I have been doing ultrasound guided sticks at my hospital. I am also a PICC RN. We do not currently have a policy in place. I have been asked to write a policy and start out training the trainer in the ED and ICU. Can anyone tell me what criteria is needed to validate non PICC RNs. I was thinking at a minimum a class and written test for anatomy of veins, nerves, and best vein selection etc etc. Then at least three successful sticks. Can anyone share their practices. Thanks, JEN
Pretty sure that is what our ED did. Not very successful b/c they don;t use it enough and US probe is too big.
Jen
Jennifer McCord, MSN, RN, CCRN, PCCN, CCNS, VA-BC
Bethesda North Hospital
Cincinnati, OH
Clinical Nurse Specialist
I am a PICC nurse in training. I have access to a SiteRite US. I don't use it everytime. I do, however, when I get the call that 2 other nurses have tried and had no luck.
I would add to ensure the initiates are competent in identifying arteries versus veins.
Art
Art Hansen BSN, RN
[email protected]
I love starting IV's with the US. I have gotten to where I can start nearly ALL difficult IV's with one stick. We do not currently have a policy in place however I don't think it would be too difficult to formulate. Take the guidelines from the Infusion Nursing Standards of Practice regarding which veins should be assessed, your current IV policies, and fuse that with some US guidelines and you've got it made. When I assess which vein to access, I start with a distal and most superficial vein I can find in the forearm.
As a competency, in my opinion they need much more than three successful sticks with the ultrasound to be remotely competent. After that it takes alot of practice... Probably took me a few months to get REALLY good at it. Because there is a real difference between accessing a basilic or accessing a vein in the forearm. A class is a good idea, after that it's all hands-on.
I think it's great you get to train more people in those key areas. I'd love to train more people at our hospital not only for my workload but most importantly for the patient. :)
Mike
Hi Jen,
Send me an email and I'll attach the policy that another PICC nurse forwarded to me. That should give you a good head start!
Ann
[email protected]
Ann Armstrong, RN
PICC Lines
MidMichigan Medical Center, Midland
I do not believe that US is the best tool for inserting peripheral catheters. US is not designed to be able to see superficial veins at shallow depths. It requires 3 hands - one to hold the skin taut, one to hold the catheter and one to hold the probe. Last time I checked nurses only had 2 hands and I don't think many facilities will look too favorably on this being a 2-person procedure. After insertion you then must be extremely skillful to remove the coupling gel so that the securement device and dressing will actually adhere to the skin - all while holding the catheter in place without causing vein damage. Finally, I know there are numerous articles documenting the high level of success with getting the catheter in the vein. But I also know that there is at least one study that has reported that about half of the US guided PIVs fail within 24 hours due to infiltration. Again, I think this is related to the hand issue. I strongly believe that infrared light devices provide a better alternative for superficial peripheral veins. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
This is a fascinating debate that has been going on for several years. I believe that the best answer to Lynn’s objections to the use of ultrasound for PIV was provided by Brian Gackenbach more than 5 years ago.. see link below
http://www.mail-archive.com/[email protected]/msg00126.html
I agree with Lynn that ultrasound changes the workflow and that acoustic coupling gel needs to be removed to ensure proper adhesion of securing tape and dressing. However, it appears that this has not been a problem for PICC placement where ultrasound guided needle insertion is commonly used. It would be interesting to hear what people who use ultrasound to guide PICC have to say on this subject.
Regarding the number of hands, people use ultrasound to guide interventional procedures all the time and, as Brian pointed out, this is a practice that can be learned. Ultrasound guidance is not a two person operation. Would you ever drive a car and control the steering wheel with your eyes closed while the person sitting next to you looks at the road?
My experience with using US for PIVs has been extremely positive. My success rate is nearly 100%. I've only had 2 patients in 3 years that I could not get the IV to thread successfully. Some have required 2 sticks d/t threading problems, but overall I've started over 2500 PIVs using many different US machines.
