"Ouch!" It's the one thing you don't want to hear when you're inserting the needle and catheter to start a patient's IV. Yet the pain-free IV start remains something of a holy grail in outpatient surgery. More than half of the 118 surgical facility managers who completed our online survey last month say patients complain of painful IV starts sometimes (52%) or frequently (6%). "The IV start is often the one thing that patients complain of most during the procedure," says Kathy LeSage, RN, director of St. Luke's Surgical Center in Tarpon Springs, Fla. Still, many seasoned nurses and anesthesia providers say there are ways to ease patients' pain when needle meets skin. Read on for their best tips on getting an ouchless IV start every time.

Take your time locating the vein
Many of our poll respondents agree that the key to a painless IV start is to find the right vein the first time. While the pressure is often on to do things quickly, there's little to be gained from rushing through the IV start. "Be patient. Use your fingertips as well as your eyes," says one facility manager. Some other tips for finding the perfect vein:

• Talk to the patient. After all, no one's more familiar with their anatomy than they are. Patients can often tell you where the best veins are located, or where they've had successful IVs placed in the past. At Florida Endoscopy & Surgery Center in Brooksville, staff make note of patients with difficult-to-find veins in the facility's computer system so they'll be flagged on future visits.
• Feel, don't just look. Once you've got a good visual assessment and located some possible IV sites, run your fingers over the veins to determine the best one. "The ones you can feel (spongy) are more likely to tolerate an IV start and decrease pain," says Ruth Keogh, CGRN, nurse manager at DHA Endoscopy in Stoneham, Mass. Another described the ideal vein as having a "bouncy" feel.
• Palpitate. Try tapping, flicking or rubbing the site to stimulate the vein, but don't slap the area, says Jennifer Sabin, ADN, nurse manager of the Aesthetic Surgery Center of Eugene (Ore.). "Patients who are nervous always become jumpy when vessels are slapped." Wiping the needlestick site with a cleaning solution also helps make the vein more visible, says Shanon Malone, RN, CNOR, director of surgical services at St. John's Hospital in Lebanon, Mo.
• Lower the extremity. Lowering the arm below the heart ensures blood will flow to the veins you're targeting. "Put the tourniquet on the patient above the elbow and let the arm hang down to the side," explains Ms. Malone. "This lets the vessels backflow and you can see the vein as well as the valves."
• Relax the patient. "Have patients keep hands and arms relaxed; don't have them make a fist," says Dawn Caridi, RN, director of clinical services at Florida Endoscopy & Surgery Center. Having patients take slow, deep breaths also helps keep the vein from constricting. Other survey respondents recommended having patients squeeze and then release their hands slowly to make veins visible.
• Warm the site. Use a warm compress, such as a towel or a gel pack, to help bring veins to the surface. At Florida Endoscopy & Surgery Center, staff make their own hot packs by wrapping a patient's arm in a towel dampened with hot tap water, then wrapping the arm further in a disposable underpad (to keep the patient from getting wet and to keep the heat in) and securing the pack with tape. "I think the results are worth the extra few minutes it takes to apply the hot towels," says Ms. Caridi. Ms. Sabin recommends that you leave wet, warm towels on the arm (from the elbow to the fingertips) for at least 5 minutes and then dry the area before seeking a vein. "This warms the area, dilates vessels and soothes patients," she explains.
• Use a vein locator. Only 6% of survey respondents use a device to help locate the vein, but those that do said it comes in handy in cases where low-tech strategies don't work. Vein locators typically work by shining a high-intensity light through the patient's skin, which helps create a more visual contrast between the veins and the surrounding tissue.

Put patients at ease
The "distraction method" is a popular way to put the patient at ease when it's time for the needlestick. After all, the patient who sits in dread, wincing and squirming as you approach with the needle, is more likely to feel pain than the patient who's chatting amiably about the weather during her IV start. You can distract patients by initiating pleasant conversation (any topic other than the reason for their surgical visit will do), scratching the skin a few centimeters away from the IV site, having the patient turn his head slightly and cough just as you're about to insert the needle or having him hold his breath and then let it out just as you insert the catheter.

Whatever distraction method you use, don't catch patients totally off-guard. "Make sure to tell them when you're going to stick them; it seems to hurt less if they know it's coming as opposed to sneaking up on them," says one surgery center manager. A hospital administrator says you can surprise patients another way by pinching the site first: "Inform the patient that's as bad as it will be. The needlestick surprises them with how little it hurts since they were sensitized to the skin pinch."

To numb or not to numb?
Nearly one-fourth (23.7%) of survey respondents say they use topical anesthesia, such as a spray or ointment, to numb the skin at the insertion site. Nearly two-thirds (61.9%) say they inject a local anesthetic, such as 1% buffered lidocaine, subcutaneously to lessen the pain of the IV start. While some believe the analgesic effects of such an injection are not worth the extra needlestick required, many said the benefits outweigh the costs. "Use an adequate amount of local anesthesia and rub it in and around the vein," says James A. Ramsey, MD, chief of anesthesiology at the Aesthetic Surgery and Laser Center in Nashville, Tenn. "Yes, it is a stick, and some people go 'ouch,' but it gives you a good idea of what their pain threshold is and if they might need stronger analgesics for the trip home."

Some tips for success with lidocaine injection:

• Use a very small-gauge needle or consider using a needleless device, such as the Syrijet.
• Buffer the lidocaine with sodium bicarbonate so that it doesn't burn.
• Inject the anesthetic right beside your intended target vein. "Make a bleb beside the vein and either insert the IV needle to the side of bleb, or some nurses insert it directly into the bleb," says Kathie Wheeler, RN, BHA, CNOR, director of surgical services at Cape Fear Hospital in Wilmington, N.C.
• Use the same injection site for the IV. Flicking the lidocaine needle when removing it makes the entrance site larger. It bleeds slightly to show where the puncture was made, says Kristine Bedford, RN, BS, clinical director of the Endoscopy Center of Marin in Greenbrae, Calif. Introducing the catheter in the same site lets you know this area is numb.

Ask for help
Patients don't want to feel like pin cushions or practice dummies for unskilled nurses. Part of your IV therapy training should involve teaching nurses when to say "when." Create a policy requiring them to seek assistance after a certain number of failed attempts. "Our rule is: 2 sticks, then get another nurse or CRNA to try," says Ms. Sabin. At the Heart of America Surgery Center in Kansas City, Kan., Medical Director Phyllis Steer, MD, says they don't even let it get to that point: "If [the vein's] not found, the nursing staff doesn't even attempt the IV start but calls anesthesia to help."