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Transcript

- Great. Welcome to the webinar.

Before we begin, please be advised all attendees are muted.

You may type your questions into the Q&A box

in the toolbar located at the bottom or side of your screen.

We will conduct a Q&A session

at the end of the presentation.

This webinar will be recorded and archived

for future reference.

Welcome to our webinar on

Advanced Peripheral Intravenous Skills

for the Emergency Nurse:

Using Point-of-Care Ultrasound for Difficult Access.

Here with us today we have Kristen Armstrong

and Carol Staveley.

Kristen is a clinical application specialist

with Fujifilm SonoSite and she's a licensed sonographer

with 20 years of experience.

And Carol is the director of Strategic Initiatives

for Fujifilm SonoSite Canada.

Carol is going to monitor the Q&A session at the end

and introduce our speaker, Lisa Gru today.

I'll hand it over to you, Carol.

- Hi everyone.

So Lisa Gru started her career in 2006

as an emergency staff nurse at Guelph General Hospital

in Guelph, Ontario,

where she's now the Emergency Clinical Educator

and Professional Practice Lead.

She followed a passion for continuous learning

in the clinical nurse setting

and obtained a master's degree in nursing

with a teaching focus in 2017.

After recognizing the value of ultrasound guided

peripheral IVs in difficult access cases,

Lisa led the development of ultrasound guided PIV training

program for nurses at Guelph General Hospital.

Her evidence-based collaborative approach resulted in

high interest and participation among ED nurses.

As a result, the nurse led ultrasound guided PIV program

has begun making a positive impact on nursing press

and patient satisfaction at her hospital.

So I'm gonna let Lisa tell you more about the why's and hows

of nurse-led ultrasound guided peripheral IVs

for difficult access.

Over to you Lisa.

- Thank you Carol, and thank you for having me today.

I was actually quite honored to be asked to speak today,

especially about emergency nursing

and talk to you about advanced skills in emergency nurses,

specifically the use of point of care ultrasound.

So some of you may have heard of ultrasound guided IV

or are currently using this technology

to gain vascular access.

However, I'm guessing that many of you

who are emergency nurses may just be curious to know

what I can offer as advanced skills for a group of nurses

who are second to none when it comes to IV skills.

So you might be thinking how a seasoned emergency nurse

could get even at IVs.

And I'm not here today to suggest that their skills

are not already great.

I'm simply here today to offer another tool

to augment IV skills in the ED.

So my role is educator.

So point of care ultrasound IV

has been more of a small grassroots project

that I latched onto because I found it valuable.

So at my hospital, we're still in the process of getting

ED nurses trained on this skill.

So to give you a little bit more context about my hospital,

so my hospitals in Guelph, Ontario, Canada,

and we are a 187 bed hospital that serves a population

of 130,000 people in Guelph, Ontario.

We're a designated stroke, vascular, and bariatric center.

And our ED is a 21 bed emergency department

that serves approximately 60,000 visits annually.

And this is climbing.

So currently our average patient assignment

that we see every day is about 160 to 170 people every day.

So my association with point of care ultrasound

began in my educator role a couple years ago

when one of my ED physicians,

Dr. Mary Cameron, came to me and told me about

her most recent POCUS update

and told me that she had learned about this new technique.

So she said, you know, ultrasound guided PIV.

She asked me, do you think we could do this for our nurses?

And she said, you know, I have IV skills,

you or I have ultrasound skills, you have IV skills.

Can we put them together and come up with some training

for the nurses?

So, which I answered yes, let's do this.

So my journey implementing point-of-care ultrasound IV

has not been a sprint to the finish,

but rather a persistent and devoted hike

to the implementation process.

I haven't arrived at my destination yet,

but I'm here today to share how I got started

and how I've been picking up momentum.

So I just wanna offer right off the bat

for those who haven't, who don't know a lot about this tool.

So as ER nurses, we use several tools to our advantage

to gain IV access.

So we use warmth, we use gravity, tourniquet sometimes,

two tourniquets sometimes, vein finders if you have them

in the department.

But what point of care ultrasound provides

is just another tool for specifically difficult AX patients.

This does require more advanced technique

and skill to deliver.

So just as physicians who blindly inserted central lines

about a decade ago, they transitioned to using

point-of-care ultrasound for their insertions as well.

So most of our EDs have this tool that can be used

in other ways too.

So before we get started and talking about implementation,

I'm just gonna show you the whole procedure.

So I'm just gonna stop my screen here

and we're gonna do a little video.

- [Nurse] Look back to make sure nothing is moved.

If nothing has moved, then I poke. Ouch.

Okay, now I find my needle tip by sliding up and down.

I can shake the needle a little bit to give some movement

on the tissue.

And the target vessel I want to take it from a circle

and make it into a heart shape.

Once I have the heart shape,

I can rely on IV skills and puncture quickly

and then find the tip.

So I'm scanning up and down with the ultrasound again

and there's the tip in the middle of the vein.