I have to say though, when I first began this I did have several infiltrate, but my experience was self taught as the only PICC nurse in a facility and I have learned many aspect of this little procedure to prevent the adverse outcomes mentioned in this discussion. I have been teaching classes for about a year now at my facility and have had good results thus far. I have apprx 20 RNs that have taken the class. Some are better than others, but it boils down to coordination and practice. We purposely keep the classes small (6 to 8 at the most) so we can offer more hands on practice. Also, it takes a while to check off everyone (we require 3 successful sticks).
Out of each class you will have a small percentage that just cant get it d/t coordination issues (holding probe/holding PIV/looking at screen). Keeping their eyes on the screen has certainly been the hardest think to get them to do. They tend to want to look at the site...which offers you no feedback.
So from my experience....
Machines
I have used every bard model and the sonosite ilook. By far, the latest bard vision is the best in clarity and had a nice size screen. The sonosite ilook is next best. No need to mention models older than this.
Catheters
Its important to use a PIV that you can cannulate with one hand. The typical caths that come as extra in most picc kits are great. (braun introcan safety - 20g - 1.75 in/45mm) Other PIVs that require both hands to maneuver will hinder your success. Also, most PIVs stocked on floors are too short. When using US, you will find sticking a vein that is .75 to 1.25 cm deep will be the easiest. If you stick veins that are superficial, its difficult to see on the US screen and you will often go completely through the vein. Sticking veins that are much deeper than that will not leave you enough catheter to dwell in the vein (this is what causes the infiltrations that Lynn was speaking about.) One of the lessons I learned early on. So a good rule of thumb is to always allow for at least half of your catheter length to dwell in the vein. I cover this concept thoroughly (vein depth/catheter length/stick angle) in my class. I even have a chart that gives the catheter length used just to reach the vein given two factors: vein depth and stick angle. A simple trig function can tell you the "hypotenuse" of the triangle and really give good illustration to how using an angle too low will burn up most of you catheter before you even reach the vein. But I also explain not to stick too steep to avoid catheter kinking...in general 45 - 65 degrees is best.
How many hands?
This takes a little practice, but i commonly use my left hand (holding the probe) to rest on the skin. I use my right hand pinky finger to pull skin back if needed and my other finger to insert the IV. Works pretty good. I've never needed a third person unless i had a patient that was a really hard one, and i was drawing blood through a butterfly. Sometimes I ask another nurse to pop the tubes for me so i dont have to let go of the probe.
Starting a training class
I have posted on this site previously my training material (ppt, policy, competency, 2 videos of insertions). I’m sure you can find them by searching. Also, I will be offer this class for CE credit later this year. I can repost the website when I’m ready to offer it.
- keep your class size small
- advise your students to use the US on every stick that even remotely looks difficult. They will never get it if they only do it a few times a month.
- make the US machine readily available...no one will use it if its a pain to access or very time consuming.
- we created a log for them to keep up with every stick and the outcomes. this can serve as their annual competency and offer good feedback for possible future training.
- allow 4 hours for class time/practice time...lunch...then begin checking off as many as you can right away. I've had some come back 6 weeks later to check off and i have re-teach everything....very difficult.
Good luck,
Kevin Arnold
Kevin Arnold RN, MSN
Kevin,
Thank you for the exhaustive description of your experience with ultrasound guided PIV. What would be your comment/recommendation concerning the issue of having gel around the venipuncture site?
In addition to the securing and dressing adhesion problems that Lynn had mentioned, I have also heard several nurses expressing concerns for inserting needles through gel although the gel is sterile. I have also seen people using chlorhexidine instead of gel because it provides the necessary acoustic coupling without the need to be wiped off. What is your opinion?
Thanks,
Alessandro
Never heard of using CHG for this purpose. I think it would be an off-label use, don't think any CHG company lists this as an indication. Have you checked with any of them? Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
No, I haven't checked. I would agree that this is an off-llabel use, and it is likely driven by availability and convenience of CHG compared to sterile ultrasound gel.
