Introducing ultrasound-guided intravenous cannulation to a service

Abstract

This article explores how an intravenous team identified a gap in service provision and implemented ultrasound-guided cannulation into their trust’s service. This method provides patients with difficult intravenous access – who would normally undergo multiple failed cannulation attempts – with peripheral cannulation. The team’s innovative approach offered reliable peripheral intravenous cannulation using a longer-length device inserted with ultrasound, with high first-time success rates.

Citation: Smith E et al (2022) Introducing ultrasound-guided intravenous cannulation to a service. Nursing Times [online]; 118: 12.

Authors: Emily Smith is vascular access lead nurse; Valentin Irimia, Sally Simpson and Mark Oxley are intravenous specialist nurses; all at Aintree Hospital, Liverpool University Hospitals NHS Foundation Trust.

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Introduction

The intravenous (IV) team at Aintree Hospital successfully implemented ultrasound-guided (USG) IV cannulation as a safe, effective alternative to midline insertion for short-term vascular access in patients with poor venous access. This included trialling and implementing a longer-length peripheral cannula – the first such move in the North West and one of the first in the UK. This aimed to reduce the number of failed cannulation attempts, increase first-time success rates and improve patient experience. This innovation, now part of the IV team’s service provision, is saving time and resources, and increasing efficiency.

Service demand

The IV team identified an increasing number of patients with difficult IV access (DIVA) undergoing multiple unsuccessful cannulation attempts before being referred to the team. This was due to altering patient demographics – namely, patients living longer with more complex health needs – and the changes in healthcare delivery, with more IV therapies being provided in hospital and in the community.

A lack of IV access and delayed IV therapy for patients exposed them to multiple painful needle punctures, which increased infection risk and resulted in procedure cancellations. The IV team would insert a peripheral midline when IV cannulation was not possible and recognised that, through USG cannulation, they could reduce the number of multiple attempts, avoid midline insertion complications, save time and money, and increase patient comfort. Delays negatively affect patient experience, delaying treatments and affecting organisations’ patient flow. The USG approach is also consistent with the use of ultrasound for IV cannulation that was recommended in Hallam et al’s (2021) vessel health and preservation framework.

In 2019-20, approximately 35% of referrals to the IV team for line insertion were for short-term IV therapy and resulted in midline insertion. Patient feedback described multiple failed cannulations (10-20 attempts before referral were reported), leading to poor patient experience and needle phobia. Carr et al (2019) found that 27% of patients needed more than one attempt for successful peripheral cannulation.

Using ultrasound to facilitate reliable first-time peripheral IV cannulation can:

• Reduce the number of needle punctures and failed IV cannulations;
• Preserve upper-arm vessels for potential future need;
• Reduce unnecessary midline insertions;
• Release the IV team’s time to care (we provide same-day cannulation via a bleep system that takes 20 minutes, compared with midline insertion, which can take significantly longer –namely, up to two hours);
• Save equipment costs – the cost of a USG longer-length cannula procedure is £11, compared with a midline procedure that costs £80-95 (with 800 cannulas placed per year, costs fell from £68,000-£76,000 to £8,800).

Implementation

In September 2019, the IV team started the insertion of standard USG cannulas and trialled a longer-length cannula for short-term IV therapy, which could be an alternative to midline insertion. Patients were identified by intended duration of up to one week of peripheral IV therapy and assessed for suitability before insertion. IV support workers were trained in USG cannulation and had their competency assessed by IV specialist nurses.

Trust-wide communications were published to notify teams of the new service and how to refer patients. We used active surveillance, which comprised patient face-to-face reviews daily, then weekly after six months. Data was entered onto a spreadsheet to monitor patient outcomes for those who had a longer-length cannula inserted. Outpatients who needed IV access for day-case IV therapy or investigations in radiology, ophthalmology or endoscopy were also offered the service. They were booked in advance or procedures were performed ad hoc as capacity allowed.

“This stood out as a nurse-led patient safety improvement entry. The impact of the innovation is transferable across organisations” (Judges’ comments)

Challenges

At first, it was difficult to identify suitable patients, as it was unknown how effective the device would be in patients with DIVA and there are varying accounts in the literature on USG cannulation’s success and reliability. Hallam et al (2021) suggested it can be used for up to 14 days of treatment, but this is dependent on whether the catheter stays in place for that long and functions normally; peripheral IV catheter placement is associated with a high failure rate (Helm et al, 2015). These were new devices, so the team had to evaluate the most appropriate insertion site and vessel. This only became apparent through placing and monitoring.

Initially, there were failures and dislodgements of USG cannulas as complication rates are higher in novice placers of any new device; however, this should reduce as experience increases. Through evaluation and a review of the literature, we found that, compared with standard cannulation, the longer device needs a shallower insertion angle and an extra securement dressing was needed. IV nurses had to modify their technique to insert cannulas with ultrasound, as the number of insertions required to gain competency is higher than that with standard cannulation.

Once details of the new service were published, the additional option of USG cannulas created high demand, with some inappropriate referrals. The IV team triaged these referrals to place the correct device, which informed the assessment criteria.

Overcoming challenges

To help overcome the higher dislodgement rate, an additional securement dressing was sourced. IV nurses sought support from colleagues for difficult cannulations and reflected on practice to aid development. As Valentin Irimia, IV specialist nurse, said:

“USG cannulation has many pitfalls; our daily discussion and reflection allowed us to examine our weaknesses and overcome them. When we fail, we learn.”

Outcomes were first captured through our surveillance database of information from device insertion to removal.

Service successes

By spring 2022, this procedure had been established into the service; the IV team inserted multiple devices daily, with high success rates. The service is offered to all patients needing peripheral access for up to seven days. This achieves longer dwell times, with devices surviving for up to seven days or beyond, proving that they are reliable, particularly in patients with DIVA, who have a >50% likelihood of catheter failure on the first attempt (Riker et al, 2011).

Patient feedback was incredibly positive; they appreciated the ease of insertion, high success rate, reduced needle punctures and low dislodgement rate, and felt reassured that there was an alternative to traditional cannulation.

Staff feedback was also positive, and practitioners request the service daily after assessing duration and type of IV therapy. They appreciate its safe, quick and effective nature. The IV team see USG cannulation as an essential tool that releases valuable time for other procedures, as demonstrated by reduced wait times.

Conclusion

We have developed our practice to provide an intervention that is valued by patients and staff. We have reduced the number of cancelled or postponed procedures due to a lack of vascular access, and work more closely with the multidisciplinary team.

The IV team has adapted to the challenge with skill and professionalism. It has demonstrated resilience, stayed calm under pressure and overcome difficulties. Flexibility and teamwork balanced the clinical workload and improved productivity. We have also developed a culture of reflective practice, which has been key to the initiative’s success.