Factors affecting difficult peripheral intravenous cannulation in adults: a prospective observational study

Development and evaluation of a PICC virtual simulator in neonatal nursing: A randomized controlled trial

BACKGROUND

Peripherally Inserted Central Catheter (PICC) is essential in neonatal care, especially for critically ill infants. Traditional training for neonatal PICC insertion faces challenges such as high costs and limited practice opportunities. Virtual simulation technology has emerged as a potential training tool, providing a realistic, risk-free learning environment.

OBJECTIVES

The study aimed to assess the effectiveness of a virtual simulation teaching system in neonatal PICC care training, focusing on improving nursing students' knowledge， skills and interest in pediatric nursing.

DESIGN

A quasi-experimental design was used, with assessments conducted before and after the activity.

PARTICIPANTS

The study involved 58 graduate nursing students from China Medical University, divided into experimental and control groups.

METHODS

The System Usability Scale (SUS) was utilized to assess teachers' experiences with the PICC virtual simulation software. Students' perceptions of the software and their interest in pediatric nursing were measured using Self-Administered Questionnaires. Furthermore, Theoretical and Operational Assessments were applied to determine the extent of students' knowledge and practical skills before and after experimentation.

RESULTS

Teachers and students have favorably evaluated the software system, with notable improvements in theoretical scores following testing. While the virtual simulation system does not enhance practical skills, it does increase student interest in pediatric nursing and employment.

CONCLUSIONS

This neonatal virtual simulation software serves as a complement to, rather than a replacement for, traditional clinical training. Its integration into educational programs significantly enhances learning outcomes.

Evaluation of a novel blood collection set for venipuncture in oncology patients with difficult venous access: Impact on sample quality, phlebotomist satisfaction and patient pain perception

PURPOSE

Difficult venous access (DVA), characterized by non-visible and non-palpable veins, is common in oncology patients. The objectives of this study were to compare the performances of two blood collection sets in an oncology phlebotomy setting: BD Vacutainer® UltraTouch™ Push Button (UT-PBBCS) and BD Vacutainer® Safety-Lok™ Blood Collection Set (SLBCS). The two sets were evaluated to assess whether use of a smaller gauge (G) needle (down-gauging) may reduce patient pain and improve peripheral venous access experience during phlebotomy in oncology patients.

METHODS

Questionnaires were used to record patient data (age, gender), phlebotomy procedural observations (venipuncture site, number of collected tubes, blood flow, needle repositioning, underfilled tubes), patient pain perception and phlebotomist difficulty perception scores (0-10 points scale). Specimen quality was evaluated by hemolysis index (HI) on Roche Cobas® 6000.

RESULTS

Subject groups showed no statistical difference. SLBCS (21/23G) or UT-PBBCS (23/25G) were used in 264 (45.8%) and 313 (54.2%) subjects respectively. Lower gauge was preferred for DVA (hand venipuncture), and DVA was associated with tube underfilling but no with type of blood collection set. For UT-PBBCS, pain perception, patients' anxiety level and phlebotomists' difficulty grade were lower when compared to SLBCS (p < 0.001). Blood samples collected with UT-PBBCS showed less hemolysis compared to samples collected with SLBCS (p < 0.001).

CONCLUSION

Provision of a smaller gauge UT-PBBCS option during phlebotomy in oncology patients with DVA reduces procedural pain and anxiety and improved phlebotomist' experience during sample collection. Despite the down-gauging, hemolysis was lower for UT-PBBCS, keeping sample quality while improving DVA patient comfort.

The impact of health disparities on peripheral vascular access outcomes in hospitalized patients: an observational study

BACKGROUND

Placement of peripheral intravenous catheters (PIVC) is a routine procedure in hospital settings. The primary objective is to explore the relationship between healthcare inequities and PIVC outcomes.

METHODS

This study was a multicenter, observational analysis of adults with PIVC access established in the emergency department requiring inpatient admission between January 1st, 2021, and January 31st, 2023, in metro Detroit, Michigan, United States. Epidemiological, demographic, therapeutic, clinical, and outcomes data were collected. Health disparities were defined by the National Institute on Minority Health and Health Disparities. The primary outcome was the proportion of PIVC dwell time to hospitalization length of stay, expressed as the proportion of dwell time (hours) to hospital stay (hours) x 100%. Multivariable linear regression and a machine learning model were used for variable selection. Subsequently, a multivariate linear regression analysis was utilized to adjust for confounders and best estimate the true effect of each variable.

RESULTS

Between January 1st, 2021, and January 31st, 2023, our study analyzed 144,524 ED encounters, with an average patient age of 65.7 years and 53.4% female. Racial demographics showed 67.2% White, and 27.0% Black, with the remaining identifying as Asian, American Indian Alaska Native, or other races. The median proportion of PIVC dwell time to hospital length of stay was 0.88, with individuals identifying as Asian having the highest ratio (0.94) and Black individuals the lowest (0.82). Black females had a median dwell time to stay ratio of 0.76, significantly lower than White males at 0.93 (p < 0.001). After controlling for confounder variables, a multivariable linear regression demonstrated that Black males and White males had a 10.0% and 19.6% greater proportion of dwell to stay, respectively, compared to Black females (p < 0.001).

CONCLUSIONS

Black females face the highest risk of compromised PIVC functionality, resulting in approximately one full day of less reliable PIVC access than White males. To comprehensively address and rectify these disparities, further research is imperative to improve understanding of the clinical impact of healthcare inequities on PIVC access. Moreover, it is essential to formulate effective strategies to mitigate these disparities and ensure equitable healthcare outcomes for all individuals.

Nurses' evidence-based knowledge and self-efficacy in venous access device insertion and management: Development and validation of a questionnaire

AIM

To develop and psychometrically test an instrument to assess nurses' evidence-based knowledge and self-efficacy regarding insertion and management of venous access devices (short peripheral catheter (SPC), long peripheral catheter/midline (LPC) and PICC) and the management of totally implantable central venous catheter (Port) in adult patients.

DESIGN

Multicenter cross-sectional observational study with questionnaire development and psychometric testing (validity and reliability).

METHODS

An evidence-based instrument was developed including a 34-item knowledge section and an 81-item self-efficacy section including four device-specific parts. Nineteen experts evaluated content validity. A pilot study was conducted with 86 nurses. Difficulty and discrimination indices were calculated for knowledge items. Confirmatory factor analyses tested the dimensionality of the self-efficacy section according to the development model. Construct validity was tested through known group validity. Reliability was evaluated through Cronbach's alpha coefficient for unidimensional scales and omega coefficients for multidimensional scales.