I've got flashback,

so I'm happy I can just drop my angle in advance slightly

and then go back to just IV skills

and just thread the catheter.

If I'm not sure, I can go in a long axis over the vessel

and visualize the end of the catheter in the vessel.

- Okay.

So, why are we here?

So that procedure is pretty neat.

As you can tell, it doesn't take long.

So you may be here for the same reasons I was

attracted to the skill.

So we take care of patients in their most acute

and vulnerable times.

We wanna do better for our patients, but we in an emerge,

we do it in a pressure cooker.

So having great skills and knowledge is paramount

to providing great care in the emergency department.

IV access is a common skill performed by nursing staff

and difficult IV access patients

make up approximately 25% of our patients in a day.

So leading to delay in access, multiple IV attempts,

and it also has that butterfly effect

on the rest of the patients in the emergency department.

So having a few tricks up our sleeves

is why we are going to discuss this today.

And so, as it says on the slide,

we want to give our patients great amazing care,

we wanna poke them less,

we want reliable IV starts and get them their treatment.

So during this presentation,

I hope to offer you some information

about point of care ultrasound IV insertions,

and a way to offer the skill to nurses in your ED.

So for those of you that have started implementing

in your department, I hope that you can share,

you can take a few pearls from we've done

and move it forward.

And for those who are just starting out,

my hope is that by the end of this presentation

you can take some lessons from my experience

and help you get started.

So I'll speak about the process implementation

that are required to get the program started,

as well as what the literature says.

I'll speak to you about collaboration,

engagement of the nurses, and about hospital resources.

I'm also an ED nurse, so I'm practical to the bone.

So I'll also be showing you the technicalities

of the procedure,

the strategies and tools I use to teach my program,

and what you'll need to implement ultrasound guided IV

in your ED.

So I'm gonna just put a few of these up just for reflection.

Unfortunately, because we're not in a real classroom,

we can't banter back and forth, but feel free to, you know,

add your reflections in the comments bar or Q&A.

So where did this come about?

Ultrasound guided peripheral IV was first described in 1978

and then it was the first tech,

it was used then and the first study actually done on this

technique was done in 1999 and it compared

ultrasound guided technique versus standard technique.

And then in 2004 was the first known nurse led

ultrasound guided vascular program

that was implemented at a level one trauma center in Texas.

So you may be thinking, this seems neat,

but what utility does this have

when I'm in emergency situation?

And really the answer,

this is not useful in an emergency situation

that when patients require immediate access.

So if you couldn't find a vein using IV,

then you would have to move to IO,

which would be the preferred choice.

So just so you know,

it can take up to seven minutes in a practiced nurse

to get IV under point of care ultrasound.

However, it is very helpful tool for the cases

listed above on this slide.

These are called difficult intravenous access patients,

so DIVA patients,

which was described in a lot of the research.

So on the screen you might also see there's a black

and white little checklist.

So this is the DIVA tool that we use in our ED.

Our nurses have them on our lanyards

and it was developed so they could kind of decide

really quickly who needed ultrasound guided ultra IV.

So the other thing to note is what your nursing college

says about using point of care ultrasound.

So point of care ultrasound's considered advanced practice

skill, which requires development through education,

attending focus training workshops,

preceptorship, and clinical practice.

So the use of ultrasound may vary by province

or state and your nursing college standards.

So for most nursing bodies that I looked into

developing this presentation, I noted that most places,

most colleges say that nurses can use ultrasound

for the purpose of an assessment and not for diagnosis.

So I, you know, moving forward I would recommend

finding out what your provincial,

state, and college recommends for the application

of ultrasound energy in IV access.

And then we wanna know why it matters.

So I'm gonna offer you a little bit more about my story.

So while the thought of offering this advanced skill

to ED nurses is exciting,

when this happened to me

due to like lots of completing priorities in the ED,

I had to wrap around my head around

whether it is worth pursuing.

So I question how difficult it could be.

So I learned the skill first.

So at the time our hospital CT technologist

started doing ultrasound guided IV in the CT suite.

So the lead CT technologist, Corey,

generously invited me and the ED doctor, Dr. Mary Cameron,

to come learn ultrasound guided PIV in the ultrasound suite.

So I was the test learner spending a day putting IV's

under ultrasound and the CT technologist helped me

learn the skill.

So while we were in CT,

I learned a few things that bought,

I got buy-in for doing the skill.

So one is that the patients who often had many IV sticks

in the past were relieved to be only poked once.

They also expressed being more cared for because you know,

we are trying something new.

Even as a new learner when I was there,

most starts were successful after the first, you know,

little while trying and you know,

that resulted in less using less equipment.

And by the end of my training day I really felt a sense

of pride that I had learned this new skill

and I was helping patients that had difficult access

feel better and only one poke.

So that was all great.

Additionally, our CT technologist, Corey,

said that before implementing ultrasound guided PIV

in the CT suite,

they would often send people home

because they needed an IV for the CT scan, didn't get it.

So once they implemented ultrasound guided PIV,

they reduced these cancellations to nil.

