Implementing and Ultrasound-Guided Peripheral Intravenous Access Clinical Practice Guideline

Abstract

Problem and Purpose: Patients with difficult intravenous access (DIVA) often require ultrasound (US) guided intravenous (IV) access to facilitate medical treatment. Literature demonstrates nurse-driven USIV training programs can decrease provider interventions and time-to-treatment. At a level 1 academic center's emergency department, a practice gap of USIV placement times greater than three hours for ~13% (22/174) was identified. The purpose of this quality improvement project was to implement an evidence-based (EB) USIV algorithm to facilitate identification of patients with DIVA that require USIV's. The aims of this project are to decrease time-to-IV's, time-to-lab requisition, and time-to-treatment. Methods: The DNP project lead (PL) reviewed with unit leadership an educational competency for the 154 staff nurses to assist with identification of DIVA criteria and facilitation of USIV placement by those trained. The project was approved and deemed non-human research by the institutions office of human research protection. To facilitate, workflow changes were identified by the PL. The primary outcome measured was time-to-IV’s in patients with DIVA. Secondary outcomes included time-to-labs and time-to-blood culture requisitions. Results: Data collection demonstrated an average of 94% (987/1045) of USIV’s being placed within 3 hours, while only 6% (58/1045) of USIV’s took greater than three hours for insertion, meeting the outcome measure goal of >90% (941/1045) inserted within 3 hours. This was a 54% reduction from baseline data demonstrating USIV’s taking >3 hours in 13% (22/174) of patients with DIVA. USIV related lab time collections also met the goal of greater than 90% (540/600) collected within three hours, weeks 5-12, during which time 762 USIV’s were placed. Conclusion: The clinical practice guideline and educational competency appears to have stimulated a staff response through project awareness and workflow changes. There has been a decrease in USIV’s taking greater than three hours and an overall shift from 1-2 hours to <30 minutes and 30-60 minutes. The project relies heavily on the units workflow and culture, which may result in poor external validity. Additionally, the data has obtained the attention of unit leadership and has stimulated discussion on further actions to reduce lengthy time-to-IV’s in this population.