RESULTS

Content validity indices and results from the pilot study were excellent with all the item-content validity indices >0.78 and scale-content validity index ranging from 0.96 to 0.99. The survey was completed by 425 nurses. Difficulty and discrimination indices for knowledge items were acceptable with most items (58.8%) showing desirable difficulty and most items (58.8%) with excellent (35.3%) or good (23.5%) discrimination power, and appropriate to the content. The dimensionality of the model posited for self-efficacy was confirmed with adequate fit indices (e.g., comparative fit index range 0.984-0.996, root mean square error of approximation range 0.054-0.073). Construct validity was determined and reliability was excellent with alpha values ranging from 0.843 to 0.946 and omega coefficients ranging from 0.833 to 0.933. Therefore, a valid and reliable tool based on updated guidelines is made available to evaluate nurses' competencies for venous access insertion and management.

An Improved Definition and SAFE Rule for Predicting Difficult Intravascular Access (DIVA) in Hospitalized Adults

Patients with difficult intravascular access (DIVA) are common, yet the condition is often ignored or poorly managed, leading to patient dissatisfaction and misuse of health care resources. This study sought to assess all published risk factors associated with DIVA in order to promote prospective identification and improved management of patients with DIVA. A systematic literature review on risk factors associated with DIVA was conducted. Risk factors published in ≥4 eligible studies underwent a multivariate meta-analysis of multiple factors (MVMA-MF) using the Bayesian framework. Of 2535 unique publications identified, 20 studies were eligible for review. In total, 82 unique DIVA risk factors were identified, with the 10 factors found in ≥4 studies undergoing MVMA-MF. Significant predictors of DIVA included vein visibility, vein palpability, history of DIVA, obesity (body mass index [BMI] >30), and history of intravenous (IV) drug abuse, which were combined to create the mnemonic guideline, SAFE: See, Ask (about a history of DIVA or IV drug abuse), Feel, and Evaluate BMI. By recognizing patients with DIVA before the first insertion attempt and treating them from the outset with advanced vein visualization techniques, patients with DIVA could be subject to less frequent painful venipunctures, fewer delays in treatment, and a reduction in other DIVA-associated burdens.

Validity and reliability of the Turkish version of the Difficult Intravenous Access Scale for adult patients

Background

Difficult intravenous access is a condition that decreases the first-attempt success rate of intravenous catheterisation. It is important to evaluate patients with difficult vascular access using a standardised scale. This study was carried out to establish the Turkish validity and reliability of the 'Adult Difficult Intravenous Access Scale'.

Methods

The methodological descriptive study was carried out in the Adult Emergency Department. The research sample consisted of 100 patients over 18 years of age, who were conscious, whose condition was not critical or who did not require resuscitation. 'Case Report Form' and 'Adult Difficult Intravenous Access Scale' were used.

Results

The mean age of the patients was 57.54 ± 19.44 years, and 55% (n = 55) were female and 77% (n = 77) had a chronic disease. The factor loads of the scale items are between 0.366 and 0.852. The Cronbach's alpha coefficient was found to be 0.708.

Conclusions

The Turkish version of the scale is a valid and reliable scale for determining the risk of difficult intravenous access. The practical use of this scale by healthcare professionals will enable earlier diagnosis of patients with difficult vascular access.

Sex Disparities in Prehospital Advanced Cardiac Life Support in Out-of-Hospital Cardiac Arrest in South Korea

OBJECTIVE

Sex disparities have been reported in the prehospital and in-hospital care among patients with out-of-hospital cardiac arrest (OHCA). The aim of this study was to investigate the association between sex and prehospital advanced cardiac life support (ACLS) interventions provided by emergency medical services (EMS).

METHODS

This was a cross-sectional observational study using a nationwide OHCA registry in South Korea. The study included adult OHCAs with presumed cardiac etiology from January 2016 to December 2019. The main exposure was the sex of the victim, and the primary outcomes were prehospital ACLS interventions, including advanced airway management (AAM), intravenous access (IV), and epinephrine (EPI) administration. Multivariable logistic regression analysis accounted for age group, health insurance, comorbidities, place of arrest, urbanization level, witness status, bystander CPR and initial rhythm was performed to calculate adjusted odds ratios (AORs) with 95% confidence intervals (95% CIs).

RESULTS

Among 71,154 eligible patients, females with OHCA received less prehospital ACLS interventions than males: risk difference, (95% CIs) -2.76 (-3.41;-2.11) for AAM, -6.03 (-6.79;-5.27) for IV, and -3.81 (-4.37;-3.25) for EPI. In multivariable logistic regression analysis, female sex was significantly associated with a lower probability of prehospital ACLS provision: AOR, (95% CIs) 0.87 (0.84-0.91) for AAM, 0.85 (0.82-0.88) for IV, and 0.81 (0.77-0.84) for EPI.

CONCLUSION

Compared to male patients, female patients were less likely to receive prehospital ACLS. This offers opportunities for EMS systems to reduce disparities and to improve compliance with OHCA resuscitation guidelines and outcomes through quality improvement and educational interventions.

Retrospective analysis of the feasibility and safety of external jugular vein cannulation in surgical patients

BACKGROUND

Establishing intravenous (IV) access is an essential procedure in surgical patients. External jugular vein (EJV) cannulation can be a good alternative for patients forwhom it is difficult to establish peripheral IV access. We aimed to investigate the feasibilityand safety of EJV cannulation in surgical patients.

METHODS

We performed a retrospective review of EJV cannulation in patients who underwent anesthesia for surgery at a tertiary hospital between 2010 and 2021. We collectedclinical characteristics, including EJV cannulation-related variables, from the anesthetic records. We also investigated the EJV cannulation-related complications, which included anyEJV cannulation-related complications (insertion site swelling, infection, thrombophlebitis,pneumothorax, and arterial cannulation) within 7 days after surgery, from the electronicmedical records during the hospitalization period for surgery.

RESULTS

We analyzed 9,482 cases of 9,062 patients for whom EJV cannulation was performed during anesthesia. The most commonly performed surgery was general surgery(49.6%), followed by urologic surgery (17.5%) and obstetric and gynecologic surgery (15.7%).Unplanned EJV cannulation was performed emergently during surgery for 878 (9.3%) cases.The only EJV cannulation-related complication was swelling at the EJV-cannula insertion site(65 cases, 0.7%). There was only one case of unplanned intensive care unit admission dueto swelling related to EJV cannulation.

CONCLUSIONS

Our study showed the feasibility and safety of EJV cannulation for surgical patients with difficult IV access or those who need additional large-bore IV access during surgery. EJV cannulation can provide safe and reliable IV access with a low risk of major complications in a surgical patient.

Quantitative phase analysis and hyperspectral imaging for the automatic identification of veins and blood perfusion maps

INTRODUCTION

Medical workers commonly physically identify subcutaneous veins to locate a suitable vesselto implant a catheter for drug administration or blood sample. The general rule of thumb is to locate a big, clean vein that will allow the medication to readily pass within the intended blood vessel. Peripheral problematic venous access happens when a patient's veins are difficult to palpate because of factors like dark skin tone, edema or excess tissue. The ability to see how the vasculature changes to support the therapeutic methods without damaging the surrounding tissue is another challenge.