So I was really decided that the skill was worth sharing.

So the ED doctor was happy to also help me

develop some training for the ED nurses to get started.

So I realize my anecdotal stories are very nice,

but it turns out that the literature supports these notions.

So I'd like to review what papers were helpful

to the development of my implementation.

Because there isn't a huge body of literature

on this skill in the emergency setting,

I'm going to use the following studies on this slide

to break down the data and support the use of POCUS in EC.

So there were some common themes that I'm gonna review

with you and they're helpful for building a case

of why the skill matters

and why it would be valuable for your ED.

So the first trend was the benefits to the patient.

So it's first good to understand what the problems were.

So there's several different problems

with your DIVA patient, so difficult IV access patient.

So they can make up, as I said in the beginning,

up to 25% of your patients in a day.

And these patients end up having longer stays in ED,

delays in care, multiple IV attempts that cause them pain.

And it's also estimated that there's a five minute delay

per PIV from the same provider.

And then if you have to get another nurse in to try the IV

as well, that creates another 15 minute delay.

So you can see how a procedure that would be only two

to five minutes can really get longer and longer and longer.

This also contributes to the backlog in ED.

So what is the benefit to the patient

is that once a nurse becomes proficient

at ultrasound guided IV,

they have a 95% success rate on the first attempt.

So as I said, you know,

when they're more proficient it takes about seven minutes

to perform an IV.

They have increased patient satisfaction with their care,

decreased wait times, and faster time to IV therapy.

So in the same, there's also efficiency of resources.

So this is the second trend.

As we know it takes longer to get an IV in a DIVA patient.

So one study said it takes twice as long to get an IV

resulting in longer length of stay in the ED,

sometimes even a longer length of stay in the hospital.

So the benefit of POCUS is as follows.

So supplies are reduced,

you're not using as many IVs to poke.

The time, reducing length of stay in the ED

in the hospital and improving flow.

And then for personnel.

So it's only one nurse coming to start that IV

and there's no need to call in for extra help.

So as a bonus kind of data in a study by Goslin et al.,

a nurse based ultrasound guided PIV program

that was conducted over three years

saved a net amount of up to $600,000

just by avoiding PICC lines in difficult access patients.

And of course there's also benefit to the nurse.

So the problem when nurses miss the IV

is that sometimes the perception from the patient

is that they're not technically competent,

it's not necessarily the case,

but they kind of lose confidence in that nurse.

So for the nurse, their technical competence goes up,

they can establish that IV quicker.

The patient perceives that the nurse has great skills

and they can also have the ability to access

non palpable veins that you just can't find

without ultrasound.

There's also a few more commonalities in the literature

that I want to address.

So one is that these studies were conducted in big centers

or teaching hospitals and the other is

that there was a dedicated project

or formal quality improvement projects

associated with the study.

So it's, you know, I wanna just address

that this may not apply to the reality of our hospitals

on this webinar today.

So for myself being a small hospital, I didn't,

I don't have as many resources.

So what I can provide you next is a bit more of a grassroots

approach to implementation.

So unlike large centers in the studies presented,

which were provided with resources

to implement their education,

I pursued POCUS in a smaller city hospital

where resources are scarce.

So I leveraged some of my,

some what we already had in our hospital

to help nudge my program forward.

So really I think that emergency departments both large

and small can utilize this skill

to benefit their population.

So, how would this benefit your environment?

This is a little reflection for you.

So if you're still here,

then you're interested in taking this on.

So is your organization ready for this?

Let's talk a little bit about that.

The first thing we wanna consider are your resources.

So those people you can collaborate with.

Support from inside and outside the organization.

Your time and your budget.

So let's break that down a little bit.

The Guelph program is progressing forward

and it's because of many gracious contributors

to the initial stages of the implementation.

So all the collaborators that our present next

came at the right time,

some serendipitously, and helped kickstart my implementation

and it's been moving forward faster than I thought it could.

So for those starting out,

the strength in your education is going to be

finding those people you can collaborate

to drive it forward and in the way of knowledge,

skill, influence, support, and resources.

So who are those people?

So for me, these are my people that I collaborated with.

So I'll break down who is part of my implementation and why.

So the first one is the ED physician, Dr. Mary Cameron,

that collaborated with me and really gifted me the training.

She had trained most of our physicians on point of care

ultrasound in the ED and now is extending that learning

to the nurses.

So for which I'm very grateful

and she gave me a great starting point.

She developed the training by watching how I learned

in the CT suite and developed a in-class training program.

So for you, you'll need to find an ED physician

to support you and the nurses.

It may, they may not give you the starting point,

but having someone to also advocate in the department

can be helpful and supportive to the brave nurses

that dare to try the skill in the ED.

The next one is, so someone who knows the skill.

So for me, this was the CT technologist, Corey,

who I sought out to help me learn the skill.

So his experience was beneficial to learning the skill,

troubleshooting new problems for the nurses.

And now he, I actually send some of my nurses

that I train to the CT suite

in this nice controlled environment when he's there

and so he can mentor and help with the learning as well.

