Painful, multiple-stick IV starts are a problem that aren't going to go away on their own (see "Challenges to Getting It Right the First Time"). The good news is that you can arm your staff with tools that can help ensure a smooth, comfortable IV start on the first try. Let's explore the different technologies and training resources available to take the pain out of IV insertion.
Light-based visualization aids
Two types of technologies can help you find suitable veins for IV catheter placement in difficult patient populations: light devices and sound devices. As Lynn Hadaway, MEd, RN, BC, CRNI, an infusion therapy and vascular access consultant based in Milner, Ga., explains, light devices, which may be more useful in the outpatient surgery setting than ultrasound, can be divided into 2 categories.
- Visible light. The small flashlights nurses will sometimes use to visualize veins in the tiny, thin-skinned arms of babies are an example of visible light. If you use a regular flashlight not designed for this purpose, the light typically emits heat that can run the risk of burning the arm if held too close for too long. LED transillumination technology directs a high-intensity light, flush with the skin, into the subcutaneous tissue of the arm to make veins appear as dark lines on the skin.
- Infrared light. Infrared light isn't visible to the naked eye, but it can help visualize internal tissue. Ms. Hadaway explains 2 ways vein-finding technology that uses infrared light can work. Transillumi-nation technologies mean you shine the light on the opposite side of the extremity, look through a scope or viewfinder and see a real-time map of the veins. Reflective technologies, on the other hand, use infrared light to take a picture of the veins and then reflect that picture onto the skin of the patient, over where the veins lie. With reflection, you see a picture of the vein on the surface of the skin, not the actual vein itself, as you do with transillumination.
Some of the devices that incorporate these light technologies started out bulky and impractical, but have gotten smaller and more user friendly, says Ms. Hadaway. "In a growing number of patients with difficult venous access, palpation skill may not be sufficient to locate a suitable vein and these light-based devices could be beneficial," she notes. However, "we do not have a lot of published evidence yet about the outcomes with their use because the technology is relatively new." Nikolaus Gravenstein, MD, professor of anesthesia and neurosurgery at the University of Florida College of Medicine in Gainesville, adds that some of these devices may be cumbersome and expensive to the point of being impractical in certain settings. As with any purchase, you'll need to weigh the costs against the clinical evidence and potential benefits before deciding what's best for your facility.
Challenges to Getting It Right the First Time
Palpation, flicking, tapping, warming, lowering the arm and applying a tourniquet: These are the tried-and-true methods of coaxing "shy" veins to come out of hiding for peripheral IV insertion. Most of these methods cost nothing (except time) and, in skilled hands, have a great track record of helping nurses locate a good vein in the kinds of healthy patients who typically present for elective surgery. But changes in the patient population, infusion technology and nurse education have altered the landscape of IV insertion, making it increasingly difficult for some clinicians to locate suitable veins and get a successful IV the first time, with minimal pain for the patient.
Patient demographics. Improved surgical technology means more challenging patients with chronic diseases, such as diabetes, or other characteristics that make vein location difficult may be coming through your facility's doors. Geriatric patients who have no visible veins, patients who are required to undergo repeated peripheral IV therapy, bariatric patients whose veins are buried deep under tissue and pediatric patients who may have a lot of subcutaneous fat because of growth and development all present challenges for staff performing IV starts, says Lynn Hadaway, MEd, RN, BC, CRNI, an infusion therapy and vascular access consultant based in Milner, Ga.
Lack of training. Whether a supplemental technology for vein visualization is needed in difficult cases "depends on the skill level of the nurses, techs and other professionals who are putting in these catheters," says Ms. Hadaway. She notes that today, the responsibility of peripheral catheter insertion has largely shifted over to the primary care nurse, who typically doesn't have extensive training and education in IV therapy. "They practice through the 'See one, do one, teach one' approach, and often haven't been taught how to palpate," she says. "They don't know how to find a vein that you can feel but you cannot see." Vein visualization technologies can help make up for this knowledge gap by going beyond what the naked eye can see.
Safety needles and catheters. Finally, it's important to note that nearly all providers have switched to safety needles and catheters that protect both staff and patients from needlestick injuries, but unfortunately can make it difficult to get the IV placement right the first time. The problem, says Nikolaus Gravenstein, MD, professor of anesthesia and neurosurgery at the University of Florida College of Medicine in Gainesville, "is that 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.
Although it's more likely to be used for the placement of peripherally inserted central catheters, midline catheters and central venous catheters, ultrasound can be used for insertion of peripheral IV catheters "after the nurse has mastered the skill of using it," says Ms. Hadaway. "It's a 3-handed process," she explains. "You've got to have one hand to hold the skin taut, one to control the catheter and that doesn't leave you with one to control the probe." Mastery of this technology for the purposes of peripheral IV catheter insertion may require extensive amounts of time and experience. In general, ultrasound might not be the best device for locating veins in superficial tissue, but "due to the excessive tissue depth in bariatric patients, ultrasound may be more beneficial than the light devices" in this patient population, says Ms. Hadaway.
Better IV sets vs. better training
The type of needle and catheter set you use for IV insertion may make a difference in how many successful first starts you have. "Just about all the catheter manufacturers have made some change in their design of the cutting edge of the bevel on the needle that makes them claim more success with the first stick," says Ms. Hadaway. However, she knows of no published studies that assessed the venipuncture success rates with these changes. Dr. Gravenstein says he prefers spring-loaded safety catheters that work at the push of a button instead of requiring you to retract the needle. They may be "the most elegant solution" to the problem of designing safety sets that promote first-stick success, he says, but concedes that you'd have to weigh the additional cost of these spring-loaded systems against their potential benefits. "At the end of the day, the typical practitioner still relies on the tried and true techniques of having the extremity warm, having a tourniquet properly applied, warming and stimulating the vein so it isn't shy," says Dr. Gravenstein.
Ensure that staff who are responsible for starting IVs actually have these skills and understand the reasons behind them. "The skill has to be based on knowledge," says Ms. Hadaway, who recommends that you use online resources, local classes or experts who will visit your facility to provide your staff with the education they may not have received in nursing school. They need to understand the anatomy of the arm and hand, physiology of the blood flow, skin and subcutaneous tissue and infection prevention issues associated with IV therapy, as well as the Infusion Nursing Standard of Practice (www.ins1.org). Once your staff has the foundational knowledge and has built up their skills, perform initial and ongoing competency evaluations to make sure the outcomes are good.