MATERIALS AND METHODS

Hyperspectral imaging (HI) is a developing technique with several potential uses in medicine. Using its spectroscopic data, veins and arterioles could be noninvasively detected and discriminated. It is frequently important to use quantitative phase analysis for vein localization. To assess hyperspectral image data for the detection of both veins and peripheral arteries, we suggest using an advanced image processing and classification algorithm based on the phase information related to the index of refraction change and associated scattering. We show that this need may be satisfied using quantitative phase imaging of forearm skin tissue at different depths.

RESULTS

To demonstrate the variations in the diffuse reflectance characteristics between skin surface and veins, phase resolved pictures were successfully produced for twelve volunteers using our imaging methodology. We found that the skin surface details are completely apparent at the unique wavelength of 441 nm. The 500-nm wavelength was the most efficient for grouping peripheral arteries and illuminating the blood perfusion maps. Using our HI experimental setup and our phase imaging procedure on the 600 nm and 650 nm visible spectral pictures, we were able to properly describe the vein map. This spectral area may be utilized as a vein locator marker which could approximately reach till 3 mm depth under skin surface.

CONCLUSIONS

Initial findings suggested that our imaging technique would be able to assist medical examiners in safely assessing the veins and arteriole's locations automatically without exposing the skin to infrared radiation. Meanwhile, our pilot research in this work to determine the best spectral wavelengths for localizing veins and mapping blood perfusion using our phase analysis imaging strategy with the HI camera. By substituting the HI camera with a custom conventional RGB camera that only functions at specific wavelengths during the discovering of blood perfusion locations or prior to intravenous catheterization, a distinctive and efficient system for precise identification may be developed to serve in the field of the vascular therapeutic methods.

Comparative Effectiveness, Efficiency, and ED Nurse Preference Between Two Methods of Visualization for Midline Catheter Insertion: A Pilot Study

Introduction

Rapid and reliable peripheral IV access is essential for many patients admitted to the emergency department (ED) to ensure administration of life-saving medications, and successful intravenous cannulation can significantly affect patient care.

Objective

The objective of this study was to assess the impact of a continuous needle tracking system on the accuracy, speed, and quality of ultrasound-guided peripheral venous catheter insertions.

Methods

A convenient sample study based on the study setting using simulated tissue was conducted with 49 US-based ED nurses to compare the insertion of a midline catheter using traditional ultrasound guidance versus an advanced needle-tracking technology along with ultrasound guidance. The purpose of this evaluation was to assess the impact of continuous needle tracking system. Informed consent was obtained from all individual participants involved in this study. All participants were made aware that the results may be published. There was no IRB approval for this study. All sources were properly disclosed within the text.

Results

The addition of the advanced needle-tracking technology significantly reduced total insertion attempts, insertion time, backwall penetrations, and redirects (probes to hit the target vein), while improving image clarity and confidence for participants.

Conclusion

The innovative needle-tracking system evaluated in this pilot study has the potential to improve emergent difficult vascular access. EDs should assess the value of this technology to potentially improve the management of difficult intravenous access patients in their settings.

Remotely supervised ultrasound-guided peripheral intravenous cannulation training: A prospective cohort study examining success rates and patient experience

Introduction

Ultrasound-guided peripheral intravenous cannulation (USGPIVC) benefits patients with difficult intravenous access (DIVA) through visualising otherwise non-visible and non-palpable veins. Supervised live-case training is an important component of learning this skill, but supervisor availability can present a barrier limiting or delaying staff completing their training.

Aims

The aim of this study was to determine the first-attempt success rate of newly trained USGPIVC inserters using remote supervision and timely written feedback based on app-based screen recordings taken during insertion. Secondary aims were overall procedural success, and inserter and patient experiences.

Methods

This study is an observational cohort study carried out between October and December 2021. Fourteen newly trained junior medical officers (JMOs) were eligible to utilise USGPIVC on a minimum of five consenting patients while simultaneously recording the ultrasound screen during insertion to capture their technique. Feedback was generated following expert review of these recordings against a standardised feedback tool.

Results

Average first-attempt success was 71% (n = 72) in the 102 patients recruited. The average time for JMOs to receive feedback was 30 h, and 13 JMOs (93%) felt well supported and completed the remote training pathway. The majority of patients were female (n = 59; 58%), were aged 41-80 years (n = 75; 74%) and had ≥2 risk factors for DIVA (n = 57; 56%).

Conclusions

First-attempt success rates were similar when comparing remote supervision used in this study to direct supervision used by other studies.This finding supports incorporating remote supervision into training guidelines for USGPIVC as an alternative method of supervision, particularly when supervisor availability is limited.

Learning Success and Influencing Factors in Out-of-Hospital Placement of Intravenous Catheters

INTRODUCTION

Placing peripheral intravenous catheters ("IV lines") is a standard procedure for health care professionals in acute and emergency medicine. The study aimed to determine the learning curve and success rates in applying IV lines during a three-year paramedic training and the factors influencing successful placement.

METHODS

This was a prospective and noninterventional observational study to determine the influencing factors, learning outcomes, and performance in the placement of IV lines by trainees and experienced paramedics. Trial registration: German Clinical Trials Register, ID DRKS00024631.

RESULTS

From February 1, 2016 through December 31, 2021, a total of 3,547 peripheral venous accesses attempts were performed: 76.5% (n = 2,712) by trainees and 23.5% (n = 835) by experienced practitioners. The trainee group had one-to-three years of training and the experienced group had 11 (SD = 11) years of work experience after training (one-to-35 years). The learning or success curve in the successful placement of peripheral venous accesses was 85.2% in the first year of training, 88.5% in the second year of training, and 92.5% in the third year (and the end of training). It was then 94.3% in the fourth year (first year of being experienced). Successful insertion of peripheral venous accesses in the experienced group was up to 97.0%. The first-attempt success rate was 90.4% across the entire trainee group versus 95.9% in the experienced group (P <.0001).Significant factors influencing successful placement of IV lines were puncture site (P = .022), catheter size (OR = 0.600; P = .002), and number of attempts (OR = 0.370; P <.001). The time of day (or night) was not influential. Work experience, patient age, or blood pressure were also not significant.

Diagnostic Accuracy of Arterial Spin Labeling in Comparison With Dynamic Susceptibility Contrast-Enhanced Perfusion for Brain Tumor Surveillance at 3T MRI

Purpose

We aimed to compare arterial spin labeling (ASL) with dynamic susceptibility contrast (DSC) enhanced perfusion MRI for the surveillance of primary and metastatic brain tumors at 3T, both in terms of lesion perfusion metrics and diagnostic accuracy.