So finding a person in or department that can help you,

you know with their experience will be valuable

to your program.

The next is a clinical educator.

So that's me in this case,

but as I see it, this could be a clinical educator,

a physician, a resource nurse, a resident,

or a clinical lead.

So this is the person that's gonna drive the training

forward.

So the commitment to the implementation requires time,

perseverance, and getting creative with resources.

The directors of care.

Of course you need support from the administrators.

So for me, while there's no additional funds for the nurses

to be paid to get trained,

the ED director as well as our director

of professional practice in our hospital

are supportive of the time that I've put into training

the staff.

And this one, if you have students around,

they're wonderful resources.

So I was really spoiled when I took on a master's student

for a semester.

She was also an ED nurse too.

So of all the projects I offered her,

she chose the ultrasound guided PIV project.

And so not only did she volunteer to be one of the first

learners, she also did a deeper dive into the literature,

which informed practice and refined the program.

She also developed three tools to be used by the learners.

So one is a DIVA tool, so a difficult IV access tool.

Two is a checklist for insertion.

And then three is a cannulation record.

The other serendipitous thing that happened to me

is that in the first year of starting point of care

ultrasound education,

the hospital bought new ultrasound units for the ED.

So through this I met Kristen and Carol

who have been a big support in offering resources

to run the courses,

some extra technical knowledge about the ultrasound units,

and real vested interest in the success of the program.

So they've since helped me improve the program

by providing extra resources like e-learning

that I now get the participants to complete

before the in-class portion,

which made my in-class portion shorter,

which is really nice for the nurses.

And finally, for the program to get traction

and for the skill to be used in the ED,

you need to find those nurses that dare to try

something new.

So the best nurses for this role

have a few targeted qualities.

So they're those informal leaders,

they're the influencers in the department,

they're skilled, and they crave innovation.

So these are those natural leaders in the clinical setting

and because of their, you know, great knowledge and skill,

people trust and respect their decisions and you know,

they want to often follow their viewpoints and actions.

So finding your trailblazers and putting some energy

into their training and experience

with the ultrasound guided PIV

will be the cornerstone in moving your program forward.

As those you know, as they come in

and start doing the skill,

those passive observers will eventually be interested

in the skill as well.

And you know, eventually they won't want to just

have call somebody else for help.

They'll want to do the skill

and be the one that saves the day.

The other thing to consider

when you're getting started is time.

So that you'll need time to develop your program

and your curriculum, and if you're the person

who is gonna be teaching,

I would also take some time to learn the skill yourself.

You know, once you have your curriculum

and practice established, keep the momentum.

For me a four to five hour commitment every few months

we'll start to establish a base of nurses

that can do the the skill.

And in terms of your curriculum,

know that there are more resources out there.

So when I started out I didn't know about all the resources

so I did have to take time to develop curriculum.

And the initial trailblazers that sign up

for the first few courses

will need a bit more time and support in the ED.

This responsibility can also go to you know,

your collaborators like your ED physician

or your POCUS expert.

And then finally there's time commitment from the learner.

So we'll talk about that 'cause less is more.

And then there's budget.

So for me, this is practically non-existent.

So when I presented this project to the director of the ED,

she was absolutely intrigued,

but unfortunately there was no extra budget

to pay the ED nurses to do the training

or for any materials.

So we did not buy an ultrasound unit for training,

we didn't have fancy phantom veins.

So this is really part of the whole deal.

You need to get creative.

So I'll discuss that in the challenges.

So just as a little reflection.

What resources can you draw from?

So let's talk about the challenges.

So the first challenge is the no budget challenge.

So we talked about that just a moment ago.

So for me, we couldn't pay our nurses to attend

and there was no budget for fancy vein models.

So I had to get creative.

So how did I deal with that?

One is that our ED physician, Dr. Mary Cameron

donated her time to get things going

and passed the baton to me, which was really great.

And for the implementation,

my role as educator would be classified as in kind funding.

So my labor as an educator during work hours

requires me to kind of work this into my regular work flow

and what I do on a regular basis.

The other in kind funding that you can look to

is your clinical expert.

So currently our CT technologist, Corey,

when he is working,

I will send the nurses to the CT suite to be trained there

because it's a nice controlled environment

and we do have a lot of difficult access patients there.

For the course, we don't have a special unit

just for training.

So we do take one of the two units off the ED floor

for the time being.

So that means that sometimes you know,

if they need it, suddenly we may have to interrupt

the course to run it back if needed.

The other thing I've done is kept the courses short,

so not taking too much of the learner's time.

So for the trailblazers that have joined my courses,

they've done so out of the just passion for learning

and so I just wanted to keep it short and sweet.

When I first started it was half a day long

and now I've reduced it down to three hours.

And I have our nurses interested because it's more doable

to do three hours rather than a half a day.

The next challenge is if I can't get the IV

then no one can challenge.

So this is a very common one in ED

'cause ED nurses have these skills.