Alessandro
Hi Kevin,
Can you provide me with your ppt, policy, competency, and videos? I have been asked by our education department to get information on what other hospitals are doing. My email is [email protected]
Thanks,
Renee
Renee / Janette,
I have emailed the documents as requested.
I agree with Lynn on preservation of the veins even during PIV placement. One of my presentations points is the general rule of thumb in where to look first, second, third....last. I teach all of our RNs to use the basilic/brachial veins as a last resort.
To anyone that has used my presentation, I will be adding more content soon (pictures, etc). I also will be presenting this topic at AVA in October. I will include all of my materials in that presentation.
Kevin Arnold RN, MSN
Every facility carries some kind of sterile lubricating jelly (KY) in small packets for placing other types of tubes like NGs and Foleys. It works adequately as a conductive medium and is much cheaper and easier to find than sterile ultrasound gel. ORs use it when they drop a gel packet or just don't have any readily available. Sonographers will tell you they use that (usually over a clear dressing) when doing vascular studies near compromised tissue.
Daniel Juckette RN, CCRN, VA-BC
I would question the use of these packets of gel. The contents might be sterile, but once the non-sterile packet is opened, it is not sterile. The edges of the packet is not sterile.
Am I missing something?
Gwen Irwin
I would question the use of these packets of gel. The contents might be sterile, but once the non-sterile packet is opened, it is not sterile. The edges of the packet is not sterile.
Am I missing something?
Gwen Irwin
I use Surgi-Lube. I use alcohol pad clean at the tearing site before opening the package. Then,I put this gel on the cleaned skin and on the probe. After that I use an off-site or tegaderm cover the probe.
Therefore, your probe is sterile with a prep skin site.
Bard Access Systems has a "competency" for the use of ultrasound. You can build off of that to add your anatomy... Contact your rep.
Kimberly DuBore, RN, BSN
PICC Chick and Imaging Nurse
I do use sterile gel, but I dont stick through it. After scanning the site, I make an impression on the skin with the round, back side of the angiocath...or any soft plactic would do. This will not come off during cleaning and gives you a good landmark of where your stick area will be.
When placing the probe on the skin, I start apprx 1 inch above the site and drag the probe almost to my stick point....leaving about 5mm. No gel will be in the way when using this technique. So I can stick through skin only. Pretty simple way to keep from contaminating the site.
As far as issues with dressings coming off...never have any problems. I use a chg sponge to wipe off the inital gel, etc. Then wipe again with the 2x2s that come in our starter package. As long as you wipe it good...there are no issues.
So to answer your question, sterile gel would be safer...but it really dont matter if you dont stick through it.
Kevin Arnold RN, MSN
I am doing the same thing that Kevin describes with the gel and I used to use the same thing to make a mark. But now I made cards with our name badge machine. Instead of saying the employee's name, they say "ultrasound marker". Then I use it to mark the skin over the vein by pressing gently for 5 seconds. Then I scrub the site and put the gel above and don't stick through it. If the vein is large enough, I don't even need to use the ultrasound again, unless I don't get it right away, because the mark shows me where it is. I mark above and below where I plan to canulate so I can see which way the vein goes. Then I double check the mark to be sure the vein is really where I think it is. I also use the 1.75" Braun catheter if the vein is over 1 cm deep, otherwise the site does not last long. I disinfect the marker card and reuse it. I have used water based lube packets for this but it is too hard to get it off and get the tape to stick. I much prefer real ultrasound gel that we purchase in 1 oz packets as it is much less slimy and I also get a better image. It is non-sterile and comes in a box of 100. After I place the line, I just use a chloraprep swab to remove it from just above the site. I don't have trouble holding my traction with the dominant little finger (bent and transverse to the arm) while placing the line and and holding the probe with my left hand. I always do it by myself but it does take practice. It has taken me about 50 lines to be better at it (faster at getting it done) and I frequently use the longitudinal view after I have entered the vein with a transverse view to see the exact angle. I am still experimenting to see which I prefer and sometimes I start with the longitudinal view. I always use a local because it takes me longer to get access than a typical start. The biggest thing to get used to is that you have to be sure the angle is the same that you would expect to use for any other IV, and not as deep as you would use with a PICC typically.
