You might be questioned during in-services about proper skin prep techniques and best practices for locating and accessing veins, but the ultimate questioning of your skills and knowledge of vascular access will likely be seen in the eyes of a patient whenever an IV start goes awry. You know the look, that sideways glance that asks, "Are you sure you know what you're doing?" Use this evidence-based quiz to find out.

Infection prevention
The Centers for Disease Control and Prevention recommend using chlorhexidine gluconate to prep the IV access site.1 The American Society of Anesthesiologists advises you to "cleanse the skin site with an appropriate antiseptic, such as 70-percent alcohol, 10-percent povidone-iodine, 4-percent chlorhexidine or 2-percent tincture of iodine, before catheter insertion."2 Iodine compounds work well in terms of antimicrobial effect, but don't work very fast; alcohol acts quickly but doesn't endure on the skin's surface; and chlorhexidine is a fast-acting, enduring prep, says Nikolaus Gravenstein, MD, professor of anesthesia and neurosurgery at the University of Florida College of Medicine in Gainesville.

Infection risks are greater in placing central lines or nerve sheath catheters when compared to starting peripheral lines, says Dr. Gravenstein. The CDC says that although the incidence of local or bloodstream infections associated with peripheral venous catheters is low, the catheters are the devices most frequently used for vascular access.1 While individual risks are minimal, the sheer volume of patients receiving peripheral IV starts each year heightens the importance of following infection control principles during this most routine practice.

Gloves offer barrier protection, but can be compromised by microscopic punctures you can't see. Following proper hand hygiene protocols is therefore an important — and often overlooked — aspect of maintaining infection control during IV starts. The CDC notes that good hand hygiene can be achieved through the use of a waterless alcohol-based product or antibacterial soap and water with adequate rinsing.1 Disposable, non-sterile gloves used in tandem with a "no-touch" technique is acceptable hand hygiene for venipuncture, says the CDC.

Practitioners who don non-sterile gloves assume they've taken the steps to protect themselves and patients, says Dr. Gravenstein. Not so, he says, especially when they prep the IV site and touch skin outside the prepped area to locate a vein. Dr. Gravenstein suggests you rub a small amount of prep solution over your gloved fingertips to protect against contaminating IV sites with bacteria left on gloves after they touch untreated areas of the skin.

Bloodborne infection risks related to needlestick injuries are heightened with hollow needles used for IV starts.5 Dr. Gravenstein says hollow-bore needles act as reservoirs that collect the infectious material that is often wiped off solid sharps (like suture needles) as they slide through tissue. Research conducted at an Australian hospital showed that replacing conventional hollow-bore needles with retractable syringes, needle-free intravenous systems and safety winged butterfly needles dropped injury rates nearly in half and virtually eliminated injuries resulting from IV starts.9

The Occupational Safety and Health Administration's Bloodborne Pathogen Standard requires you to trial and implement sharps safety products in your facility.7 Many effective designs are available, ranging from needleless catheters, retractable needles or automatically activated plastic sheaths. Dr. Gravenstein says some IV safety devices lock out users after false starts. He recommends you look for products that let staff reset safety mechanisms.

Needleless valve connectors reduce the risk of biohazardous injuries from needle sticks and exposure to bloodborne path-ogens. But they put patients at significant risk of catheter-related bloodstream infections when users don't adhere to strict disinfection practices before use, and their design allows contamination when the connectors are not in use.8 Researchers say the accepted practice of swabbing the connectors' membranous septum with 70 percent isopropyl alcohol may not eliminate septal surface contamination, and claim an antiseptic barrier cap was highly effective in sterilizing the septum.8

Pain-free IV?
Pain with intravenous insertion is a common fear for pre-operative patients. Research has shown that bacteriostatic normal saline and the commonly used lidocaine injections are effective local anesthetics for IV insertion.4 There is a comparable decrease in the incidence and severity of pain associated with IV injection of propofol between the pre-injection of bacteriostatic saline and the mixing of lidocaine and propofol.10 EMLA cream (a topical anesthetic consisting of 2.5 percent lidocaine and 2.5 percent prilocaine) can also significantly decrease IV insertion pain.11

Accessing a vein on the first attempt reduces patient discomfort, limits the handling of needles and, by extension, the risk of needlestick injury. Ultrasound can help target peripheral veins for venipuncture,12 although its use is uncommon in the perioperative setting, says Dr. Gravenstein. So, too, can a device that uses infrared light to help you spot superficial veins below the skin's surface. Dr. Gravenstein likes the technology, but thinks it might be cost-prohibitive for budget-conscious administrators.

Patients notice and appreciate the steps you take to ease their pain. Dr. Gravenstein offers an optional shot of local anesthetic before IV starts. The slight pinch of a 25-gauge needle numbs access sites and paves the way for the larger, more painful stick felt during IV starts. He also recommends the counter-stimulation technique: Scratch the top of the patient's thumb while injecting to distract the brain's pain sensors from the needlestick.