< Previous42 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com Ultrasound-guided I.V. catheter insertion Standardized protocols and education can improve patient safety, reduce costs, and enhance nursing practice. By Carrie A. Cromwell, MS, APRN, CRNA, and Alice L. March, PhD, RN, FNP, CNE E STABLISHING peripheral I.V. access is an es- sential, high-priority nursing procedure. How- ever, access sometimes can be difficult to ob- tain even for experienced clinicians. Recently, the evidence-based ultrasound-guided short peripheral catheter (USGSPC) insertion method has been established as effective when caring for patients with difficult venous access. The success rate is high, and the added advantages of improved accuracy and more timely inser- tion increase patient safety and satisfaction. However, recent research demonstrates that USGSPC insertion hasn’t been widely adopted. This may be due to a lack of awareness or an absence of organizational protocols for training and use. To increase adoption of USGSPC, nurses first need to understand its benefits and use. They will then be well positioned to integrate the method into nursing education and imple- ment it in clinical practice. Why USGSPC? According to Hunter and colleagues, approxi- mately 90% of hospitalized patients require some form of peripheral venous access, yet this procedure can be difficult to complete, with at least one study (Whalen and col- leagues) suggesting that up to 50% of children and 35% of adults have difficult venous ac- cess. (See Difficult access. ) When performed properly, short peripheral catheter (SPC) insertion is a safe procedure with minimal serious risks. When insertion can’t be achieved using traditional direct visu- alization, palpation, or landmark-based tech- niques, ultrasound provides a high rate of suc- cess with substantial benefits for both patients and nurses. USGSPC insertion benefits The 2016 Infusion Therapy Standards of Prac- tice state that no more than two attempts at SPC insertion should be made per clinician, with no more than four total attempts. Quickly and efficiently obtaining I.V. access using ul- trasound guidance in patients with difficult venous access reduces the number of at- tempts, increases success rates, and decreas - es insertion pain. It also reduces care delays, provides cost and time savings, improves pa- tient satisfaction, reduces nurse and provider frustration, and attenuates the complications of multiple attempts or more invasive proce- dures (Miles and colleagues and Shokoohi and colleagues report that USGSPC insertion performed by trained nurses can decrease STRICTLY CLINICALMyAmericanNurse.com February 2020 American Nurse Journal 43 the need for central venous catheter [CVC] placement by as much as 74% to 80%). Nursing implications In most healthcare organizations, a provider, specialty trained vascular access nurse, or oth- er ultrasound-proficient healthcare profession- al uses the USGSPC procedure to obtain can- nulation only after a nurse is unsuccessful with traditional techniques. However, evi- dence shows that with structured training, nurses can effectively use the USGSPC method (Feinsmith and colleagues report con- sistent success rates as high as 96%). In a study by Edwards and Jones, nine out of 10 nurses agreed that dedicated training ade- quately prepared them to use ultrasound guidance for insertion, and seven out of 10 found actual placement to be easy. According to Bahl and colleagues, nurses using the US- GSPC technique after completing training were more likely to achieve cannulation com- pared to nurses using standard visualization and palpation, and the time required to com- plete the procedure was shortened. Many large academic healthcare organiza- tions have dedicated vascular access teams composed of experts in difficult venous ac- cess. These multidisciplinary teams, which fre- quently include nurses trained in USGSPC in- sertion, identify patients with difficult venous access and intervene early to establish time- ly insertion. Across the United States, state boards of nursing do not require board certi- fication for vascular access nurse specialists; however, many state laws do require that healthcare organizations have written policies and procedures to ensure that nurses dem - onstrate and maintain competency. With in- creased access to educational resources and technology (guided by organizational policies and procedures), USGSPC insertion training that includes staff nurses who routinely obtain