Finding The Vein: Best Practices for First Attempt Peripheral Catheter Insertion

Spencer Jones, Registered Nurse and CTO/Founder of Lineus Medical

Spencer Jones, Registered Nurse and CTO/Founder of Lineus Medical

Peripheral IV catheter (PIVC) insertion is one of the most common invasive procedures performed in hospitals today (1). Surprisingly, most nurses receive little formal training in this area during nursing school and initial job training. PIVC insertion is an important part of the patient experience that requires the nurse to possess adequate knowledge, confidence, and skill. With the lack of formal training, first attempt insertion success rates for staff nurses are not stellar, ranging from 44% to 76% (1). Not surprisingly, first attempt success rates with more educated and experienced IV nurses are much higher, ranging from 91% to 98% (1). Let’s look at the factors that impact first attempt success rates, hospital policies around multiple sticks, ways that facilities are training their nurses to improve these rates, and new technologies that aid in the successful placement of PIVCs. 

Being on the other side of the needle, it’s easy for clinicians to forget that having a PIVC inserted is one of the more stressful events a patient may experience while in the hospital. A 2012 survey found that 24% of parents and 63% of children have a fear of needles (2). With the elevated importance of the patient experience in today’s hospital setting, limiting the amount of painful needle sticks helps the patient, the nurse, and the hospital at large. Beyond the impact on patient experience, PIVC insertions are not cheap. A pediatric study from 2012 found that 28% of children required ≥3 PIVC insertion attempts, and had costs increasing from $69 to more than $125 in patients requiring 3 or more attempts (4). 

Every day in hospitals across America, patients who have multiple unsuccessful attempts from a nurse are thinking the same thing; “How many times do I have to let this nurse stick me!”. Because multiple unsuccessful PIVC insertion attempts happen so frequently, many hospitals have adopted a policy to guide nurses on how to handle these situations. The Infusion Nurse Society Standard 42 Catheter Placement, Practice Criteria I states, "No more than two attempts at cannulation by any one nurse should be made in order to avoid multiple unsuccessful attempts, causing unnecessary trauma to the patient and limiting future vascular access" (5). Often times a more experienced nurse will be sought out, likely a nurse working on the same unit. If two attempts from that second nurse are unsuccessful, an experienced vascular access team member will be called on to aid in the insertion. If the patient’s condition is critical or life-threatening, this rule does not apply. 

Seeing the need to improve PIVC insertion outcomes, some facilities have implemented blended, comprehensive instructional programs that incorporate interactive online education with deliberative PIVC procedural practice using a synergistic mix of different simulation technologies. A 2016 study aiming to determine the impact of such a program found that the intervention was effective and resulted in several statistically significant improvements in knowledge, confidence, and skills both within and between both study groups over time (1). While the test subjects improved in knowledge, confidence, and skill, the study found no significant changes in PIVC insertion procedural time or proportion of first attempt success during the simulation intervention. However, they found that first attempt success rates were significantly improved between the simulation intervention (60% first attempt success average) and the follow-up period two months later (86% first attempt success average) (1). This suggests that the simulation experience alone is inadequate to improve first attempt success rates, and that continued clinical practice after obtaining the knowledge and skills training is necessary to refine and solidify the skill. 

There are a number of steps that nurses should take to maximize the chance that their first attempt will be successful. Starting with the patient’s non-dominant arm, assess their upper extremities for visible veins that can be palpated. Applying a tourniquet above the insertion site on the patient’s arm and telling them to clench their fist multiple times causes veins to distend and become more visible. The nurse should avoid areas of flexion like the elbow or wrist, and try to avoid placing the catheter near valve branches of veins. Try and find veins that have straight sections, avoiding windy or tortuous veins. If the patient has had an infiltrated IV, or other attempts to insert an IV that have “blown” a vein, avoid those sites as well. 

Device selection is another important factor impacting first attempt success, as large catheters can be harder to insert. The nurse should understand the patient’s infusion therapy and level of acuity and use the smallest-size catheter to accommodate the prescribed therapy (5). When it comes to the actual venipuncture, the bevel of the needle should be facing upward, and the needle should be inserted directly over the vein at a 30 to 40-degree angle, or a lower angle for extremely superficial veins, slowly advancing until resistance is met. The nurse should then lower the needle to a 15 to 20-degree angle, and slowly advance the device to pierce the vein, observing for flashback of blood in the device. Once flashback/blood return is visualized, the catheter portion of the device should be advanced until it is fully inserted and the needle removed. Once the catheter is inserted, the tourniquet should be released and thrown away. 

Figure 1 - Christie Medical VeinViewer (6)

Figure 1 - Christie Medical VeinViewer (6)

Figure 2 - Nurse inserting a peripheral IV catheter using ultrasound probe (7)

Figure 2 - Nurse inserting a peripheral IV catheter using ultrasound probe (7)

A growing trend in vascular access that aims to combat this first attempt success problem is the use of near infrared and ultrasound technologies that help visualize the patient’s vasculature. These devices use imaging technologies to better display and/or illuminate the patient’s vasculature, allowing clinicians to easily see superficial veins and even deep veins barely visible to the naked eye. These devices can be used by floor nurses and vascular access professionals alike, and first attempt success rates with these types of devices are typically, above 90%, a significant improvement from the aforementioned 44%-76% success rates seen with floor nursing not using any assistive vein visualization devices (6). While these devices are proven to deliver better first attempt success rates, hospitals must weigh the clinical improvement against the increased cost of such devices. 

Whether through advanced clinical training or the adoption of vein finding technologies, improvement in first attempt success rates with PIVs should be a priority for hospitals everywhere. Fewer needle sticks means happier patients and less supply waste; improvements that every hospital can benefit from. 

MKG-0059 02/19 Rev. 00 

References 

1. Keleekai NL, Schuster CA, Murray CL, King MA, Stahl BR, Labrozzi LJ, Gallucci S, LeClair MW, Glover KR. Improving Nurses' Peripheral Intravenous Catheter Insertion Knowledge, Confidence, and Skills Using a Simulation-Based Blended Learning Program: A Randomized Trial. Simul Healthc. 2016 Dec;11(6):376-384. 

2. Taddio A, Ipp M, Thivakaran S, Jamal A, Parikh C, Smart S, Sovran J, Stephens D, Katz J. Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine. 2012 Jul 6;30(32):4807-12. 

3. Ripple Effect Research Poster, Internal Data On File 

4. Goff, D. A., Larsen, P., Brinkley, J., Eldridge, D., Newton, D., Hartzog, T., & Reigart, J. R. (2013). Resource Utilization and Cost of Inserting Peripheral Intravenous Catheters in Hospitalized Children. Hospital Pediatrics,3(3), 185-191. 

5. L. Gorski, L. Hadaway, M. Hagle, M. McGoldrick, M. Orr, & D. Doellman (2016). Infusion Therapy Standards of Practice. Journal of Infusion Nursing, 39(1S). Retrieved January 31, 2019, from http://source.yiboshi.com/20170417/1492425631944540325.pdf 

6. Christie Digital Evidence Based Technology Flyer, On File 

7. Gottlieb, M., Sundaram, T., Holladay, D., & Nakitende, D. (2017). Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-based Best Practices. Western Journal of Emergency Medicine, 18(6), 1047-1054.