So you know, if you think, if there's any ED nurses

out there, can you think of a time

when you know, you had this very sick patient,

maybe they're in DKA,

they have a history of IV drug use,

they're edematous and on top they're on a blood thinner.

So after several attempts by your colleagues,

you know somebody gets that 24 in the thumb

and you know, life is great again

because have a little bit of access.

But, so why would I need an ultrasound machine

to do that, right?

So how do we deal with that?

So I rely on my nurse trailblazers or the influencers,

they're my biggest focus because when they get good at this

skill, they put the energy and time into doing IVs

under ultrasound.

And so when it comes time to you know,

see one of these patients that has difficult access

and everybody else has tried,

they can sneak in there and get a bigger IV

than that little 24 in the thumb.

So really target those who are interested first

for your training and then others will follow naturally.

So the, you know, the DKA patient I just described

a slide earlier is actually a real case

just a few weeks ago.

Is that my trailblazing nurse came in after the fact

when you know all, the nurses had tried.

They say oh, come try this.

And you know, they had the lip 24,

which she was able to get a nice 18 in a non palpable vein

and the patient did well.

So the other thing to consider

is the climate of ED challenge.

So realizing there's seasons of change in the ED

and what's happening at the time.

The staff, the culture, everyone's time ups and downs.

So how do we deal with this?

A couple ideas.

So you know, the skill takes time to develop.

So those bold risk takers need the time

to actually get in there and try the skill.

So in ED we all know the ebbs and flows that comes with

the seasons.

So staff turnovers, full moons, now pandemics, right?

So good planning is essential.

We all know best laid plans can fail.

So while you might wanna get this going,

you know when energy is low and volumes are high,

too many new projects it, you know,

engagement can be very difficult.

So for me, I've positioned a lot of my courses

in down times for my organization

and I have a good sense of when we're doing lots of projects

in the organization 'cause I am part of

professional practice.

But for example,

I try to avoid September altogether

because it's the back to school rush.

Mid-December, I don't usually do anything for this

kind of thing because of winter holidays

and people are relaxed at that time.

And my classes are also very small,

so I can accommodate a date and time that works

for those nurses.

So classes are really four to five to six people.

So know that all of these challenges can be overcome.

So despite lack of budget,

paid training time, and now a pandemic,

guess what I didn't do for IV courses?

I've now successfully run five courses

over the last couple years and have 28 nurses

out of my 100 nurses trained on ultrasound guided PIV.

So I also have a waiting list of a dozen more nurses

that want to take the course this upcoming year.

So I am gonna put this out to you.

What challenges might you have?

Those were my challenges, but maybe you can think of some

that right off the top that you may run into.

So let's get into the practical stuff,

which is my favorite stuff.

So implementation in your ED.

So this is one of my classrooms on this picture.

You can see that is pretty simple.

So you have to consider your timeline.

We talked about time before.

so we've already talked about collaborating with your,

you know, internal people and getting buy-in.

And then you wanna do your curriculum development,

you wanna get teaching.

So for me, I teach a course,

I try to teach a course every three months

except for when there's pandemics.

And then from those courses I want,

I try to get one to two super users or champions

that can help out in the department with new learners.

So my curriculum is pretty simple.

So I do an hour of e-learning before class

and that was provided to me by SonoSite.

So this is why I suggest reaching out to your

ultrasound representative 'cause they may have a resource

like that for you.

And then I have a three hour in-class education

where we do hands-on training on phantom veins.

And then from there I do three to five supervised

cannulations with the learner on patients.

So that can be with me,

it can be with the CT technologist or the ED physician

or now because I have so many super users,

there's other nurses that can help with these

initial cannulations as well.

I do ask them to target 20 cannulations before they start

helping others.

So before they are considered a super user.

And then I do recommend them trying at least 10 starts

per month, just to keep the skill going.

So you might be saying, like why 20?

So in a study by Moore in 2013 that I presented earlier,

it was determined that after 10 successful IV attempts,

IV cannulations, nurses had an 80% success rate

on the first attempt.

So that's really great.

But after 20 attempts that rate increased

to greater than 91% success rate on the first attempt

when using ultrasound guided PIV.

There's a few many objectives in my course

and they're very simple and to the point.

So short and sweet is,

I want them to be able to identify those DIVA patients

and start to use ultrasound as your first choice

instead of trying to couple pokes and then going to that.

The second is just successfully inserting IVs

under point of care ultrasound following, you know,

following the procedure that I give to them.

I do like them to report on their cannulations

and troubleshoot through different cases.

And then the last objective is to help new learners.

So I actually have a little informal contract

with all the learners that come in that, you know,

at the end of this the expectation is

that you will become a super user

and help the new learners going forward.

So I said I'd had a three hour in-class course,

so this is how I break it down.

So many nurses, especially ER nurses, love and you know,

love to learn and love hands-on experience.

So give them lots of playtime.

So in the hands-on course I will spend 5 to 10 minutes

on a concept and then 20 to 30 minutes practicing the skill

that was presented.

