Gaining vascular access through inserting a peripherally inserted central catheter (PICC) or a peripheral intravenous line (PIV) can be downright daunting for “difficult” patients, including the elderly, obese, and patients with underlying conditions such as cancer or drug addiction. When you’re treating the veterans who have served our country, every single needle stick and every single minute truly counts.
In recognition of National Nurses Week (May 6-12), Fujifilm Sonosite is spreading awareness of a proven and effective method of inserting PIV lines in challenging patients—ultrasound-guided vascular access. By taking advantage of the superior imaging and portability of ultrasound machines, clinicians can reduce the time and pain associated with drawing blood and injecting medicine.
Towards the One-Stick Standard
In 2016, the American College of Emergency Physicians (ACEP) issued a policy statement advocating a new safety goal for vascular access: the One-Stick Standard. To help clinicians achieve the One-Stick Standard, ACEP recommends using procedural ultrasound at the bedside for placement of central venous catheters (CVC) and PIV lines. ACEP cites such benefits such as "improved patient safety, decreased procedural attempts, and decreased time to perform many procedures in patients whom the technique would otherwise be difficult."1
Many common therapies, such as administering fluids and medications, resuscitation, hemodialysis, and hemodynamic monitoring, cannot be initiated until a line has been successfully placed. Similarly, vascular access is often a prerequisite for transferring patients in the emergency department to other departments for additional treatment, such as surgery, the cardiac catheterization lab, or the critical care unit.
New Jersey Hospital Leads the Way in Ultrasound-Guided PIV
St. Joseph’s Regional Medical Center, located in Paterson, New Jersey, houses the second-busiest emergency department in the nation, serving over 175,000 patients in 2016. “Before we had the Sonosite ultrasound technology, we had a lot of patients with multiple sticks, bruises,” says Judy Padula, Vice President of Patient Care Services and Chief Nursing Officer at St. Joseph’s Healthcare System. “As minor as that may sound to some people, getting the IV in can be the make or break to their treatment.”
St. Joseph’s partnered with Sonosite to create an ultrasound-guided vascular access program, which trained nurses in using ultrasound visualization to locate and access hard-to-see vasculature. St. Jospeh’s didn’t realize what a huge difference the technology would make. Nurse practitioner Matthew Ostroff, head of the Vascular Access Program at St. Joseph’s, explains:
“With ultrasound, we assess the vein before we stick it. We can see our needle going into the vein. It takes roughly 40-45 minutes at the bedside to do a PICC line. When we’re able to substitute an ultrasound-guided PIV, it’s a 5 to 10-minute procedure. We’ve essentially changed the entire landscape of IV-insertion.”
Ostroff describes one case where ultrasound guidance was pivotal. “We had a patient who was pulling out all of his lines, but required long term vascular access to be discharged from the hospital. I had the idea of tunneling a catheter to his back from his jugular vein. I was able to scan the left jugular vein, assessing the path to the back with the ultrasound to assess for collateral vessels in the path. We were able to provide tunneled catheter from the back to the jugular vein at the bedside with a navigation system confirming our placement—without fluoroscopy.”
In his article published in Becker's Infection Control & Clinical Quality, Ostroff further expands upon the benefits of ultrasound-guided vascular access. “Over the past two years, our program has saved nearly $1 million through one simple, but extremely important change in the type of catheters used for patients with problematic vasculature due to obesity, chronic illness, chemotherapy, IV drug abuse, or other conditions. Without ultrasound guidance, such patients—sometimes known as "difficult sticks"—often end up with central lines because clinicians found it difficult or even impossible to achieve PIV. Since implementing ultrasound-guided PIV at our center, we have reduced the use of central lines, which can have complication rates of up to 15% if inserted blindly, by 40%.”2
Ostroff says that using procedural ultrasound at the bedside avoids the need to send patients to interventional radiology for such vascular access procedures as peripherally inserted central catheters (PICCs), which in turn frees up radiologists for other procedures. Use of ultrasound guidance, which provides direct, real-time visualization of the target vessel and surrounding structures as the needle is advanced to the desired destination, has enabled his team to achieve a 96.4% first-pass success rate, thus accelerating the care of critically ill patients.3
Recognizing the Leadership Role of Nurses
Awareness of the One-Stick Standard’s effectiveness is only the first step to bringing ultrasound-guided vascular access to your hospital or clinic. In an article published in Axis Imaging News, Ostroff and Padula describe how nurses play a key role in implementing a successful ultrasound program.
“Nurse-led ultrasound-guided vascular access programs have achieved impressive improvements in the safety and quality of care, particularly for patients with problematic vasculature. In what is believed to be the first such program in 2004, nurses at a Level 1 trauma center in Georgia were trained to use ultrasound to access deep peripheral veins. Of 258 patients identified as difficult sticks before this technique was used, 80% were rated as ‘hard’ and none as ‘very easy.’ With ultrasound guidance, the nurses reported in a 2006 survey that only 11% of these patients remained ‘hard’ and 42% were ‘very easy,’ with an overall success rate of 85% to 89%. A recent study at Texas Health Harris Methodist Hospital found that after launching a registered nurse-led ultrasound-guided vascular access program, CVC and PICC placements due to problematic PIV access decreased by 74%.
As nurses providing hands-on care to patients ranging from the frail elderly to the tiniest preemies, we find these success stories fuel our passion for spreading the word about the many benefits of ultrasound guidance. We hope that sharing our experiences will inspire other healthcare professionals to join the growing movement toward the one-stick standard and adopt the ideal technology to achieve it. Ultrasound machines at the bedside to help clinicians provide safer, more compassionate care.”4
Want to know more? You can read more about St. Joseph’s story, and visit us at www.sonosite.com to contact a representative to learn what ultrasound-guided vascular access and the One-Stick Standard can do for your hospital, nurses and staff, and the veterans you serve.
1Emergency Ultrasound Imaging Criteria Compendium. Annals of Emergency Medicine, Vol. 68, Issue 1, e11-48. http://www.annemergmed.com/article/S0196-0644(16)30096-8/abstract.
2Feller-Kopman D. Ultrasound-Guided Internal Jugular Access: A Proposed Standardized Approach and Implications for Training and Practice. Chest Journal. 2007;132(1):302-309.
3Ostroff M. Ultrasound-Guided Vascular Access Program Saves St. Joseph’s $3.5 Million. Becker’s Infection Control and Clinical Quality. February 10, 2017. https://www.sonosite.com/sites/default/files/Beckers-Vascular-0217.pdf.
4Padula J., Ostroff M. Establishing an Ultrasound-guided Vascular Access Program. Axis Imaging News. September 10, 2019. https://www.sonosite.com/sites/default/files/Axis-Ultrasound-0919%20%281%29.pdf.
