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Reducing peripherally inserted central catheters and midline catheters by training nurses in ultrasound-guided peripheral intravenous catheter placement
  1. Benjamin Galen1,
  2. Sarah Baron1,
  3. Sandra Young2,
  4. Alleyne Hall2,
  5. Linda Berger-Spivack2,
  6. William Southern1
  1. 1 Department of Internal Medicine, Division of Hospital Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, United States
  2. 2 Deparment of Nursing, Montefiore Medical Center, Bronx, New York, United States
  1. Correspondence to Dr Benjamin Galen, Department of Internal Medicine, Division of Hospital Medicine, Montefiore Medical Center, Bronx, NY 10461, United States; bgalen{at}montefiore.org

Abstract

Background Training nurses in ultrasound-guided peripheral intravenous catheter placement might reduce the use of more invasive venous access devices (peripherally inserted central catheters (PICC) and midline catheters).

Methods We implemented an abbreviated training in ultrasound-guided peripheral intravenous catheter placement for nurses on an inpatient medical unit and provided a portable ultrasound device for 10 months.

Results Nurses on this unit placed 99 ultrasound-guided peripheral intravenous catheters with a high level of success. During the implementation period, PICC and midline catheter placement decreased from a mean 4.8 to 2.5 per month, meeting criteria for special cause variation. In the postimplementation period, the average catheter use reverted to 4.3 per month on the intervention unit. A comparison inpatient medical unit without training or access to a portable ultrasound device experienced no significant change in PICC and midline catheter use throughout the study period (mean of 6.0 per month).

Conclusions These results suggest that an abbreviated training in ultrasound-guided peripheral intravenous catheter placement for nurses on an inpatient medical unit is sufficient to reduce PICC and midline catheters.

  • Nurses
  • Patient safety
  • Quality improvement
  • Statistical process control
  • Hospital medicine

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Introduction

Hospitalised patients for whom the traditional technique of peripheral intravenous catheter placement is unsuccessful may undergo peripherally inserted central catheters (PICC) and midline catheters (short PICCs) solely for venous access.1 2 While PICC and midline catheters might be necessary in some cases, they are invasive, posing potential risks during placement (eg, bleeding, arterial puncture, haematoma, air embolism, arrhythmia) and during their use (eg, catheter-related thrombosis and infection). Infections associated with PICCs represent a significant proportion of central-line associated bloodstream infections (CLABSI).3 CLABSIs prolong hospital stay and are associated with an estimated US$2.68 billion excess cost each year in the USA.4

Using ultrasound to place a peripheral intravenous catheter is a technique that has gained popularity among physicians in emergency medicine and critical care medicine, particularly in patients for whom peripheral intravenous catheter placement is challenging.5 6 Ultrasound-guided peripheral intravenous catheter placement was recommended in recent national guidelines for venous access ‘to facilitate placement of peripheral intravenous catheters in arm veins that are difficult to palpate or visualise’.2 Our research group recently demonstrated that ultrasound-guided peripheral intravenous catheter placement is an effective tool to reduce central venous catheter use on the inpatient medical units when performed by an investigating physician.1 Previous research on nursing use of this technology was limited by the extensive training required for the intervention, which may limit adoption on a busy inpatient medical unit.7 8 Therefore, we sought to evaluate the use of this technology by training nurses in ultrasound-guided peripheral intravenous catheter placement in an expedited fashion. Our aim was to determine if potentially inappropriate short-term PICC and midline catheters could be avoided in patients with difficult venous access. We hypothesised that the intervention would be associated with a reduced number of newly placed PICC and midline catheters because some of these catheters would no longer be necessary following successful placement of ultrasound-guide peripheral intravenous catheters.

Methods

This was a quality improvement project aimed at reducing the number of newly placed PICC and midline catheters on the single inpatient medical unit. The number of newly placed catheters was extracted for 21 months pre-implementation, during the 10-month implementation of the intervention, and followed for an additional 7 months after the end of the implementation period (postimplementation).