So this is the skill.

A few pearls to help them build their skill.

One is just practice, practice, practice.

And first I ask them to practice with the ultrasound probe

before they start cannulating.

And then once they get used to it

is to use it on easy people first.

So my target person for my new learners is that, you know,

they look for people who are maybe well hydrated,

but just have really deep veins.

So you know, we're aiming for that half a centimeter

deep vein and that has a diameter

of at least a half a centimeter.

So those are the most successful first attempts.

Once they get those, then they start to pick up steam.

So I'm gonna show you a few videos.

So the first thing we teach them is IV

or trying to find a vein in short axis.

So if you look at this video you can see

that she's holding the probe in a perpendicular to the vein.

And what we get is this little black dot.

And so that's the vein or vessel

and that's what I get them to look for.

The next skill is distinguishing whether there's a vein

or artery.

So you get to see way more underneath the skin

with ultrasound probe.

And so it's a wonder, you know,

out of the thousands of IVs that I've put in

that I've never got an artery,

'cause a lot of them run right beside each other.

So their second skill that they learn

is distinguishing a vein from a artery.

So here you can see when she pushes on the probe,

one little dot squishes down

and the other one stays circular.

And so veins are much more compressible

and that's how we can distinguish between a vein

and an artery.

And then the other view that we like to to practice

is long access.

So this is a really great one.

So you can see she's holding the probe

along the length of the vein.

So in the middle of the screen

you'll see this nice black line.

And so this is a nice shot for when once we get the IV in,

you can thread the cannula in

and actually see the cannula between the, in the vein

and you can actually see the flush too.

So I'll show you the whole procedure here,

if I can get this working.

Sorry about that. Just a moment.

- [Laura] Yeah Lisa, I just looked,

I don't have that video so.

- Okay, I might have to...

Sorry about that.

- [Laura] They worked yesterday.

- Oh, here we go. Okay, We're back on track here.

Hopefully everybody can see it.

So we're, this is a phantom vein

so you can see the black in the middle of the screen.

And what's happening is she's using the probe

to find the vein.

So we are looking in short and long access.

And then what she's gonna do is there's like a center line

in the middle of the video as well as in the middle

of your probe, so that's where we aim the IV.

And so from here she's just going to walk the IV down

towards the vein.

You should start to see a little white dot now

just above that black dot and that's the IV tip.

So once she gets it right over the vein,

she pops it into the vein and now you can see

it's like a target

and that in long access we can see it become cannulated.

So she's gonna start to advance the IV

and also still check that it's right in the middle

of the vein.

So that's the value of the short access

is that we can see that it's right in the lumen of the vein

versus long access, we can see the catheter come through.

So that was a nice little model that we saw

in the last video.

If you don't have these models yet

and you wanna get started,

my suggestion is using chicken and gelatin.

So this is what I've been using for my first few courses.

I've still since kind of borrowed a few items to help,

but I find chicken models work well.

They look like tissue and so I just cannulate them

with some animal balloons.

Seems silly but it works.

So you might be thinking you know, what's the same here?

You have this extra piece of equipment.

So you're still using your regular IV equipment,

maybe a longer cannula,

but otherwise it's all the same stuff.

You're using a tourniquet and once the IV is accessed,

you're still using IV skills.

So once you get flashback you can drop the probe

and then just do IV skills.

So what is different is that there's no palpation

of the vein.

So this is a really weird sensation for a nurse

that is so reliant on palpation.

I'm one of those people.

There's a change in workflow.

So you have to ensure that your ergonomics are correct

when you have the screen and the patient in front of you

because any little movement in your body

can create big movements inside next to the vein

with the angio.

Visualization of the vein.

So there's so many different new structures

that you'd never even knew existed under the skin.

Well you knew what they existed, but you get to see,

and that's a really interesting thing to see

'cause you can even see a hematoma develop

when you kind of nick the vein

and the vein will shrink and then be pushed away

from where you had originally started.

The angle of insertion changes as well.

Because these are deeper veins,

the steeper the angle for the IV,

it creates more successful attempts.

And then the hand eye coordination of course

is a big difference for nurses who,

especially those who haven't used this skill before.

So I just anecdotally,

the nurses that come into my courses that play video games,

catch on to this very quickly.

I was one of the ones, I don't play video games.

The hand-eye coordination was really difficult.

So there's a few tools you can use

to increase the success for your learners.

So there's the I, USIV... Pardon.

Ultrasound guided PIV checklist.

There's that DIVA tool that I showed you

where you can actually score if they're a DIVA or not

and whether you should just move to ultrasound

or give it a try by standard method.

Cannulation records.

So collecting data and troubleshooting with your learners.

What went well, what went wrong.

E-learning. So because my learners have e-learning,

they can reference back to it.

And then based on your college standards or organization,

you might need a policy procedure.

And then of course it's always good to discuss the pitfalls.

So this is, you know, the more successful

and less frustrated nurses are by their new skill,

the more often they'll use it and build more confidence

and the better they'll get.