We show all of our nurses how to find the veins with the ultrasound. We teach about the nerve and the artery and instruct them to stay full away from them and any brachial veins. It is about a 10 minute explanation. They are only to find veins that are 1cm or less deep and then mark them with the card. Then they are to use their regular technique of lab draw or IV start and either insert on the mark or try to feel for the vein depending on the depth. If it is over 0.5cm deep then they should try and find a vein that is at least 0.4cm big to go in on the marking, otherwise they will need the more advanced guidance for a smaller or deeper vein. I call it "basic Ultrasound finding technique". Ultrasound-guided placement is much more advanced and it is what I use if they can't get a line or labs or if the patient only has brachial veins, and what I use for PICC placement.
Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland [email protected]
I have to say I place them the same way Kevin does to the letter and I have never had issues with the gel or the marking. I must say that ultrasound is great even for surface veins. 90% of mine are .5-1cm in depth. We will hopefully be trying the power wand soon so that will help me out as well.
Frank
excellent idea Kevin about marking your site. I do have a comment thought, if we take the precautions to make our site sterile including sterile gel, aren't we doing best practice. After all, when we place a PICC line, we "stick" through the gel - I don't see the big concern here about sticking through the gel unless it's just a sterility issue. You could open the pack and prop open the gel and use a steril cotton swab to extract your gel as well. Also, I think that in my facility, when we are called to obtain a difficult PIV with the use of U/S it is usually (about 95% of the time) on an obese patient. I know Lynn had mentioned that U/S guided PIV's tend to not last as long -in these instances I think you need to look at the depth of your vein and compare that to the length of your needle - if you are using a short catheter, then barely the the tip will be in the vein and you will have extravasion/infiltration issues. In patients such as these, we will use a 1.88 inch cathlon know that enough of the cathlon resides in the vein to achieve success and our IV's usually last for the desired length of therapy.
Frequently a 1.88 inch catheter is not long enough often resulting in infiltation or worse extravasation. At the recent LITE conference there was a very interesting product introduced called the M/29 midterm catheter that as demonstrated seemed like a safe and effective alternative. It is being marketed as a Midline Catheter System and information can be found at www.flexicath.com.
Robbin George RN, VA-BC Vascular Access Resource Department Alexandria Hospital Virginia
Robbin George RN VA-BC
Frequently a 1.88 inch catheter is not long enough often resulting in infiltation or worse extravasation. At the recent LITE conference there was a very interesting product introduced called the M/29 midterm catheter that as demonstrated seemed like a safe and effective alternative. It is being marketed as a Midline Catheter System and information can be found at www.flexicath.com.
Robbin George RN, VA-BC Vascular Access Resource Department Alexandria Hospital Virginia
Robbin George RN VA-BC
true, there are times whena 1.88 inch catheter is not long enough; however, our hospital only stocks the 1.16 inch cathlone which is definitely not long enough. I have had great success with maintaining IV's with the 1.88 inch catheter. Thanks for the info on the device you mentioned, I will look into it. I have a question - we occassionally place a midline, but seem to have a lot of complications with them - leakage, thrombus etc. I do not feel it is techniques related, but rather nurses who refuse to comply by the infusion guidelines we set up for midlines - even though they state they are. What is your take on this, is there possibly something we as clinicians are doing that may be contributing to this. We place just as if we were placing a PICC line with all the precautions in place, but still always have a problem with a mid line several days after placement. We do not place very many of these at all, I would just like to get some input. thanks.
I often hear the following recommendations:
a) at least half of the catheter length should be left into the vein
b) the catheter outside diameter should be less than 30% of the vessel lumen
Are these general best practice rules? are these recommendations captured in any of the standards?