venous access could reasonably be achieved. USGSPC implementation The 2016 Infusion Therapy Standards of Prac- tice state that only nurses who possess the ap- propriate skills and validated competencies should insert SPCs, but the literature reveals that even traditional SPC insertion education is inconsistent. To ensure nurses can efficiently, safely, and comfortably perform USGSPC in- sertion, enhanced organizational SPC curricu- lum should include standardized, evidence- based USGSPC training and use protocols. (See Education basics.) The protocols should encompass training expectations and curricu- lum, skills assessment and maintenance, and portable ultrasound equipment availability. Guidelines and protocols are readily available to help facilitate implementing USGSPC inser- tion into nursing practice. Video tutorials, such as one published by The New England Journal of Medicine, demonstrate the technique. And a formal online training course for teaching and learning the USGSPC insertion technique is available at IvyLeagueNurse.com. With so many resources and evidence-based materials avail- able, developing a structured hands-on training curriculum and obtaining proficiency in US- Patients with difficult venous access include those with: • obesity • a history of I.V. drug use • multiple chronic illnesses. Some pathophysiologic changes also may decrease the ability to use traditional visualization when inserting a short peripheral catheter. These conditions include: • edema • hypovolemia • vascular pathology. Two out of every five patients require multiple attempts to achieve I.V. access, sometimes taking 30 minutes or more to complete. The result can be: • patient pain and discomfort • lack of blood specimens • delayed diagnosis and treatment • decreased nurse productivity • increased supply costs • increased likelihood of using a more expensive high-risk procedure, such as central venous catheter (CVC) insertion. CVC risks Inserting and maintaining a CVC can be dangerous, exposing patients to serious complications including: • catheter-associated bloodstream infections • large vessel injuries • hematomas • cardiac arrhythmias • venous air embolisms • pneumothorax. Difficult access44 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com GSPC insertion is attainable for nurses in all geo - graphic areas and practice settings. Spreading the word Sufficient research exists to support USGSPC for patients with difficult venous access; how- ever, many nurses still don’t use the tech- nique. Nurses can take the lead in encourag- ing USGSPC implementation in practice so patients can reap the benefits. AN Carrie A. Cromwell is a certified registered nurse anesthetist at the Central Texas Veterans Health Care System in Temple and a doctor of nursing practice student and Jonas Veterans Healthcare Scholar at the University of Alabama Capstone College of Nursing in Tus ca - loosa. Alice L. March is a professor at the University of Alabama Capstone College of Nursing. References American Institute of Ultrasound in Medicine. AIUM practice parameter for the use of ultrasound to guide vascular access procedures. J Ultrasound Med . 2019;38(3):E4-E18. Arnold K. Ultrasound guided peripheral IV insertion. Ivy LeagueNurse.com. November 11, 2014. ivyleaguenurse.com/ courses/Ultrasound_Guided_PIVs.pdf. Bahl A, Pandurangadu AV, Tucker J, Bagan M. A random ized controlled trial assessing the use of ultrasound for nurse-per- formed IV placement in difficult access ED patients. Am J Emerg Med. 2016;34(10):1950-4. Björkander M, Bentzer P, Schött U, Broman ME, Kander T. Mechanical complications of central venous catheter inser- tions: A retrospective multicenter study of incidence and risks. Acta Anaesthesiol Scand. 2019;63(1):61-8. Chopra V, Kuhn L, Vaughn V, et al. Does certification in vas- cular access matter? An analysis of the PICC1 survey. Am J Nurs. 2017;117(12):24-34. Dietrich CF, Horn R, Morf S, et al. US-guided peripheral vascular interventions, comments on the EFSUMB guide- lines. Med Ultrason. 2016;18(2):231-9. Edwards C, Jones J. Development and implementation of an ultrasound-guided peripheral intravenous catheter program for emergency nurses. J Emerg Nurs. 2018;44(1):33-6. Feinsmith S, Huebinger R, Pitts M, Baran E, Haas S. Out- comes of a simplified ultrasound-guided intravenous train- ing course for emergency nurses. J Emerg Nurs. 2018;44(2): 169-75. Gorski LA. The 2016 Infusion Therapy Standards of Practice. Home Healthc Now. 2017;35(1):10-8. Gosselin É, Lapré J, Lavoie S, Rhein S. Cost-effectiveness of introducing a nursing-based programme of ultrasound-guid- ed peripheral venous access in a regional teaching hospital. J Nurs Manag. 