Ultrasound Guided Intravenous Access by Nursing versus Resident Staff

Introduction

The use of ultrasound (US) technology in placing peripheral lines has been shown to reduce the need for central venous catheters—a more painful process with more grave possible complications. Nurses are at the frontline of clinical contact with patients in the emergency department (ED). As a result, there have been repeated calls for training of nurses on the use of US guided IV (USGIV) access in the ED and hospital setting, in general. In response to such calls, programs for nurses have been designed and implemented. When nursing staff in the ED of a hospital are unable to obtain peripheral venous access after multiple attempts, they have the option to forego any venous access, request to place a central venous catheter, or request ultrasound (US) guided IV access by a physician. This is particularly the case in most community teaching hospitals.

Multiple studies [7–10] have demonstrated the efficacy of nurses and ED technicians using US for IV access. This finding has not been widely used and in some institutions a culture of “hands off” for nurses and technicians still exists around ultrasound guidance for some procedures. The emergent issue, therefore, has not been over whether ultrasound is safe and effective but about who should be able to use the machines and for what purpose.

In underserved community hospitals, such as the one under study, low levels of workforce have necessitated that limited available human resources are utilized to the fullest in patient care. Consequently, nurses and residents face the task of performing many procedures including IV placements frequently. Anecdotally, it was observed that fear has led to low levels of comfort among nurses regarding the use of US as a guide for IV access and placement in patients especially those with difficult access, “difficult sticks.” The training requirements of emergency residents and physicians have meant that, to a large extent, they are relatively facile with USGIV access and placement. In light of this, it is important within a community hospital environment to have nurses at par with residents with regard to success in placing USGIVs. However, there are no studies found in the literature comparing the efficacy of ultrasound use by nurses and residents in situations where US guided access to IVs is necessary for the patient.

From the foregoing, therefore, the goal of our study was to directly compare success rate between emergency medicine (EM) residents and emergency room nursing staff at obtaining peripheral venous access under real time ultrasound guidance. We assert that the nursing staff can be, if properly trained, as effective as the emergency medicine residents at this technique.

Discussion

The success rates of 85% and 86% observed for residents and nurses, respectively, in USGIV placements were consistent with results reported in some studies involving nurses. Those studies reported success rates in the range 53%–85% depending on technique (one-person versus two-person), type of vein (basilic versus brachial), number of attempts (one or multiple), and overall cannulation.

Our study observed no statistically significant difference in the success rate between the providers: nurses and EM residents. However, there was a measured difference in complications rate (5% for residents and none for nurses). Further studies involving larger sample size are needed to determine if that result was purely due to chance or a real difference. In this study, no overall association was found between complication and provider type (nurse or resident). Each provider did not work on the same patient more than once and so interoperator reliability (measured by kappa) was not relevant and not computed. Moreover, the primary outcome of success as defined was not based on interpreting the sonographic images thereby rendering the issue of reproducibility of images untenable. We did not determine time to success mostly due to the lower acuity of the patient with IV access needs.

Conclusion

Nurses have used ultrasound to perform peripheral IV insertion in the past but this study has provided further evidence that they are equally adept at this procedure as emergency medicine residents. This was in light of the fact that no significant difference was observed between residents and nurses with regard to the success rate of US guided IV placement. Based on this result, a protocol can be developed for training and routine use of ultrasound for peripheral IV insertion in the ED for nurses. Implementing a program for use of intermediate lines under ultrasound guidance for nurses could expedite care, reduce pain, and decrease possible complications associated with central access.

Source:
Ultrasound Guided Intravenous Access by Nursing versus Resident Staff in a Community Based Teaching Hospital: A (Noninferiority) Trial
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4568038/pdf/EMI2015-563139.pdf