So there are a few pitfalls to be aware of in training.

So one is don't let them try cannulating a patient

on the first day after the course.

So if they miss, they will feel bad

and shy away from trying it again.

So I have a couple people that this happened to.

So have them stick to the plan that you've put out for them

and just, you know, get them to simply scan their, you know,

colleagues in the middle of the night

or get them used to using the ultrasound machine first.

Don't let them go it alone for the first few times.

So ensure that there's clinical support available

in their first attempts.

'Cause if they get frustrated then somebody can take over.

Encourage 'em to follow the steps in the training exactly

before adding their own flare to the skill.

So in my experience,

if they don't start with all of the steps

and then try to skip a few,

they wind up unsuccessful and frustrated.

The other is just I'd suggest playing Nintendo.

So the most difficult part for the nurses learning this

is the hand-eye coordination, and as I said,

nurses who already play video games are actually really good

at picking up the ultrasound skills.

The other thing is ergonomics and body position

when setting up.

So them so they, if they do this properly,

they will move their head and then they will be unsuccessful

in their IV attempts because it moves the needle

inside the body.

And last is simply not using the skill.

So if they go off and they don't try the skill,

don't try to scan or don't try to start to cannulate,

then sometimes they just don't end up using it.

And there are a couple of people that I have

that ended up in this position.

So sustaining it and driving it forward.

So for myself, I have a few next steps for my program

that I'd like to offer you.

So for me, I really want most of my ED nurses

to learn the skill in the department.

So this will take time.

As you know, I only run the course a few times a year

and I only do you know, a dozen people at a time.

But before you know,

I get a full compliment of ED nurses using the skill.

I also want all ED nurses to identify DIVA patients

and that ultrasound be the first choice

in starting that IV rather than poking them a few times

and then calling that super user to come and put in the IV

under ultrasound.

The other thing I really wanna do is collect data

to help that validate its utility.

Often data does tell a story.

And then bread the skill to other units.

So I also have done a course for a few ICU nurses

who are now using it,

but I would like to spread that to ICU and other floors too.

I think this would actually be very valuable

on a medical floor where you do have a lot of DIVA patients.

So I hope that through this talk you've attained

a better understanding about the benefits

of ultrasound guided PIV

and also can think of some strategies to get this going

and leverage some resources in your own organization.

I hope that some of the strategies and tools

that I've provided you will help with your implementation

going forward.

So we all strive to give amazing care to our patients

and I hope in the future adding this additional skill

will enhance the care that it's already in place

in all of our emergency departments.

So that's what I have to offer you today.

So thank you for listening.

I think the next stage is doing some questions.

- [Carol] Hey, Lisa.

So yeah we do have quite an interest

in having some questions answered by you, which is great.

- Okay.

- [Carol] So there were,

given the demonstration videos that were shown,

there were quite a few questions about what about gloves

and probe covers.

So I can understand in this current environment,

so gloves, probe covers, sterile gel, those kinds of things.

So comments on that?

- Yeah, no that's a great question.

So you could see in our pictures

obviously we're using chicken,

so there's a risk of salmonella,

so we definitely needed gloves.

But yes we do use all of our PPE that we regularly do.

But for the probe covers

we have, there's a couple of ways you can do this.

So one of the strategies we use is just a sterile glove

that we put over the probe with an elastic.

You have to put some of the ultrasound gel just between

the glove and the probe so then you get a good view.

The other one and it,

I don't know if it's been validated for sure,

is using a Tegaderm over the probe in order to clean,

to keep it clean and you know, I'm sure there's some other,

there's also just sterile probe covers

that you can use as well.

- [Carol] Excellent. What about sterile gel?

- Yeah, so we ordered a bunch of sterile gel for starts,

but we also just use, the best method for getting contact

is just sterile saline.

So that's more accessible in the ED and easy to find.

So we often just use saline instead of gel.

The other benefit to using saline is it dries up quickly

so then once you put your IV in

you don't have to clean off the gel around the cannula

in order to put your Tegaderm on and secure it.

- [Carol] Excellent.

There's also a question around how did the ultrasound guided

IVs fare in terms of dwell times in patients?

Any differences?

- You know what, I don't have the data on that.

I do know that I've done a few on patients that had,

you know, like a cellulitis that had to go home

with the IV and then come back.

They did fare well.

In terms of like going up to get admitted,

I actually don't know how it progressed after they left

the ED and that's why I say, you know,

more data is required for our program.

- [Carol] Okay.

Also just a comparison question,

do you know whether there's evidence of the success rate

with ultrasound guided versus using a vein finder?

- That's a great question.

I do not.

I never compared a vein finder to ultrasound,

so hopefully somebody out there...

I haven't come across it in the literature

and to tell you the truth, I haven't looked into it so.

And my student never found anything about it either.

- [Carol] Okay.

So you mentioned the seven minutes approximately, you know,

once someone is trained and competent.

Seven minutes to get the IV in.

Does that include limb assessment?