Thank you,
Alessandro
What type of catheter are you asking about? PIV or PICC? The standard of practice is now and has always been that the smallest size and shortest length of catheter that will accommodate the prescribed therapy be chosen. There has been some suggestions about comparing vein internal diameter to catheter outer diameter and discussions at conferences but I don't think this has been published yet. So a standard can not quantify this yet. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Our experience is that ultrasound-guided PIVs are not an "occasional use" skill set. Our nurses who do them do not place PIVs any other way. Like PICC placement, a consistent procedure and frequent repetitions are the best predictor of high success and low complication rates. Our hospital policy is that no one should receive a 3rd stick without calling for ultrasound guidance. iIf the patient has been stuck twice by each of 3 different nurses plus lab, they are hysterical and and the best potential sites are already gone. Trying ultrasound at that point is just continuing the abuse. We have a written procedure and competency validation checklist. I can provide it if you send me an email address. Our nurses practice on simulators and then are precepted in US guidance for PIVs, just like with PICCs.
Braun Introcan that is 45mm long is available in both 20 and 22 gauge. We usually don't have any difficulty placing them in the mid forearm cephalic. For most patients you can access it at .5 to 1cm depth and have little difficulty getting more than 50% of the catheter in the vein. Use of a securement device is required. If you can only find 1.5cm or deeper veins in the forearm, then push for a CVAD. If the antecubitals are ruined the upper arm cephailc is worth a try, but it's much harder to position for placement and harder to secure. Getting serious about vein preservation over a lifetime means minimizing the number of sticks every time. Patient satisfaction scores are directly affected by the number of punctures (and bruises) they go home with.
[email protected]
Daniel Juckette RN, CCRN, VA-BC
I was asking specifically about the selection of gauge and length for PIV catheters.
Daniel, thank you for offering to share your ultrasound guided vascular access procedure and competency checklist.
Alessandro
[email protected]
We are about to start our program and I have been charged with gathering policy, competency etc information. We plan to have our MDs in the ER train the nurses. I would be very grateful for any and all information. Thank you JMoss
[email protected]
I have just read several studies on PIV with US inserted in ED. One thing that struck me is many of these used the basilic or brachial veins of the upper arm for US insertion of a short PIV. My concern is what that is doing to these veins and their later use of a PICC if the patient needs it. These were physician-insertion studies. So you might want to get clarification from these ED doctors about where their preferred insertion site is and then think about how that might influence future PICC needs for each patient. Just a thought, Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
If anyone has found a way to get traction convincing ER Staff that the antecubital veins aren't the only veins for initial IV/Lab in the ER, I would appreciate access to any resources that helps with that culture change. It doesn't really matter if you can place peripheral IVs with ultrasound if all the antecubltal veins are already punctured.
Daniel Juckette RN, CCRN, VA-BC
This is not available yet, but it is in the publications process. I wrote a chapter on IV therapy for a major ED textbook. I am not sure when it will be out but it does discuss this issue. That would be one resource to use as a step to change this culture. There are other studies that show higher rates of complications in the hand, wrist and ACF. If your hospital relies on evidence, that could help to change their thinking. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Hi Lynn,
Our ED EBP team will be developing a program for training our emergency nurses with US-guided peripheral access tailored to our difficult access population. I've gathered a lot of literature and am in reviewing them for our group. I was wondering if you could provide the studies your mentioned, about complications with access in the hand, wrist, acf, or let me know where to find them? Thanks,
Bruce Schilling, RN, BSN, CEN
barnes-Jewish Hospital, Saint Louis, MO
So sorry, but time limitations now do not permit me to provide lit search results as a free service. You can easily locate studies of this nature by searching PubMed. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I am a PICC nurse in training. I have access to a SiteRite US. I don't use it everytime. I do, however, when I get the call that 2 other nurses have tried and had no luck.
I would add to ensure the initiates are competent in identifying arteries versus veins.
Art
—
Art Hansen BSN, RN, CRNI
[email protected]
_______
Name: paigebertrand
Website:nespresso
For Kevin and Michelle,
I would love to see your training materials for U/S guided PIV insertions. I have been using the U/S for PIVs for about four years with good success, but also have run into some of the same issues. It sounds like you guys have worked out some of the bugs. Any info you are will to send me I would appreciate.