Intervention

The study consisted of two components: mandatory nurse training in ultrasound-guided peripheral intravenous catheter placement followed by access to the ultrasound device for use in peripheral intravenous catheter placement. The complete curriculum for training is provided in online supplementary file. Briefly, after an introduction, bedside nurses on a single inpatient medical unit were shown an instructional video on ultrasound-guided peripheral intravenous catheter placement and then given an in-service on the use of the study device: SonoSite S2 with vascular probe L25 (FujiFilm SonoSite, Bothell, Washington, USA). Trainees were then required to practice ultrasound-guided peripheral intravenous catheter placement using a mannequin with physician oversight. After completing two successful 20 or 22 gauge standard length ultrasound-guided peripheral intravenous catheter insertions (transverse technique) on the mannequin, the trainees were considered certified to use ultrasound for peripheral intravenous catheter placement on patients. Total training time for each trainee was <60 min. All 29 full-time nurses on the intervention unit were trained. None of the nurses had prior experience using ultrasound to place peripheral intravenous catheters. The study device was provided to the intervention unit for the duration of the implementation period, and was removed from the unit at the start of the postimplementation period. Trainer assistance for the placement of intravenous catheters was available on request. A same-sized inpatient medical unit with similar patients was chosen for comparison and the nurses on this unit underwent no training and did not have access to an ultrasound device for peripheral intravenous catheter placement. The intervention and comparison units used identical, standard length intravenous catheters placed in forearm veins during the entire study.

Supplemental material

Measures

To compare the intervention and comparison units, the number of patient discharges, their lengths of stay and case-mix index for each unit during the study period were extracted from the clinical information system. The primary outcome was the monthly count of newly placed PICC and midline catheters for the study units during the study period. Newly placed catheter counts were obtained from interventional radiology billing records as interventional radiology is the only service that places these devices. Number of catheters were examined for a 21-month pre-implementation period, a 10-month implementation period and 7 months after the intervention stopped (postimplementation). Catheters placed within 2 days of hospital discharge were excluded from the analysis given the likelihood that these catheters were placed for postdischarge use rather than for venous access during hospitalisation.

In addition, we recorded the number of ultrasound-guided peripheral intravenous catheters placed by nursing staff using a logbook affixed to the ultrasound device. Unsuccessful attempts were noted. Requests for refresher training in ultrasound-guided intravenous catheter placement were also tracked.

Statistical analysis

The characteristics of the intervention and comparison units were compared using the Mann-Whitney U test. The monthly number of PICC and midline catheters on the intervention unit were recorded and plotted on a C-type statistical process control chart, for Poisson distribution (‘count’) data, using the Shewart method.9 10 The mean catheter count during the pre-intervention period was used as the centerline, which was carried forward into the intervention period until special cause was detected. Upper control limits were calculated as 3 SD from the mean of each time period. Criteria for detecting special cause variation were predefined: 1) six points in a row all below or above the centerline, 2) six consecutive points either rising or falling, 3) a single point outside the control limits and 4) two points out of three close (outer third) to the control limit. When special cause was detected the centerline was moved at the first point that defined special cause and a new mean was established.9 10 The success rate for ultrasound-guided peripheral intravenous catheters placed by nurses during the study period was calculated as a ratio of the number of successful intravenous catheters/attempted intravenous catheters. In a sensitivity analysis, we constructed similar statistical process control (SPC) charts including all catheters placed during each admission (i.e., not excluding the predischarge catheters).

Results

Characteristics of intervention and comparison units

In the year leading up to this study, the intervention and comparison medical units had similar numbers of discharges during the study period (1874 vs 1925, respectively). The intervention and comparison units had similar mean lengths of stay (6.58 vs 6.35 days, p=0.32) and similar mean case-mix indexes (1.38 vs 1.42, p=0.13).