Methods

In this retrospective study, we included 115 patients, who underwent both ASL and DSC perfusion in the same 3T MRI scanning session between 1 January and 31 December 2019. ASL-derived cerebral blood flow (CBF) maps and DSC-derived relative cerebral blood volume (rCBV) maps, both uncorrected and corrected for leakage, were created with commercially available software. Lesions were identified as T2-/T2-FLAIR hyperintensity with or without contrast enhancement. Measurements were done by placing a region of interest in the visually determined area of highest perfusion, copying to the contralateral normal appearing white matter (NAWM), and then propagating to the other perfusion maps. Pearson’s correlation coefficients were calculated between the CBF and rCBV ratios of tumor versus NAWM. Accuracy for diagnosing tumor progression was calculated as the area under the receiver operating characteristics (ROC) curve (AUC) for the ASL-CBF and leakage corrected DSC-rCBV ratios.

Results

We identified 178 lesions, 119 with and 59 without contrast enhancement. Correlation coefficients between ASL-derived CBF versus DSC-derived rCBV ratios were 0.60–0.67 without and 0.72–0.78 with leakage correction in all lesions (n = 178); these were 0.65–0.80 in enhancing glioma (n = 80), 0.58–0.73 in non-enhancing glioma, and 0.14–0.40 in enhancing metastasis (n = 31). No significant correlation was found in enhancing (n = 8) or non-enhancing (n = 7) lymphomas. The areas under the ROC curves (AUCs) for all patients were similar for ASL and DSC (0.73–0.78), and were higher for enhancing glioma (AUC = 0.78–0.80) than for non-enhancing glioma (AUC = 0.56–0.62). In brain metastasis, the AUC was lower for ASL-derived CBF (AUC = 0.72) than for DSC-derived rCBV ratios (AUC = 0.87–0.93).

Conclusion

We found that ASL and DSC have more or less the same diagnostic accuracy. Our findings suggest that ASL can be used as an alternative to DSC to measure perfusion in enhancing and non-enhancing gliomas and brain metastasis at 3T. For lymphoma, this should be further investigated in a larger population.

Nurses' Practices in the Peripheral Intravenous Catheterization of Adult Oncology Patients: A Mix-Method Study

A significant number of adult oncology patients require at least one peripheral intravenous catheter to fulfill their therapeutic plan. Recent evidence indicates that catheter failure rates are high in this cohort, impacting care outcomes and patient experience during cancer treatment. This reality represents a challenge to nurses worldwide since in most international settings they are responsible for delivering quality care during the insertion and maintenance of such devices. This study aims to explore current nursing practices regarding the insertion, maintenance, and surveillance of peripheral intravenous catheters in oncology patients. A two-phase mix-method study was conducted with the nursing team from the surgical ward of a large oncology hospital in Portugal. In phase one (observational prospective study), nurses' practices during catheter insertion and maintenance were observed by the research team and recorded using standardized instruments and validated scales. In phase two, three online focus groups were conducted with the nursing team to present the results observed in phase one and explore their perceptions of current practices. All ethical principles were assured throughout the study. Significant divergent practices were observed and identified by the nurses, especially concerning patient involvement, nurses' adherence to the aseptic, non-touch technique, catheter stabilization and dressing, and catheter flushing and locking. Such practices may partially explain the high complication rate found (26%) and substantiate the need for future intervention in this field.

Defining difficult intravenous access (DIVA): A systematic review

BACKGROUND

The term "difficult intravenous access" (DIVA) is commonly used but not clearly defined. Repeated attempts at peripheral intravenous catheter (PIVC) insertion can be a traumatic experience for patients, leading to sub-optimal clinical and economic outcomes. We conducted a systematic literature review (SLR) to collate literature definitions of DIVA, with the aim of arriving at an evidence-driven definition.

METHODS

The SLR was designed to identify clinical, cost, and quality of life publications in patients requiring the insertion of a PIVC in any setting, including studies on US-guidance and/or guidewire, and studies with no specific intervention. The search was restricted to English language studies published between 1st January 2010 and 30th July 2020, and the Ovid platform was used to search several electronic databases, in addition to hand searching of clinical trial registries.

RESULTS

About 121 studies were included in the SLR, of which 64 reported on the objectives relevant to this manuscript. Prevalence estimates varied widely from 6% to 87.7% across 19 publications, reflecting differences in definitions used. Of 43 publications which provided a definition of DIVA, six key themes emerged. Of these, themes 1-3 (failed attempts at PIV access using traditional technique; based on physical examination findings for example no visible or palpable veins; and personal history of DIVA) were covered by all but one publication. Following a failed insertion attempt, the most common number of subsequent attempts was 3, and it was frequently reported that a more experienced clinician would attempt to gain access after multiple failed attempts.

CONCLUSIONS

Considering the themes identified, an evidence-driven definition of DIVA is proposed: "when a clinician has two or more failed attempts at PIV access using traditional techniques, physical examination findings are suggestive of DIVA (e.g. no visible or palpable veins) or the patient has a stated or documented history of DIVA."

Pre-operative peripheral intravenous cannula insertion failure at the first attempt in adults: Development of the VENSCORE predictive scale and identification of risk factors

STUDY OBJECTIVE

Our objective was to develop a clinical scale (the VENSCORE) to predict pre-operative peripheral intravenous cannula (PIVC) insertion failure at the first attempt in adults.

DESIGN

This was a prospective multicenter cohort study that included internal validation with bootstrapping.

SETTING

The operating rooms of 14 hospitals in southern France from June 2016 to June 2018.

PATIENTS

Consecutive adult patients aged 18 years or older were recruited upon arrival to the operating room, regardless of American Society of Anaesthesiology (ASA) physical status.

INTERVENTIONS

PIVC insertion on arrival to the OR.

MEASUREMENTS

PIVC insertion failure at the first attempt was the outcome of interest. Data collected included the number of PIVC insertion attempts and potential predictors of the risk of failure (including pre-operative patient characteristics and data relative to the procedure). Uni- and multivariable logistic analyses were performed. Based on these results, the VENSCORE scale was developed to predict the risk of failure of the first PIVC insertion.

MAIN RESULTS

In total, 3394 patients were included, and 27 were excluded because of protocol violations. The PIVC insertion failure rate at the first attempt was 20.3%. Based on multivariable analysis, a history of difficult PIVC insertions, high-risk surgery, poor vein visibility, and moderate to poor vein palpability were identified as risk factors for insertion failure at the first attempt. The area under the curve of the predictive model was 0.82 (95% confidence interval: 0.80-0.84). A VENSCORE value of 0 points was associated with a failure rate of 7%, versus 97% for a score of 6.

CONCLUSIONS

The four-item VENSCORE scale could be useful for prospectively identifying adults at risk of first PIVC insertion attempt failure.

