Ultrasound-Guided PIV Insertions and Patient Safety : How Practice Variations are Putting Patients at Risk
By Jaclyn Landon
For organizations looking to move beyond a patchwork of quality and safety initiatives to create a culture of safety across every care setting , a good first step would be to take a closer look at a procedure that affects nearly every patient who walks through their doors : the insertion of a peripheral intravenous catheter ( PIVC ).
PIVC insertion is the most commonly performed invasive procedure in all of healthcare . It is estimated that 90 percent of hospitalized patients require a PIVC at some point during their stay . Each year , approximately 330 million PIVCs are sold in the United States , and some 2 billion are sold worldwide . 1-2 The number of U . S . patients requiring PIVC access is only expected to increase as the population ages and more treatments requiring intravenous access are required . 3
However , researchers estimate that up to 60 percent of patients requiring a PIVC can be classified as presenting difficult vascular access ( DiVA ). This can be caused by aging veins , obesity , repeated cannulations , irritating medications , and IV drug use , in addition to such chronic conditions as cancer , diabetes , and sickle cell disease . The prevalence of DiVA patients has led to greater reliance on the use of ultrasound imaging to guide PIVC insertions . Approximately 12 million ultrasound-guided PIV ( UGPIV ) insertions are performed each year in North America . 4
The benefits of UGPIV include improved IV success rates , faster procedures , and fewer needlesticks . 4 What is less clear is the most effective way to utilize and disinfect the technology so that it minimizes potential harm to the patient .
Part of this confusion can be attributed to conflicting practice recommendations from a variety of professional organizations , affecting everything from the selection of appropriate infection control supplies to the adoption of procedures for transducer disinfection . As a result , significant practice variations have been observed not only among hospital departments , but sometimes among individual clinicians within the same department . A recent survey published in the Journal of the Association for Vascular Access ( JAVA ) highlights this variability , bringing renewed attention to the patient safety risks associated with UGPIV insertion . 5
The Rise of Point-of-Care Ultrasound in Vascular Access
While ultrasound imaging has been used to guide the insertion of vascular access devices ( VADs ) in a variety of clinical settings for more than 30 years , such applications have become increasingly common in the past decade . Today , numerous healthcare professional organizations support its use in this
This photo depicts an unprotected probe and gel all over the insertion site , which can be a patient safety hazaed . Image courtesy of PICC Excellence
context , and the benefits of ultrasound guidance for PIV insertion are well documented .
By enabling the visualization of vessels , arteries , nerves and surrounding structures during assessment and insertion , ultrasound has been shown to improve IV success rates , decrease the number of placement attempts , and enable clinicians to achieve IV access in less time . 3-4 , 6 In addition , the use of ultrasound can help avoid the need to perform more-invasive vascular access procedures , such as the insertion of a central access venous device ( CVAD ) or an external jugular catheter — both of which are associated with much higher complication rates than PIV catheter insertion . According to the American Institute for Ultrasound in Medicine , ultrasound guidance can be invaluable for patients who are difficult or impossible to access . 7
“ Ideally , clinicians want to be able to insert a peripheral line on the first attempt , and the advent of better visualization technologies like ultrasound have made that much easier to accomplish ,” says Nancy Moureau , RN , PhD , CEO of PICC Excellence . “ In addition to guiding insertion , ultrasound can be used to evaluate and select the best vein for PIV placement , and then facilitate assessment after insertion to ensure the catheter is positioned properly so that it will last for the duration of therapy .”
Successfully placing a catheter on the first attempt and having it last until the end of treatment typically results in improved patient outcomes and lower costs associated with PIVCs . However , the use of ultrasound to guide PIV insertion is not without risks . Research shows that ultrasound probes can be frequently contaminated with bacteria , posing a serious risk of transmission between the ultrasound equipment , skin , and bloodstream . 8-10 Cross-contamination can occur from a variety of sources , including multi-use bottles of ultrasound transducer gel , skin and touch contamination , and inadequate probe disinfection practices .