This image depicts proper technique . Image courtesy of PICC Excellence
Moureau suggests that the ideal solution would be a consensus group of experts representing different specialties — including vascular access , emergency medicine , and infection control , among others — to conduct and assess research and ultimately agree on best practices to guide UGPIV procedures .
non-intact skin , mucous membranes , blood , or other body fluids are classified as semi-critical . Devices that contact only intact skin are considered non-critical .
Based on the Spaulding system , critical and semi-critical devices require high-level disinfection ( HLD ), which is defined as the complete destruction of all microorganisms on or in a device . By contrast , devices used in non-critical procedures require only low-level disinfection ( LLD ), typically achieved through use of a germicidal spray or wipe to eliminate most viruses and bacteria .
For UGPIV , the question remains whether sterile probe protection , or probe and gel separation from the insertion site and blood , coupled with LLD represent adequate protection . Differing interpretations of the Spaulding classifications , as well as data on the efficacy of various barrier methods , have led to differences among ultrasound transducer disinfection recommendations .
Some organizations , including AIUM and ACEP , consider LLD to be sufficient when protective covers and sterile gel are used . Other entities , including the Healthcare Infection Control Practices Advisory Committee ( HICPAC ) of the Centers for Disease Control and Prevention ( CDC ) have taken a different stance . These groups assert that even with the use of probe covers , ultrasound-guided PIV insertions should still be classified as semi-critical , thereby requiring HLD
6-7 , 21
before and after any insertion .
Many organizations appear to be moving in the direction of imposing greater safety controls by requiring HLD for ultrasound probes involved in any invasive procedure , including UGPIV . Nevertheless , experts point out that there is a delicate balance between the level of disinfection needed to ensure patient safety and the practices needed to make day-to-day performance of UGPIV procedures practical .
When requiring HLD for devices , there are important workflow issues to be considered , and some of these also have significant economic implications . Ensuring the proper use of HLD processes requires staff to undergo additional training , and also requires additional equipment and supplies . Furthermore , HLD reprocessing can add 10 to 15 minutes in between procedures . Without additional staffing , the imposition of HLD requirements would almost certainly increase costs and reduce the number of ultrasound-guided PIV insertions that an institution is capable of performing in a given day .
“ First and foremost , we have to protect patient safety . There ’ s no doubt about that ,” says Judy Thompson , MSNED , RN , VA-BC™ , AVA ’ s director of clinical education . “ But we also have to consider the real-world implications of ultrasound reprocessing recommendations that would make compliance difficult , which could potentially discourage the use of ultrasound guidance for vascular access procedures .”
Indeed , research has revealed a high degree of non-compliance with infection control guidelines for UGPIV . In a survey of U . S . infection preventionists , only
22 percent indicated using a probe that had undergone HLD before and after performing a UGPIV insertion . 22
Moureau suggests that more research is necessary to determine whether low-level disinfection procedures could be sufficient if other patient safety measures — such as proper aseptic technique and adequate probe protection — are consistently applied to mitigate contamination risks .
“ Unfortunately , we don ’ t yet have enough research to provide clear proof of direction as to the most appropriate level of disinfection when adequate safety measures are employed ,’” she says . “ Further research on this topic should be done to provide much-needed clarity for clinicians .”
Overall , the patient safety issues highlighted in Moureau ’ s study seem to reflect the experience and observations of others within the field , including AVA ’ s Thompson , who observes , “ It is necessary for hospitals to address patient safety concerns and work together to establish standardization in accordance with evidence-based safety practices .”
An Urgent Need for Standardization
Given such significant patient safety issues , are the benefits of point-of-care ultrasound worth the potential risks ? “ Absolutely ,” says ECRI ’ s Merton , noting that “ in the proper hands , it can expedite diagnoses , improve care , and save lives .”
When it comes to ultrasound use to guide vascular access , an AVA position paper confirms that the benefits outweigh the negatives , as evidenced by improved rates of first-stick success . 16
“ With the correct training , ultrasound enables clinicians to gain access on the first attempt with little to no pain for patients ,” Thompson says . “ But clearly there is work to be done in terms of improving patient safety .”
This work includes incorporating research into recommendations that establish minimum requirements for UGPIV training , supplies , and insertion practices .
“ The goal of all clinicians and infection practitioners should be to establish an evidence-based standardized process for UGPIV procedures in order to improve patient safety ,” says Moureau . “ Fortunately , I think we ’ re moving in the right direction .”
A Multidisciplinary Approach to Patient Safety
Given the complex nature of vascular access , spanning across multiple specialties , clinicians and experts agree that the development of consistent , evidence-based UGPIV practice recommendations needs to be a multidisciplinary effort .
Moureau suggests that the ideal solution would be a consensus group of experts representing different specialties — including vascular access , emergency medicine , and infection control , among others — to conduct and assess research and ultimately agree on best practices to guide UGPIV procedures .
In addition , vascular access experts need to be included at the highest levels of patient safety discussions , says Jim Davis , MSN , RN , senior infection