Missed Nursing Care Among Patients With Dementia During Hospitalization: An Observation Study

Patients with dementia (PwD) are characterized as a vulnerable group as they are unable to communicate their needs, putting them at risk for care omissions. The current study aimed to explore care toward PwD and detect if any aspects of care are omitted. An observation study was conducted in three medical-surgical adult wards of an acute general hospital. Data were collected by an observer, through field notes, and were analyzed with content analysis. A face scale was used to assess PwD's mood. Thirteen PwD were observed for 90 hours. Four thematic areas were identified: (a) Unmet Fundamental Patient Needs, (b) Human Right to Dignity and Respect, (c) Communication Deficiencies, and (d) Implementation of Nursing Interventions. Nurse-patient contact lasted from 5 to 7 minutes and numerous care omissions were noted. The face scale assessment revealed that most PwD looked very sad after nursing care. This study enriches insight for the care of PwD during hospitalization and emphasizes the need for health care workers' education and support. [Research in Gerontological Nursing, 14(3), 150-159.].

The impact of a notched peripheral intravenous catheter on the first attempt success rate in hospitalized adults: Block-randomized trial

INTRODUCTION

Peripheral intravenous cannulation is the preferred method to obtain vascular access, but not always successful on the first attempt. Evidence on the impact of the intravenous catheter itself on the success rate is lacking. Faster visualization of blood flashback into the catheter, as a result of a notched needle, is thought to increase first attempt success rate. The current study aimed to assess if inserting a notched peripheral intravenous catheter will increase first attempt cannulation success up to 90%, when compared to inserting a catheter without a notched needle.

DESIGN

In this block-randomized trial, adult patients in the intervention group got a notched peripheral intravenous catheter inserted, patients in the control group received a traditional non-notched catheter. The primary objective was the first attempt success rate of peripheral intravenous cannulation. Intravenous cannulation was performed according to practice guidelines and hospital policy.

RESULTS

About 328 patients were included in the intervention group and 330 patients in the control group. First attempt success was 85% and 79% for the intervention and control group respectively. First attempt success was remarkably higher in the intervention group regarding patients with a high risk for failed cannulation (29%), when compared to the control group (10%).

CONCLUSION

This study was unable to reach a first attempt success of 90%, although first attempt cannulation success was higher in patients who got a notched needle inserted when compared to those who got a non-notched needle inserted, unless a patients individual risk profile for a difficult intravenous access.

Difficult intravenous access as an independent predictor of delayed care and prolonged length of stay in the emergency department

OBJECTIVES

Difficult intravenous access (DIVA) is common in the emergency department (ED). We investigated the extent to which DIVA is associated with care delay outcomes including time to first laboratory draw, therapies, imaging, and ED disposition.

METHODS

An observational retrospective cohort analysis of patients with DIVA treated between 2018 and 2020 at 2 urban academic EDs was performed. DIVA was defined as patients requiring ultrasound-guided intravenous access placed by physicians or advanced practice providers (APPs) as opposed to landmark-based intravenous placement by nurses. ED throughput variables and disposition time were compared. We correlated DIVA with time to administration of intravenous pain medications, fluids, imaging contrast, laboratory results, and ED disposition.

RESULTS

A total of 108,256 subjects with 161,122 total encounters were included. DIVA occurred in 4961 (3.1%) of ED visits. Patients with DIVA were more likely to be female (3.5% vs 2.6% for males, odds ratio [OR] 1.34, 95% confidence interval [CI]: 1.27-1.42), self-identify as black (OR 1.78, 95% CI: 1.66-1.91), and have higher acuity of illness (P < 0.001). Among pediatric patients, DIVA occurred most often in the first year of life at a rate of 3.25%. In adults, DIVA occurred in 2 age peaks; at 35 years (4.02%), and at 63 years (3.44%). In all workflow metrics, the presence of DIVA was associated with significant delays in median time to completion: 50 minutes for pain medication administration, 36 minutes for intravenous fluid administration, 29 minutes for laboratory results, 57 minutes for intravenous contrast administration, and 87 minutes for discharge orders.

CONCLUSION

DIVA was associated with increased time to therapies, diagnostic studies, imaging completion, and ED disposition. A more expeditious approach to achieving intravenous access in patients with predicted DIVA could improve ED throughput and patient care overall.

Translation and Validation of the Modified A-DIVA Scale to European Portuguese: Difficult Intravenous Access Scale for Adult Patients

(1) Background: In Portugal, no accurate and reliable predictive instruments are known that could assist healthcare professionals in recognizing patients with difficult venous access. Thus, this study aimed to translate and validate the Modified A-DIVA scale to European Portuguese. (2) Methods: A methodological and cross-sectional study was conducted in two phases: translation of the Modified A-DIVA scale to European Portuguese following six stages proposed by Beaton and collaborators, and assessment of its psychometric properties in a non-probability sample of 100 patients who required peripheral intravenous catheterization in a Portuguese hospital. (3) Results: The European version of the Modified A-DIVA scale (A-DM scale) showed excellent inter-rater accordance scores, k = 0.593 (95% CI, 0.847 to 0.970), p < 0.0005. The A-DM scale's criterion and construct validity was assessed through predictive, convergent, and correlational analysis with variables identified in the literature as associated with difficult peripheral intravenous access, with moderate to large magnitudes and statistical significance. (4) Conclusions: The A-DM scale is a reliable and valid instrument that can support healthcare professionals and researchers in the early identification of patients at risk of difficult peripheral intravenous access. Future validation studies are needed to test the A-DM scale's applicability across clinical settings and in different patient cohorts.

Handheld Ultrasound: Overcoming the Challenge of Difficult Peripheral Intravenous Access in the Emergency Department

OBJECTIVES

The purpose of this study was to evaluate the performance of a handheld ultrasound device for difficult peripheral intravenous (PIV) access performed by nurses and paramedics in the emergency department (ED).

METHODS

This was a retrospective review at an academic medical center. Participants were ED nurses and paramedics with competence in ultrasound-guided PIV placement. Participants were asked to log their use of the handheld device when used on patients deemed to have "difficult" access and complete a questionnaire, which consisted of items related to the effectiveness and ease of use of the device. Data were collected over the course of 1 year. An electronic medical record review was performed to track the success rates and the occurrence of any associated complications throughout the hospital stay.

RESULTS

Nurses and paramedics logged a total of 483 cases in which PIV access was attempted with the handheld ultrasound device. Ninety-two percent (95% confidence interval [CI], 89%-94%) of the ultrasound-guided PIV lines attempted were placed successfully. Eighty-four percent (95% CI, 80%-87%) of the lines were placed successfully on the first attempt. In most cases (396 of 483 [82%]), no complications associated with the PIV occurred. A total of 429 questionnaires were completed over the study period. Most of the operators (84%; 95% CI, 80%-87%) stated that the handheld device was adequate to perform ultrasound-guided PIV access.

CONCLUSIONS

The handheld ultrasound device performed well in terms of usability and reliability for PIV access.

Blood sampling from peripherally inserted central catheter is effective and safe for patients with head and neck cancers

OBJECTIVE

To evaluate the validity of laboratory tests for blood sampling from a peripherally inserted central catheter.

