SAFE IV STARTS With the push of a button, a spring-activated safety mechanism on this safety catheter retracts the needle into the barrel of the applicator.

Can't feel a vein, can't see a vein. As pressure-packed events in surgery go, what else but the difficult IV start can knot the stomach and clench the jaws of patient and provider alike?

SAFETY CATHETER Chris Lippert RN, MBA, CAPA, of Avera Queen of Peace Hospital in Mitchell, S.D., uses a catheter that features a spring-activated safety mechanism.

For your patients, there's the dread of impending pain — or at least what they expect will be a hurtful stick. As Kathy LeSage, RN, director of St. Luke's Surgical Center in Tarpon Springs, Fla., says, "The IV start is often the one thing that patients complain of most during the procedure."

For your pre-op nurses, there's the pressure of not getting it right on the first 2 tries — followed by the shame of being relieved by an anesthesia provider and letting him take a stab at starting the IV.

"There's stress, especially if it's a skill that you don't use all the time," says Michele Sena, MSN, RN, the clinical nurse educator at Winthrop University Hospital in Mineola, N.Y. "But experienced nurses tend to not get nervous, to not feel the pressure and tension. Plus, they know that if they can't find a vein that there will be an anesthesiologist to back them up."

At Winthrop University Hospital, advances in technique and technology go hand in hand. The use of a simulation mannequin helps nurses to practice IV insertion and venipuncture in a hands-on, reality-based scenario, says Ms. Sena. "This type of experience is priceless in developing the skills of the nurse with limited exposure to venous access," she says. What's more, there are devices that can make IV starts safer and simpler for your patients and your staff.

AN ANESTHESIOLOGIST'S VIEW
IV Starts Take "Experience and Courage"

LOCAL ANALGESIA Many providers never start an IV without first injecting the site with lidocaine.

Starting IVs well takes experience and courage. I always use local anesthesia once I've identified the best location. This takes experience, too. Some veins must be found by palpation and can't be visualized, but they are found in the usual locations. Always inject about 1/10cc lidocaine plain 0.5% and then compress the weal to disperse the local and identify the vein again. Carefully puncture the skin, usually in the location of the needle puncture from the local, and look for flash in your needle hub. Once seen, you can advance the catheter off the needle into the vein.

Some will argue there is pain from the injection of the local, so they don't or won't do it. Others argue that the injection obscures the vein. But if done the way I described, you'll still have good landmarks and a happier patient who's not complaining about the pain from the IV stick due to "preemptive analgesia" of the local in the skin. Otherwise, you may have a successful vein cannulation, but the patient will complain about the pain, which makes an unhappy patient until the catheter is withdrawn. This doesn't always ensure the pain will go away, either.

— Dean B. Berkus, MD

Dr. Berkus ([email protected]) is an anesthesiologist at Specialty Surgical Center in Beverly Hills, Calif.

Safety catheters
If you use safety catheters, even your nurses who are nervous about starting IVs don't have to worry about one of the hazards of IV starts: the accidental needlestick, which can happen when you withdraw the needle and advance the catheter in the vein. With renewed focus on bloodborne pathogens and accidental sticks, your nurses will be relieved to know they're starting IVs with a safety device.

"It's one less thing they need to worry about: being stuck with a needle after an IV insertion," says Ms. Sena. "Safety catheters let you focus more on what you're doing." They also let you "maneuver the catheter safely," says Jillanea Winchester, RN, BS, of Advanced Family Surgery Center in Oak Ridge, Tenn. And they "keep our clinicians safe," says Linda Stair, RN, clinical supervisor at the Western Maryland Surgicenter in Cumberland, Md.

Pay attention to the mechanism of action if you purchase safety catheters. They either self-retract or feature a sheath that slides over the bevel of the needle. Chris Lippert, RN, MBA, CAPA, OR director at Avera Queen of Peace Hospital in Mitchell, S.D., prefers safety catheters with a spring-activated safety mechanism. "When a button is pushed, the needle retracts into the barrel of the applicator," he says. "I find them to be more useful."

