Reducing Catheter Insertion Attempts: Implementation of a Difficult Intravenous Access Screening Tool

Abstract

Problem: Cardiac Surgery Intensive Care Unit (CSICU) nurses at a large, academic tertiary care center identified difficulty with peripheral intravenous (PIV) access skill and indicated an average of 3.2 insertion attempts to obtain PIV access. Root cause analysis highlighted nonstandardized training for ultrasound-guided peripheral intravenous (USGPIV) access skill certification and no screening process to identify patients that are difficult for establishing intravenous access (DIVA). Purpose: To implement the Modified Difficult Intravenous Access Scale for Adult Patients (A-DIVA) screening tool to assist CSICU nurses to screen, identify, and risk-stratify DIVA patients. Patients that score moderate- or high-risk for DIVA prompted use of the ultrasound. Project outcome goals were to improve the weekly average of insertion attempts and to improve PIV access first attempt success rates. Methods: Project implementation took place over 15-weeks and impacted 264 patients and 91 nurses. Nurses were trained for A-DIVA screening tool competency and USGPIV champions completed USGPIV access skill training. Nurses utilized the A-DIVA tool for all patients requiring PIV access prior to insertion. Weekly electronic health record (EHR) PIV insertion audits were compared to A-DIVA screening tool data. Project results and updates were disseminated at staff meetings. Results: By the end of implementation, 11 nurses completed formal USGPIV access skill training, 72.5% of nurses completed A-DIVA screening tool competency, and 31.9% of nurses utilized the A-DIVA screening tool. Ultrasound compliance remained 100% throughout implementation. Weekly average patient A-DIVA scores ranged from 3.5/5 – 5/5. Weekly average number of PIV insertion attempts ranged 1 – 3 on the A-DIVA screening tool and 1.1 – 1.8 in the EHR. Weekly average number of PIV insertion attempts remained below the 1.6 attempts goal for 14 of the 15 weeks. Weekly successful PIV first attempts ranged 66.7% – 100% on the A-DIVA screening tool and 60% – 94.1% in the EHR. Weekly successful PIV first attempts in the EHR remained above the 75% goal for 14 of the 15 weeks. Conclusions: Using the protocol, the A-DIVA Tool was a useful tool that assisted CSICU nurses to reduce PIV insertion attempts and improve PIV first attempt success rates in patients moderate- or high-risk for DIVA.