizing the inherent challenges present in ED settings, it is feasible to effectively and efficiently train emergency clinicians to be expert in both basic and advanced PIVC placement techniques through participation in a well-organized vascular access training program.

A standardized educational program to improve peripheral vascular access outcomes in the emergency department: A quasi-experimental pre-post trial

OBJECTIVE

Difficult intravenous access (DIVA) patients are known to have disproportionately poorer vascular access outcomes. The impact of education and training on vascular access outcomes in this vulnerable population is unclear. We aim to demonstrate the success of a program (Operation (O) STICK) on improving vascular access outcomes in DIVA patients.

METHODS

This was a quasi-experimental pre-post interventional study conducted at a tertiary care emergency department (ED) with 120,000 annual visits and 1100 hospital beds. Adult patients requiring an ultrasound-guided (US) peripheral intravenous catheter (PIVC) in the ED were eligible participants. Traditional (palpation method) insertions were excluded. Using multivariable linear regression and inverse probability weighted (IPW) linear regression, the standard group inclusive of PIVCs inserted by staff without formalized OSTICK training were compared to the interventional group inclusive of PIVCs inserted by staff with training and competency in the OSTICK training model.

RESULTS

Data were collected over two time intervals: 4/1/21-9/30/21 (pre; non-OSTICK) and 10/1/22-3/31/23 (post; OSTICK). 2375 DIVA patients included 1035 (43.6%) non-OSTICK and 1340 (56.4%) OSTICK PIVCs. Overall, OSTICK PIVCs had a higher proportion of upper arm or forearm placements (94.6% vs 57.4%; p < 0.001), 20 gauge catheters (97.1% vs 92.3%; p < 0.001), and left-sided placements (54.4% vs 43.5%; p < 0.001). 62.7% of OSTICK PIVCs were placed by ED technicians, compared to 25.5% in the non-OSTICK group (p < 0.001). OSTICK PIVCs were placed on the first attempt 86.2% of the time and by the second attempt 95.4% of the time. In a subanalysis of 1343 hospitalized patients (689 (51.3%) OSTICK vs 654 (48.7%) non-OSTICK), OSTICK PIVCs survived for a median of 92% of the patient's hospital length of stay, compared to non-OSTICK PIVCs at 74% (p < 0.001).

CONCLUSIONS

Formalized vascular access training in the ED leads to improved adherence to best practices for PIVC insertion, high success of cannulation with minimal attempts, and improved PIVC functionality during hospitalization for DIVA patients. Importantly, these outcomes are sustainable as they were captured 12 months after implementation of the program.

Evaluating the impact of external forces on peripheral intravenous catheter movement using ultrasound: A randomized pilot study

BACKGROUND

A major contributor to peripheral intravenous catheter (PIVC) failure may be related to PIVC movement within the vein which is associated with vein wall damage. The magnitude of PIVC movement against the vein wall has not previously been quantified. This study aimed to examine PIVC movement within the vein when minor forces were applied to the PIVC.

METHODS

This was a prospective, pilot trial including healthy volunteers in an outpatient research laboratory. The primary objective was to examine the in movement (millimeters) of the PIVC using ultrasound with external pull forces (4, 5, and 6 lbs; 1.8, 2.3, and 2.7 kg, respectively) applied to the PIVC in random order.

RESULTS

Participants (N = 11) were aged 40.36 ± 16.10 years with 54.55% being Male. Mean ± SD PIVC movement for 4, 5, and 6 lbs of force was 4.65 ± 1.88, 3.88 ± 2.28, and 5.25 ± 2.06 mm, respectively. There was substantial PIVC movement when a force was applied to the PIVC, but no statistically significant difference between 4, 5, and 6 lb forces (p > 0.05).

CONCLUSION

When external pull forces were applied to the PIVC, substantial PIVC movement within the vein occurred in a healthy population. Strategies that reduce PIVC movement and/or remove or limit external pull forces from the PIVC are needed. Future studies on hospitalized patients are warranted to quantify vein wall injury and PIVC failure due to PIVC movement from various pull forces.

Incorporating Near Infrared Light Vein Visualization Technology Into Peripheral Intravenous Access Protocols

Placement of peripheral intravenous catheters (PIVCs) is a frequent occurrence. Yet, PIVCs consistently require multiple attempts for successful cannulation, leading to an increased use of resources and risk of complications. Even though hospitals have established vascular access teams to improve outcomes and increase longevity of PIVCs, not every facility has one, and some struggle to meet demand. In these cases, PIVC placement depends on the confidence and skills of bedside nurses. Difficult access risk identification tools, as well as vein visualization technologies, like near infrared (nIR), have been developed to assist nurses with cannulation. This study sought to explore how hospitals are using vein visualization technology in nurse-driven protocols and to evaluate whether the technology is being meaningfully integrated into venous assessment and PIVC access protocols. In a survey sent to facilities utilizing nIR technology, 48% of respondents incorporated nIR in nurse-driven protocols. Of these respondents, 88% reported improvement in patient satisfaction, 92% saw a reduction in escalations, and 79% reported a reduction in hospital-acquired infections associated with PIVC placement. Integrating vein visualization technology into nurse-driven PIVC placement protocols has the potential to make a positive impact but requires future research to reproduce these findings in clinical studies.

Peripheral vascular access as exclusive access mode in pediatric intensive care unit

Introduction

The type of vascular access (central or peripheral) in pediatric critical care depends on several factors, including the duration of treatment, the properties of the medication (osmolarity or vesicant), and the need for central pressure monitoring. The utilization of peripheral intravascular catheters (PIVCs) has shown a notable increase in the number of patients being treated. Extended dwell or midline catheters are another peripheral access option in addition to PIVCs. However, there are currently no established guidelines on their placement.

Objectives

The aim of this study is to estimate the duration of dwell time for PIVCs, analyze the specific parameters affecting it, and develop recommendations for switching to extended dwell and midline catheter placement as an alternative to peripheral access.

Methods

The study enrolled patients aged 0-18 years admitted to the pediatric intensive care unit (PICU) for over 24 h and managed with peripheral access only over 2 years (2019-2021).

Measurements and main results

A total of 484 patients met the specified criteria. Patients who had peripheral access exhibited a lower PRISM score and a shorter length of stay in the PICU, with mean values of 18 (SD: 8.5) and 9.5 (SD: 6.4) days, respectively, compared with patients who had central access with mean values of 8.9 (SD: 5.9) and 5.7 (SD: 3.6) days, respectively. The PIVC dwell time was found to be 50.1 h (SD: 65.3) and required an average of 1.6 insertion attempts. Patients with three or more insertions exhibited an increased odds ratio of 5.2 (95% CI: 3.1-8.5) for receiving an extended dwell or midline insertion. Increased dwell time was associated with female gender, 59.5 h (P < 0.001), first attempt insertion, 53.5 h (P < 0.001), use of 24 Ga bore, 56.3 h (P = 0.04), left-sided insertions, 54.9 (P = 0.07), less agitation, 54.8 h (P = 0.02), and less edema, 61.6 (P < 0.001). Decreased dwell time was associated with the use of vancomycin infusion at 24.2 h (P < 0.001) and blood transfusions at 29.3 h (P < 0.001).

Conclusions

Extended catheters last longer than PIVCs in PICU patients. Extended catheter placement requires consideration of the length of treatment, as well as the overall body edema, the level of the patient's restlessness, and the need for vancomycin infusion or blood transfusions, as these factors reduce PIVC dwell time and expose the patients to painful insertions. For such cases, an extended dwell catheter may be a better option, even if the projected treatment time is less than 6 days.