Although safety catheters can protect both staff and patients from needlestick injuries, they can be cumbersome, more of a hindrance than a help in getting the IV placement right the first time, making it harder — and much more likely — to result in multiple sticks and spillage of blood. The problem, says Nikolaus Gravenstein, MD, professor of anesthesia and neurosurgery at the University of Florida College of Medicine in Gainesville, is "once you activate the safety mechanism, they are slightly bulkier, and many do not allow you to rotate the catheter off the needle, so you lose the ability to finesse" what you're doing. He suspects that these safety catheters have somewhat lowered the success rate of IV starts even as they've helped to reduce sharps injuries.

Because all safety catheters "act a little bit differently," says Mr. Lippert, it's important that your vendors' clinical specialists in-service your staff on how to use the devices properly.

"It does give a comfort level to the practitioner starting the IV," says Mr. Lippert. "Newer nurses truly feel more comfortable that they're not going to get stuck. With all of the bloodborne pathogens out there, why needlessly expose your staff to sticks?"

Sandy Berreth, RN, BS, MS, CASC, administrator of Brainerd Lakes Surgery Center in Baxter, Minn., has been using safety catheters to start IVs since her facility opened 8 years ago. She spoke of how they put your mind at ease. "The big thing with safety catheters is knowing that you don't have an open needle and that you won't get stuck," she says. "You tend to be more comfortable with that needle. It doesn't make it easier to start the IV, but it makes you more relaxed in starting the IV."

Vein finders
Ultrasound for IV guidance appears to be gaining traction, especially for patients with hard-to-find veins (pediatric patients, IV drug users and chemotherapy patients, for example). You just point the device at the skin and click to display the superficial veins closest to the skin's surface. Many vein finders come in both handheld and hands-free models.

"For less experienced nurses, they're pretty handy," says Mr. Lippert. "Newer nurses not as confident in their IV start abilities will find a lot of comfort in having these devices to help them find a vein."

Vein locators shine a high-intensity light through the patient's skin, which helps create a more visual contrast between the veins and the surrounding tissue.

Not all facilities use a dedicated vein finder. Ms. Berreth uses the ultrasound device her facility uses for regional block anesthesia for difficult IV starts. Ms. Sena uses Doppler to auscultate venous flow. "While vein lights or vein locators are more expensive, they can decrease the number of attempts at IV access, improve first-attempt success and decrease procedure time," she says. "It is also cost effective when there are less venous access attempts and fewer supplies are needed."

Betty O'Neal, RN, OR manager at Summersville (W.Va.) Regional Medical Center, says her facility is shopping for an ultrasound device for difficult IV sticks. "The ultrasound will find the vein," she says, "and we will be able to guide our IV needles into it for easier access."

Lidocaine
Mr. Lippert feels strongly that lidocaine should be used in IV starts. "So much so that I bring nursing students from our local university up for a day and teach them the technique," he says. "Nursing schools don't give a very good education starting IVs."

The comments from patients who receive lidocaine ("Geez, that's the best IV I've ever had done. I didn't even feel it!") are overwhelmingly positive, he says. "This gives staff a sense of comfort," he says. "When you know that you're not hurting patients, it's much easier to perform procedures that are otherwise painful."

BEDSIDE ULTRASOUND Michele Sena, MSN, RN, uses a Doppler ultrasound to listen for a venous blood flow.

One and done
It's estimated that every failed attempt to start an IV costs your facility about $32 in direct costs and loss of efficiency. It also increases the risk of a catheter-borne infection. "In the past, nurses relied on the 'blind stick' in patients with veins that were difficult to palpate or to visualize," says Ms. Sena. "Now, technique and technology have advanced in the area of venipuncture and IV insertion."

"The best way to reduce the pain of an IV start is to be assertive when inserting the needle through the skin," says Shanon Malone, RN, CNOR, director of surgical services at St. John's Hospital in Lebanon, Mo. "One smooth, quick motion will take the needle through the skin and into the vein, reducing the pain associated with the needlestick. A slow, unsure stick will cause pain every time." And the more confident your nurses are, the less anxious your patients will be when they see that needle heading toward their arm.