Matt Gibson RN, CRNI, VA-BC
[email protected]
Matt Gibson RN, CRNI, VA-BC
I'd love a copy of any tools you have. I searched the site for your old postings, but did not come across them.
Thanks in advance,
Jenn Marusich
Team Leader-VAT
CMCD
[email protected]
sent email Jen/Matt.
Kevin Arnold RN, MSN
Kevin......I am unable to find the training materials you use for ultrasound guided peripheral IV catheter insertion. Would you please re-post them or send to me at [email protected]
Thanks!!
Alma Kooistra RN CRNI
How soon do you need them? I am presenting on this topic at AVA this year...so i am currently polishing my materials. If you can wait a week or so, I should be done with them. I will probably put them on a hidden page in one of my web sites (www.ivaccess.com or www.ivtags.com) to make them easy to find. In addition, i can resubmit them to this site and email them.
If you need something immediatly, I can send you now my 98% finished version. Just let me know.
Kevin Arnold RN, MSN
Kevin,
We are very interested in your information, guidlines, policies, and/or training information on this topic.
Could you please send me a link or email us your information.
Thank you!
Angela Wright, RN, BSN, VA-BC
PICC Team, NRHS
[email protected]
I would like a copy of your presentation for AVA. We are researching the possibility of using sonon to place peripherals, however , we deal in high volumes of CT patients that need access for high pressure injections. Would appreciate yourinput.
Thanks,
Pat
Pat,
I am still putting together some of my outcome stats each week, but I can email it to you if you like. The classroom slides are complete. Please post your email or send me an email at [email protected] and I will send it your way.
Kevin Arnold RN, MSN
I am the Coordinator for the Ultrasound Guided IV Placement for Nurses in the Duke Emergency Department. We started developing the training 5 years ago and have trained approximately 60 RN's to perform this skill as well as many of the Emergency Medicine Residents. We have a 3 hour didactic and then clinical performance guidelines for check-off. We teach the skill and a proven "method" which, if adheared to, results in high success rates of placing reliable venous access. We have also adapted this skill to arterial punctures for ABG's, and have trained RT's who place arterial lines. Please let me know if we can be of any assistance.
Sincerely,
Phillip L. Stone RN CN-IV
Ultrasound Program Coordinator
[email protected]
Hello Philip,
Was wondering if you wouldn't mind sending me your training/protocol/policies for ultrasound guided IV placement?
We are working to develop these at our hospital and really could use any guidance you can offer.
Thanks,
Shaun rn,bsn
Email: [email protected]
Hi JEN, I was going through similar situation about a month ago. One of my good friends wanted to carry out the procedures himself. So I didin't really look deep into it. But there's this site i checked out in a review iu22 but didn't have time to really see what it offered. I am not sure if it is exactly what you want.
I would be willing to share my US guided PIV Procedure and Competency Verification Checklist through the site if the webmaster will contact me for it.
Daniel Juckette RN, CCRN, VA-BC
Hi All,
I have also been asked to develop teaching tools and policies for ED, Radiology and chemo unit staff in the skill of u/s guided cannulation.
Great points re correct vein selection ongoing battle to champion change in this area.
Any info available would be much appreciated, please email me ([email protected])
Hoping to get to AVA this year depending on staffing, so hope to meet some of you there.
Cheers
Gavin
Gavin Jackson
IV Therapy CNC
Sir Charles Gairdner Hospital
Perth, Western Australia
Kevin-Educational Tools
Hi Kevin-I would also love a copy of any tools (p&p, presentation, etc) you have. Could not find them on the old site.
Thanks so much, Jeannette
[email protected]
Jeannette Andrews, RN, CRNI, VA-BC
Kevin-Educational Tools
Hi Kevin-I would also love a copy of any tools (p&p, presentation, etc) you have. Could not find them on the old site.
Thanks so much, Jeannette
[email protected]
Jeannette Andrews, RN, CRNI, VA-BC
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