Catheter placements

During the pre-implementation period, a mean number of 4.8 PICC and midline catheters per month were placed on the intervention unit (figure 1A). Starting the third month of the implementation period, a shift in the number of monthly PICC and midline catheters was appreciated and met special cause criteria. The monthly number of newly placed PICC and midline catheters was reduced to a mean of 2.5 on the intervention unit (figure 1A). In the postimplementation period, a second special cause was detected and the monthly number of PICC and midline catheters reverted to a mean of 4.3 catheters per month (figure 1A). The comparison inpatient medical unit utilisation of PICC and midline catheters remained stable during all phases of the study and variation in catheters per month (mean of 6.0) did not reach special cause (figure 1B). In the sensitivity analysis that included all catheters (ie, not excluding pre-discharge catheters), the number of catheters placed each month did not exhibit special cause variation throughout the study period (data not shown).

Figure 1

(A and B) C-type statistical process control charts. PICC and midline catheters placed each month on the intervention unit (A) and comparison unit (B) for the 21-month pre-implementation period, 10-month implementation period (denoted by blue lines) and 7-month postimplementation period. The centerline (solid line) was established using the mean of the 21-month pre-implementation period and the upper control limit was defined as mean+3σ (dotted line). Both were recalculated when criteria for special cause variation were met. PICC, peripherally inserted central catheter.

Nurses on the intervention unit attempted 99 ultrasound-guided intravenous catheters during the 10-month study period, with 96 (97%) noted to be successful. Trainer assistance was requested for 15 of these, all in the first 6 months of the 10-month implementation period.

Discussion

In this study of nurse training and utilisation of ultrasound to place peripheral intravenous catheters, we found the intervention was associated with a decrease in the number of newly placed PICC and midline catheters. A comparison inpatient medical unit experienced no reduction in the number of PICC and midline catheters placed. During the implementation period, nurses on the intervention unit attempted on average about 10 ultrasound-guided peripheral intravenous catheters per month, the overwhelming majority of which were successful. Our findings suggest that nurse training in the ultrasound-guided peripheral intravenous catheter procedure and access to an ultrasound device are valuable quality improvements on the inpatient medical unit.

Technicians have been successfully trained in ultrasound-guided peripheral intravenous catheter placement in the emergency department, but there is little research to guide programme development for nurses on the inpatient medical unit.11 12 A recent study of nurses on a medical-surgical unit and step-down unit reported a reduction in non-essential PICC line placements using ultrasound-guided intravenous catheter placement.7 However, this protocol included 8 hours of didactic training and 12 hours of hands-on supervision, which may limit its adoption. Other programmes have combined ultrasound-guided peripheral intravenous catheter training with PICC and midline training for nurses, which is also time intensive.8 We evaluated an abbreviated training model for inpatient medical unit nurses to learn and implement ultrasound-guided intravenous catheter placement and found it to be successful. The finding that trainer assistance was only requested during the first 6 months of implementation and for only 15 of 99 intravenous catheters further suggests that the abbreviated training model was sufficient.

This study has several limitations. First, it was conducted on a single inpatient medical unit and therefore results might not be generalisable to other patient populations. Second, formal evaluation of individual nurse’s competency at placing ultrasound-guided intravenous catheters was not conducted, either after the abbreviated training session or during the implementation period. The ultrasound device used in this study is portable, but relatively of high cost. It is not clear if smaller, less expensive, hand-held devices would be as effective. We also did not collect data on complications to ultrasound-guided peripheral intravenous catheter insertion on the intervention unit, such as extravasation or thrombosis leading to catheter failure.

Conclusions

Placement of peripheral intravenous catheters can be difficult in some hospitalised patients. PICC and midline catheters are often used in this situation, even though a peripheral intravenous catheter would be sufficient. Nurse training in ultrasound-guided peripheral intravenous catheter placement was successful at reducing PICC and midline utilisation on one inpatient medical unit.

References

Footnotes

  • Twitter @DrGalenMD

  • Contributors All authors contributed to study design, implementation and manuscript revisions.

  • Funding This study was supported by a grant from the Hospitals Insurance Company / FOJP

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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