2017;25(5):339-45. Haddadin Y, Regunath H. Central line associated blood stream infections (CLABSI). StatPearls. December 9, 2019. ncbi.nlm.nih.gov/books/NBK430891 Hunter MR, Vandenhouten C, Raynak A, Owens AK, Thomp- son J. Addressing the silence: A need for peripheral intra- venous education in North America. J Assoc Vasc Access. 2018;23(3):157-65. İsmailoğlu EG, Zaybak A, Akarca FK, Kiyan S. The effect of the use of ultrasound in the success of peripheral venous catheterisation. Int Emerg Nurs. 2015;23(2):89-93. Joing S, Strote S, Caroon L, et al. Ultrasound-guided peripher- al IV placement. NEJM. August 4, 2012. youtube.com/watch ?v=-fduIjQ8EH4&t=6s McCarthy ML, Shokoohi H, Boniface KS, et al. Ultrasonog- raphy versus landmark for peripheral intravenous cannula- tion: A randomized controlled trial. Ann Emerg Med. 2016; 68(1):10-8. Miles G, Salcedo A, Spear D. Implementation of a successful registered nurse peripheral ultrasound-guided intravenous catheter program in an emergency department. J Emerg Nurs. 2012;38(4):353-6. National Healthcare Safety Network. Central line-associat- ed bloodstream infections (CLABSI). nhsn.cdc.gov/nhsn training/courses/2018/C04 Oliveira L, Lawrence M. Ultrasound-guided peripheral intra- venous access program for emergency physicians, nurses, and corpsmen (technicians) at a military hospital. Mil Med . 2016;181(3):272-6. Pare JR, Pollock SE, Liu JH, Leo MM, Nelson KP. Central ve- nous catheter placement after ultrasound guided peripheral IV placement for difficult vascular access patients. Am J Emerg Med . 2019;37(2):317-20. Shokoohi H, Boniface K, McCarthy M, et al. Ultrasound-guid- ed peripheral intravenous access program is associated with a marked reduction in central venous catheter use in noncrit- ically ill emergency department patients. Ann Emerg Med. 2013;61(2):198-203. Stolz LA, Stolz U, Howe C, Farrell IJ, Adhikari S. Ultrasound- guided peripheral venous access: A meta-analysis and sys- tematic review. J Vasc Access. 2015;16(4):321-6. Weiner SG, Sarff AR, Esener DE, et al. Single-operator ultra- sound-guided intravenous line placement by emergency nurses reduces the need for physician intervention in pa- tients with difficult-to-establish intravenous access. J Emerg Med. 2013;44(3):653-60. Whalen M, Maliszewski B, Baptiste DL. Establishing a dedi- cated difficult vascular access team in the emergency depart- ment: A needs assessment. J Infus Nurs. 2017;40(3):149-54. With basic education and hands-on practice with the ultrasound- guided short peripheral catheter insertion method, nurses can achieve a high level of I.V. access success. Nurse education and train- ing should include: • basic ultrasound knowledge, including how to operate the machine and identify venous structures • knowledge of vascular anatomy and vessel selection • an awareness of vein depth, catheter insertion angle, and catheter length to facilitate safe and effective insertion • skills such as how to hold the probe, view the needle, and identify successful cannulation. Education basicsMyAmericanNurse.com February 2020 American Nurse Journal 45 PRACTICE MATTERS Shared decision making and patient-centered care Engage patients in healthcare decisions to ensure patient autonomy. By Christy L. Skelly, DNP, APRN, WHNP-BC; Carrie Ann Hall, PhD, APRN, FNP-C; and Carrie R. Risher, DNP, MA(Ed), CMSRN P ATIENTS have to make many healthcare deci- sions during hospital stays and throughout care. These decisions can vary dramatically in context and severity. For example, one patient may need to choose the type of facility he or she will be discharged to and another may need to make a simple medication or activity decision. Nurses understand the importance of patient autonomy and that ultimately all de- cisions are up to the patient. However, many barriers can make that process difficult. (See Decision-making barriers.) A 2017 study by Burke and colleagues of 54 patients and professional caregivers mak- ing decisions about skilled care after hospital discharge found that patients frequently felt passive in their care decision-making and felt an overall lack of autonomy. Nurses can help change this by practicing shared decision making (SDM), which engages patients in making active choices about their care. As SDM becomes standard in healthcare organi- zations, various