METHODS

A total of 22 patients diagnosed with head and neck cancers were enrolled. In total, 101 paired blood samples were taken both via venipuncture and peripherally inserted central catheter for hematology and biochemistry testing. Paired t tests and linear correlation analysis were used to evaluate the results. Blood sampling-related pain was recorded by visual analogue scales and numerical rating scales. Infusion occlusion, hemolysis, and catheter-related blood stream infection were also recorded.

RESULTS

The peripherally inserted central catheter-associated test results were slightly lower than those with venipuncture. Some parameters differed more than others. However, the degree of difference was less than 5% for every pair. There was a high correlation between the test results with two methods of blood sampling with the representative equation approximately being "y = x." According to visual analogue scales and numerical rating scale analysis, the pain degree with peripherally inserted central catheter was significantly lower than that of the venipuncture (p < 0.001). No case of infusion occlusion, catheter-related blood stream infection was reported with both methods. Hemolysis rate in blood samples from peripherally inserted central catheter (1/101) was much lower than that seen with venipuncture (11/101) with significant difference (p = 0.0056).

CONCLUSION

Blood sampling via peripherally inserted central catheter and venipuncture showed equivalent reliability in laboratory testing. Compared with venipuncture, blood sampling via peripherally inserted central catheter causes less pain and is safer. Blood sampling via peripherally inserted central catheter is strongly recommended for clinical use.

Peripheral intravenous cannulation: reducing pain and local complications

Caring for patients with peripheral intravenous cannulas/catheters (PIVCs) is an important part of the nurse's role and insertion of PIVCs has traditionally been a post-registration nursing skill. With the introduction of the Nursing and Midwifery Council Standards of Proficiency for Registered Nurses in 2018, insertion of PIVCs is to be incorporated in pre-registration nursing programmes for all four fields of nursing practice. Although IV cannulation is a commonly performed clinical procedure, it is associated with significant risks and complications, which can cause pain for patients. This article outlines the factors that can cause pain for adult patients requiring a PIVC and recommends that the use of local anaesthetics be more widely considered when inserting a cannula. The identification, prevention and clinical management of commonly occurring painful local complications that can arise post-PIVC insertion are also discussed.

Speeding the Detection of Vessel Cannulation: An In-Vitro Stimulation Study

BACKGROUND

Some practitioners "prime" small IV angiocatheter needles with 0.9% sodium chloride-claiming this modification speeds visual detection of blood in the angiocatheter flash chamber on vessel cannulation.

METHODS

We compared the time required for human blood to travel the length of saline-primed and saline-unprimed 24- and 22-gauge angiocatheter needles (Introcan Safety IV Catheter; B. Braun, Bethlehem, PA). A syringe pump (Medfusion 4000, Cary, NC) advanced each angiocatheter needle through the silicone membrane of an IV tubing "t-piece" (Microbore Extension Set, 5 Inch; Hospira, Lake Forest, IL) filled with freshly donated human blood. When the angiocatheter needle contacted the blood, an electrical circuit was completed, illuminating a light-emitting diode. We determined the time from light-emitting diode illumination to visual detection of blood in the flash chamber by video review. We tested 105 saline-primed angiocatheters and 105 unprimed angiocatheters in the 24- and 22-gauge angiocatheter sizes (420 catheters total). We analyzed the median time to visualize the flash using the nonparametric Wilcoxon rank sum test in R (http://www.R-project.org/). The Stanford University Administrative Panel on Human Subjects in Medical Research determined that this project did not meet the definition of human subjects research and did not require institutional review board oversight.

RESULTS

In the 24-gauge angiocatheter group, the median (and interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.14 (0.61-1.47) seconds compared with 0.76 (0.41-1.20) seconds in the saline-primed group (P = 0.006). In the 22-gauge catheter group, the median (interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.80 (1.23-2.95) seconds compared with 1.46 (1.03-2.54) seconds in the saline-primed group (P = .046).

CONCLUSIONS

These results support the notion that priming small angiocatheter needles, in particular 24-gauge catheters, with 0.9% sodium chloride may provide earlier detection of vessel cannulation than with the unprimed angiocatheter.

Factors affecting superficial vein visibility at the upper limb in healthy young adults: A cross-sectional observational study

OBJECTIVE

Venipuncture is an invasive procedure, and repeated puncture attempts may be uncomfortable or even traumatic for patients. Vein visibility is one of the most influential variables for the failure of venipuncture; however, the factors affecting vein visibility remain unclear. The present study was conducted to identify the factors influencing vein visibility at the upper limb in healthy young adults.

METHODS

Twenty-seven healthy volunteers were included. All measurements were performed at the right arm, right cubital fossa, and right forearm. The depth and cross-sectional area of superficial veins were measured by ultrasonography. Skin color was assessed by a spectrophotometer and quantified according to Commission International d'Eclairage L*a*b* values.

RESULTS

Invisible superficial veins were significantly deeper and had a larger cross-sectional area than visible superficial veins. Skin color b* of invisible superficial veins was significantly higher than that of visible superficial veins. Vein depth, skin color b*, and gender markedly affected superficial vein visibility at the upper limb. The cutoff for vein depth was 2.3 mm (area under the curve = 0.91).

CONCLUSION

The present results confirmed that vein depth, skin color b*, and gender strongly influenced vein visibility at the upper limb. The cutoff for vein depth was 2.3 mm.

Risk Factors for Difficult Peripheral Intravenous Cannulation. The PIVV2 Multicentre Case-Control Study

BACKGROUND

Difficult peripheral intravenous cannulation (DPIVC) is associated with serious complications related to vascular access. These complications might be avoided if the risk factors were identified previously, enabling the detection of potentially difficult situations at an early stage. The aim of this study is to consider these risk factors, to determine the influence of the hospital setting, to examine the association between DPIVC and the different techniques of catheter insertion and to analyse the importance of the clinician's experience in this context.

METHODS

Case-control study following a previously published protocol, conducted in 48 units of eight public hospitals in Spain. Adult patients requiring a peripheral intravenous cannula were prospectively included in the study population during their hospital stay. Over a period of 11 months, for consecutive eligible patients, nurses in each participating unit recorded data on their assessment of the vascular access performed and the technique used. Variables related to these medical personnel were also recorded. One of the researchers reviewed the patients' clinical history to compile the relevant health variables and to characterise the healthcare process. The statistical analysis included association tests among the main study variables. The risk factors were analysed using bivariate logistic regression. The variables found to be statistically significant were included in a multivariate logistic regression model incorporating each of the healthcare environments identified.

RESULTS

The study population was composed of 2662 patients, of whom 221 (8.3%) presented with DPIVC. A previous history of difficulty, the presence of non-palpable veins, acute upper limb alterations and punctures in the ante-cubital fossa were found to be independent risk factors for DPIVC. Differences were found in the frequency of occurrence of DPIVC and in some risk factors, according to the healthcare context. The variables related to the characteristics of the hospital personnel did not influence the study event.

CONCLUSION

The present study identifies four independent risk factors for DPIVC that can be incorporated into algorithms aimed at preventing its occurrence and facilitating the referral of patients to vascular access specialist teams.

Patient Position Affects Venodilation for Peripheral Intravenous Cannulation

BACKGROUND

Larger veins are associated with a higher rate of success of peripheral intravenous cannulation. Although patient position affects venodilation during central venous cannulation, the association between patient position and vein size for peripheral intravenous cannulation remains unclear.

PURPOSE

We examined the effect of seated versus supine positioning on vein size during peripheral intravenous cannulation before and after tourniquet application.

METHODS

In the present study, we recruited 81 participants (20-64 years) and included 80 in the analysis. We measured outcomes before and after tourniquet application in the seated and supine positions. The primary outcome was the cross-sectional area of the target forearm vein (ultrasonography by a blinded assessor). Subgroup analysis was used to test the effects of positioning combined with difficult peripheral intravenous cannulation (DPIVC) defined as poor visibility and/or palpability of the target vein.

RESULTS

Results of paired t tests demonstrated that the venous cross-sectional area significantly increased in the supine position with tourniquet application compared with the seated position with tourniquet application. Subgroup analysis with two-way repeated measures analysis of variance revealed that the venous cross-sectional area was significantly larger in the supine position than in the seated position despite DPIVC.

CONCLUSION

Vein size during tourniquet application was greater in the supine than in the seated position even in cases of DPIVC. We thus recommend the supine position over the seated position for peripheral intravenous cannulation.

A Model of Phlebitis Associated with Peripheral Intravenous Catheters in Orthopedic Inpatients

Phlebitis leads to increased discomfort for patients, longer hospital stays, and higher healthcare costs. This study aimed to identify predictive factors of peripheral phlebitis related to intravenous injection among orthopedic inpatients, develop a prediction model, and evaluate the goodness-of-fit of the prediction model. This study included 270 orthopedic patients who were hospitalized in the orthopedic ward of a general hospital. A peripheral intravenous injection-related questionnaire based on previous studies and the modified Infusion Nurses Society scale were used to collect data. Phlebitis risk factors were identified, and a prediction model was developed using the Bayesian regression model. Vein quality, contrast medium use, hygiene duration, and period of nursing clinical experience were significant based on their 95% confidence intervals. The prediction model exhibited good discrimination. The prediction model developed in this study can be used for screening high-risk patients for peripheral intravenous catheter-related phlebitis and for providing basic data for developing interventions for the prevention and management of peripheral intravenous catheter-related phlebitis.

Intravenous Lidocaine for Chronic Neuropathic Pain A Systematic Review Addressing Nursing Care

BACKGROUND

The intravenous administration of lidocaine for patients with chronic neuropathic pain is well documented in the literature. However, little is known about the role of the nurse caring for patients receiving the infusion.

AIM

The purpose of this systematic review was to examine and describe common side effects associated with the intravenous administration of lidocaine to patients with chronic neuropathic pain and outline nursing care described in an effort to develop evidence-based protocols for care.

METHOD

A comprehensive search of databases was completed and yielded eleven (n = 11) articles and one care protocol for analysis.

RESULTS

Evidence was appraised and findings suggest intravenous lidocaine has a low risk of causing adverse events, however patients should be monitored closely.

CONCLUSIONS

Nursing care focuses on pain assessment, close observation and intervention if neurological changes occur.

Risk factors for a difficult intravenous access: A multicentre study comparing nurses' beliefs to evidence

AIMS AND OBJECTIVES

To summarise the evidence about patient-related risk factors for difficult intravenous access in adults, and at identifying nurses' beliefs and their consistency with evidence.

BACKGROUND

Peripheral intravenous cannulation is a common procedure for nurses, but rates of failure at first attempt of peripheral intravenous cannulation range 10%-40%. Nurses' beliefs about difficult intravenous access factors might influence their clinical practice more than current evidence.

DESIGN

The study included a literature review of the evidence on patient-related risk factors for difficult intravenous access, the development of an instrument to investigate nurses' beliefs about this topic and a cross-sectional multicentre survey on clinical nurses.

METHODS

The quality of the studies included was evaluated through the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. A synthesis of evidence for each risk factor was produced. A survey instrument was developed including 26 risk factors, which were then rated by nurses as perceived predictors of difficult intravenous access. The STROBE guidelines for study reporting were followed.

RESULTS

Four hundred and fifty clinical nurses working in four hospitals in Italy were surveyed. Nurses' beliefs were in line with evidence in considering body mass index, drug abuse, lymphadenectomy and chemotherapy as difficult intravenous access factors. Beliefs about difficult intravenous access factors were influenced by nurses' work experience and frequency of peripheral intravenous cannulation. Nurses also identified as risk factors for difficult intravenous access oedema, thrombophlebitis, hypovolaemia, skin lesions and irritant therapies, which have been minimally investigated by research.

CONCLUSIONS

An overall congruence between nurses' beliefs and evidence about risk factors for difficult intravenous access was found. With their expertise, nurses may fill the knowledge gap of clinical evidence and open new paths for clinically meaningful research.

RELEVANCE TO CLINICAL PRACTICE

Nurses' beliefs about difficult intravenous access factors can be influenced by their work experience and clinical setting. Integrating nurses' beliefs with scientific evidence can increase the quality of care.

Investigating the effect of local warming on vein diameter in the antecubital area in adults aged 20-40 years

BACKGROUND

peripheral intravenous cannulation is the most prevalent invasive procedure performed on patients admitted to hospital. The procedure is not always easy to undertake and can lead to problems for the patient and nurse. Alongside various procedures, local warming is one technique that could be used to increase the diameter of superficial veins. This prospective non-randomised trial aimed to determine the effect of local warming on vein diameter in the antecubital area in adults aged 20-40 years.

METHOD

the subjects included 55 volunteers who were in good health. The cephalic vein diameter of the right arm cubital area was measured for each participant using ultrasound guidance. The arm was warmed for 10 minutes using a heating device maintained at 42ºC. A second ultrasound scan was then undertaken immediately afterwards and cephalic vein diameter measured.

RESULTS

local warming increased the cephalic vein diameter in the cubital area by 0.43±0.4 mm. There was no significant relationship between change in cephalic vein diameter and participants' gender, age or body mass index.

CONCLUSION

the results indicate that the application of heat is an effective technique for venodilation and could be considered in emergencies or in cases when other veins are difficult to access.

Hypermedia on peripheral venipuncture: effectiveness in teaching nursing students

OBJECTIVE

To assess the effectiveness of an educational hypermedia in the knowledge of Nursing academics on peripheral venipuncture.

METHOD

Quasi-experimental study with pre and post-test design.