decision-making models are being developed, and the National Quality Fo- rum is designing certification standards for pa- tient decision aids used in the United States. Implementing a decision-making model that includes patients can improve care quality. SDM: A closer look According to the National Learning Consor- tium, SDM is the process by which patients actively work with a nurse or other healthcare professional to make informed decisions about their healthcare options. As part of pa- tient-centered care, SDM is critical when a pa- tient is faced with multiple healthcare options with varied benefits and risks. SDM is associ- ated with increased patient knowledge, satis- faction, and confidence with healthcare deci- sions. In addition, researchers have found that it improves patient autonomy and disease self- management. SDM stems from the 1978 International Conference on Primary Health Care Declara- tion of Alma-Ata that recognized the impor- tance of patients actively participating in all aspects of their care, including planning, or- ganizing, and implementing care decisions. Since then, several steps have been taken in support of SDM. For example, the National Academies of Sciences, Engineering, and Med - i cine recommends adopting SDM into patient care delivery, the Agency for Healthcare Re- search and Quality (AHRQ) notes the impor- tance of providing patients and their families with evidence-based care options in accessi- ble formats that take into account individual learning and cultural needs, and the Patient Protection and Affordable Care Act supports 46 American Nurse Journal Volume 15, Number 2 MyAmericanNurse.com SDM that includes the healthcare team, pa- tients, and caregivers. In addition, Quality and Safety Education for Nurses competencies in- clude preparing nurses to foster and support SDM. SDM also is supported by the American Nurses Association Code of Ethics for Nurses with Interpretive Statements and Nursing Scope and Standards of Practice. To facilitate SDM, nurses need to under- stand the process. Truglio-Londrigan has iden- tified nine competencies—reflective practice, nurse-patient relationship, communication, as- sessment, cultural knowing, teaching and learning, ethical knowing, interprofessional practice, and negotiation—necessary for nurs- es to practice SDM. (See Build your compe- tence.) Combining these competencies with an effective decision-making model helps en- sure that care remains patient centered. The SHARE Approach model The AHRQ SHARE Approach decision-making model is designed to guide SDM by examining and analyzing healthcare option advantages, disadvantages, and potential risks. The options are identified via meaningful patient-nurse di- alogue that allows the patient to openly ex- press what’s most important to him or her. The model comprises this five-step process: Seek your patient’s participation. Help your patient explore and compare treat- ment options. A ssess your patient’s values and preferences. R each a decision with your patient. E valuate your patient’s decision. According to AHRQ, benefits of the SHARE Approach include increased patient satisfac- tion resulting from improved care quality and a good care experience. The model also helps build trust between healthcare professionals and patients. AHRQ offers a workshop cur- riculum (User’s Guide for Clinical Teams, avail- able at ahrq.gov/shareddecisionmaking ) with resources and tools for teaching nurses how to implement the SHARE Approach. Putting SDM into practice starts with lead- To ensure patient participation in shared decision making (SDM), build these competencies: • Reflective practice: Engage in reflection. Patient and nurse reflec- tion should occur while the SDM process is underway and after it’s complete to identify areas of strength and opportunities to improve. • Nurse-patient relationship: Be mindful of patients’ goals and needs; doing so will help you develop meaningful, therapeutic rela- tionships that foster SDM. • Communication: Communicate effectively with patients, families, communities, interprofessional teams, and organization leadership to ensure that patient needs are heard and shared with the health- care team. • Assessment: Assess the patient’s ability to engage in SDM so you can modify resources and techniques based on individual patient characteristics. For example, consider the patient’s developmental stage, literacy level, disease severity, and treatment options to guide SDM planning and engagement. • Cultural knowing: Respect and value individual patients’ cultural differences so you can identify healthcare choices that align with their beliefs. • Teaching and learning: Design a teaching plan that accounts for patients’ specific needs (developmental age, literacy level, cultural considerations, primary language, learning style, and any needed accommodations). • Ethical knowing: Understand and balance ethical principles while engaging in SDM. For example, a patient’s choice may conflict with your values and beliefs, but you’ll still need to ensure that the pa- tient is fully supported. • Interprofessional practice: Nurses facilitate SDM with the health- care team as well as the patient, so take into consideration each team member’s expertise and how it supports the best patient care. • Negotiation: When conflict arises, work with the patient, family members, and healthcare team to facilitate understanding of op- posing views, identify commonalities, and promote a shared deci- sion. Use strategies that foster collaborative agreements and be open to seeking an understanding of each person’s views. Build your competence Patient autonomy is crucial to patient-centered care, but several barriers can prevent patients from participating in healthcare decisions. Those barriers include: • insufficient knowledge • limited time • lack of experience • no family support • reduced mental capacity • inadequate resources. Nurses also may encounter barriers, includ- ing limited time and lack of knowledge and confidence about certain topics or resources. In addition, family members may disagree with a patient’s decision or doubt the provided in- formation. Decision-making barriers ership buy-in and a well-coordinated plan. In addition, the AHRQ user’s guide recommends creating an implementation team, adopting an approach that fits your practice, providing staff training and ongoing support, taking an incremental approach by starting small and then increasing over time, creating a physical space for SDM, building a library of evidence- based resources and decision aids, integrating SDM processes into daily care, and evaluating ongoing SDM implementation. Follow the evidence Nurses who strive to provide quality care should follow the evidence that leads to best practices. A team-based approach to SDM enables patients to examine their options and actively participate in their healthcare. The result is improved outcomes, care qual- ity, and patient satisfaction. AN To view a list of references, visit myamericannurse.com/ ?p=64346. Christy L. Skelly, Carrie Ann Hall, and Carrie R. Risher are assistant professors of nursing at Florida Southern College in Lakeland. A D I NDEX American Nurses Association/American Nurses Credentialing Center ANA’s Principles for Nurse Staffing ..................... 23 ANCC Accreditation NCPD Summit ...................... 5 ANCC Pathway to Excellence Conference® ........ 15 The Washington Post/ANA Star Nurses .............. IFC Berkshire Hathaway Specialty Insurance ................. IBC Exergen Corporation ...................................... Cover Tip Hewlett Packard Inc. (HP) ........................................ BC Mercer Consumer ...................................................... 13 Monmouth Medical Center – RWJBarnabas ................. 9 National Institute of Whole Health ............................ 47 For advertising and partnership information please contact John J. Travaline 215-489-7000 jtravaline@healthcommedia.com Go Beyond Symptomatic Care ™ Earn Credentials in an Additional Scope of Practice as a Patient Health Educator, Advocate and Coach Provide your patients with the What, Why and How of their chronic health concerns and empower them with a demystified understanding of how they can reduce or prevent disease and increase longevity. Nationally accredited by the Institute for Credentialing Excellence – which accredits 15 nurse specialty trainings – this 400 hour program provides 200 ANCC approved contact hours and leads to Health Care Provider status and an NPI number as a patient health educator, to be used in today’s medical environments or your own private practice. Disease Prevention and Patient Education are two of the most urgent needs in medicine. Train today to enhance your nursing career with an additional scope of practice! Call us at 1-888-354-HEAL (4325) or visit us at www.niwh.org Nurses Save $ 650 Find out how EXCLUSIVELY for NURSES Educate, Advocate, Coach ™ MyAmericanNurse.com February 2020 American Nurse Journal 47Next >