RESULTS

The mean number of right answers of the 73 individuals who participated in the study, in the pre-test, was 7.7 (DP = 1.05), and 8.3 in the post-test (DP = 0.74). The comparation of pre and post hypermedia mean number of right answers showed significant difference (p < 0.001).

CONCLUSION

Hypermedia is a strategy that increases knowledge and is feasible in the teaching-learning process, being useful as a support tool for teachers and for the development of undergraduate Nursing students.

The Modified A-DIVA Scale as a Predictive Tool for Prospective Identification of Adult Patients at Risk of a Difficult Intravenous Access: A Multicenter Validation Study

Peripheral intravenous cannulation is the most common invasive hospital procedure but is associated with a high failure rate. This study aimed to improve the A-DIVA scale (Adult Difficult Intra Venous Access Scale) by external validation, to predict the likelihood of difficult intravenous access in adults. This multicenter study was carried out throughout five hospitals in the Netherlands. Adult participants were included, regardless of their indication for intravenous access, demographics, and medical history. The main outcome variable was defined as failed peripheral intravenous cannulation on the first attempt. A total of 3587 participants was included in this study. The first attempt success rate was 81%. Finally, five variables were included in the prediction model: a history of difficult intravenous cannulation, a difficult intravenous access as expected by the practitioner, the inability to detect a dilated vein by palpating and/or visualizing the extremity, and a diameter of the selected vein less than 3 millimeters. Based on a participant’s individual score on the A-DIVA scale, they were classified into either a low, moderate, or high-risk group. A higher score on the A-DIVA scale indicates a higher risk of difficult intravenous access. The five-variable additive A-DIVA scale is a reliable and generalizable predictive scale to identify patients at risk of difficult intravenous access.

The eutectic mixture local anesthetics (EMLA) cream is more effective on venipuncture pain compared with lidocaine tape in the same patients

Introduction

Although venous cannulation is imperative during perioperative period, it inevitably causes venipuncture pain. Eutectic mixture local anesthetics (EMLA) has been used to reduce this pain, and various studies have been conducted to evaluate the efficacy of EMLA. But these studies did not elucidate the effect of EMLA exactly, because there were large individual differences in pain sensitivity. The aim of this study is to accurately evaluate the efficacy of EMLA cream for venipuncture pain relief compared with lidocaine tape in the same patients.

Methods

Participants were randomly allocated into EL or LE group. Participants received EMLA cream at one side dorsum of hand and lidocaine tape at another dorsum of hand before entering operation room. Local anesthetics were strictly applied according to their manufacturers’ instruments, respectively. In the EL group, participants received venipuncture at EMLA cream site firstly. In LE group, participants, conversely, received venipuncture at lidocaine tape site firstly. Before anesthetic induction, local anesthetics were removed followed by venous cannulations. After cannulation, participants evaluated the pain by visual analog scale (VAS) and verbal rating scale (VRS).The primary outcome was VAS, and the secondary outcome was VRS.

Results

Data from 24 patients were analyzed. The VAS of EMLA cream was significantly lower than that of lidocaine tape (4 [0–18] vs 17 [8–45], p = 0.001, 95% CI − 25 to − 6). The VRS of EMLA cream was also significantly lower than that of lidocaine tape (2 [1–2] vs 2 [2–3], p = 0.002, 95% CI − 0.8 to − 0.2). The local skin adverse events were observed in five patients at EMLA cream applied hands.

Conclusions

We conducted a comparative study to elucidate the efficacy of EMLA cream for venipuncture-pain comparing with lidocaine tape in the same patients. Our results strongly suggest that EMLA cream is more effective for venipuncture pain relief than lidocaine tape.

Trial registrations

UMIN Clinical Trials Registry, UMIN000023030. Registered 5 July 2016.

Outcomes of an Innovative Evidence-Based Practice Project: Building a Difficult-Access Team in the Emergency Department

PROBLEM

Difficult venous access is a common problem in health care-especially in the emergency setting-that relies on quick diagnostics to differentiate patient acuities and administer critical medications. The creation of a dedicated team to address difficult venous access (DVA) is a possible solution to the problems of delayed venous access, yet no studies have been published on implementing such a team in the emergency department.

METHODS

This was a quasi-experimental study in an urban emergency department. Researchers performed chart audits of staff-identified patients with DVA to gather baseline data. A DVA team was subsequently implemented 16 hours a day, 7 days a week. Data were recorded on patients referred to the team and included time, number of IV attempts, and patient characteristics.

RESULTS

Baseline data were collected on 53 patients, and postintervention data included 135 patients. The implementation of a DVA team decreased the mean lab order-to-lab completion time by 115 minutes (P < 0.0001). Decreases in the number of attempts were not statistically significant. Patients requiring increased numbers of IV attempts also had many common characteristics including history of multiple attempts, poor skin quality, and IV drug use.

DISCUSSION

The use of a dedicated team for DVA reduces the lag time from physician orders to actionable diagnostics or administration of medication. A dedicated DVA technician is a concrete solution to threats of patient safety, as well as ED crowding, and has the potential to affect both patient- and department-level care.

Tools, Clinical Prediction Rules, and Algorithms for the Insertion of Peripheral Intravenous Catheters in Adult Hospitalized Patients: A Systematic Scoping Review of Literature

BACKGROUND

First-time peripheral intravenous catheter (PIVC) insertion success is dependent on patient, clinician, and product factors. Failed PIVC insertion are an under-recognized clinical phenomenon.

OBJECTIVE

To provide a scoping review of decision aids for PIVC insertion including tools, clinical prediction rules, and algorithms (TRAs) and their findings on factors associated with insertion success.

METHODS

In June 2016, a systematic literature search was performed using the medical subject heading of peripheral catheterization and tool* or rule* or algorithm*. Data extraction included clinician, patient, and/or product variables associated with PIVC insertion success. Information about TRA reliability, validity, responsiveness, and utility was also extracted.

RESULTS

We screened 36 studies, and included 13 for review. Seven papers reported insertion success ranging from 61%-90% (4030 insertion attempts), 6 on validity, and 5 on reliability, with none reporting on responsiveness and utility. Failed insertions were associated with obesity (odds ratio [OR], 0.71-1.7; 2 studies) and smaller gauge PIVCs (OR, 6.4; 95% Confidence Interval [CI}, 3.4-11.9). Successful inser tions were associated with visible veins (OR, 0.87-3.63; 3 studies) or palpable veins (OR, 0.79-5.05; 3 studies) and inserters with greater procedural volume (OR, 4.4; 95% CI, 1.6-12.1) or who predicted that insertion would be successful (OR, 1.06; 95% CI, 1.04-1.07). Definitions of insertion difficulty are heterogeneous such as time to insert to a number of failed attempts.

CONCLUSIONS

Few well-validated reliable TRAs exist for PIVC insertion. Patients would benefit from a validated, clinically pragmatic TRA that matches insertion difficulty with clinician competency.