- Does that include limb assessment did you say?

- [Carol] Yeah, yeah.

- I don't know specifically.

Sorry I'm not giving a lot of good answers here.

- [Carol] That's okay. - No, that's set up.

Yeah, assessment.

Oh yeah, assessment with the probe.

Like looking around for the vein, is that...?

- [Carol] That's what I'm assuming.

- Yeah.

- [Carol] Yeah, doing a little bit of-

- Yes. Yeah, I think from start to finish,

setting up your ultrasound machine

to actually getting the cannulation is seven minutes.

- [Carol] Okay. Got it.

Okay. Another one.

So another one it relates to standards of practice.

Do you have a like sort of a guidance

around applying standards of practice for vascular access

to the skill of ultrasound guided PIV?

Like how do you bring those two together?

- Right, so I did look at the International Nursing Society

for, or sorry,

like all of the standards of practice around IV access.

I did look at CNO standards for,

so CNO being the College of Nurses of Ontario standards.

But in our organization we do have,

based on all the evidence,

we have our own standard of practice.

So it's a policy procedure that I've included

this particular skill into.

- [Carol] Okay. Right.

So you, basically the conclusion is

that all of the standards of practice apply

and you're at, you're simply just adding a tool

with some guidelines within your institute?

- Yes, sorry. Yeah, exactly.

So all of those standards that you would usually use

for a standard IV insertion are all the same.

It's really just the assessment with the ultrasound probe

and utilizing that probe to visualize the cannula

going in.

- [Carol] Got it.

There's a question on tourniquets.

Someone is saying that they understand tourniquets

are not recommended with ultrasound.

Your thoughts on that?

- Hi Carol, are you still there?

- [Carol] I'm still hearing.

You froze on me as well, so let's try that again.

- Oh, okay.

- [Carol] There's a comment about someone understanding

that tourniquets are not recommended with ultrasound.

Do you have thoughts on that?

- Yeah, so there's two trains of thoughts on that is that,

you know, you're just visualizing the IV,

the vein anyway under ultrasound

and some people do not use tourniquets in this procedure.

I find there is more success with the tourniquet

'cause it does increase the size of the vessel

and so therefore you can see it better

or the diameters bigger on the ultrasound screen.

I was taught by our CT technologist to use a tourniquet.

So that's been my practice.

- [Carol] Okay.

Like I said, a lot of questions.

This is really good.

How did you address infusion practice

via ultrasound guided PIV,

such as it not being suitable for vesicants?

Did you create a policy for this?

- I did not, but you know, I think it,

this would be valuable in those particular situations

because you can get access to say basilic vein

or bigger veins that aren't palpable

and you can get bigger IVs sometimes.

it would be more valuable in those instances

to get it under ultrasound rather than trying to get

a tiny vein IV somewhere else.

- [Carol] Right.

There were some questions around needle, or sorry,

catheter length because you know quite often

the DIVA patients are obese patients.

What are your thoughts on catheter length selection?

- Yeah, so we actually did end up getting longer catheters.

I'm trying to pull the length outta my head right now

because of that purpose.

One, you know the, you go steeper into the vein

than we do with a standard technique.

But if you have a long, if you have more,

if it's deeper than like a centimeter on the ultrasound,

then you do need a longer angio as well.

So we did purchase a few longer angios to be able to do this

and our CT suite also has items available

so sometimes we trade back and forth,

they have the 22 long and we have the 20 long.

So based on how deep the vein is,

especially in that obese patient,

you may need a longer angio.

- [Carol] Okay, that's a good question.

Question on the e-learning.

Question is how do I get the e-learnings set up

for my nurses?

- So I would recommend reaching out

to your ultrasound representative.

So for me, Carol and Kristen just provided me

with the SonoSite e-learning

and it is just simply a web link that they have

a code to get in and they e-learning at home

just over regular internet.

- [Carol] All right.

Oh, so I think we've got a lot more questions

that'll take us well past our 12 o'clock.

Laura, what do you recommend?

Do we do a couple more?

- [Laura] What I was just about to say is I will capture

all these questions that we still have open

and we can work on creating some answers

and then reach out to the attendees with those answers.

Just so, just out of respect for everybody's time,

I know it's after the hour,

so I did see a lot of people ask about a recording

of this session and we will be posting that on the page

that you see here on the screen,

the secure.sonosite.com/behind-the-scan-webinar.

That will be posted within the next 24 hours.

But yes, we will capture all of these questions

and work to get those answers to you all.

Lisa, Carol, if there's not anything else,

I think we can conclude for today.

Did you have anything else you wanted to say?

- For me, just thank you for coming out today

and being interested in this.

It's worth, it's valuable for your ED

and it's worth looking into.

So thank you so much for listening today.

- [Laura] Yes, I agree.

Thank you Lisa, for an excellent presentation.

That was a ton of information that I sure learned a lot.

So thank you so much for taking the time to speak with us

today and thank you all for joining us.

We will conclude and again,

we'll reach out to you these questions as best we can.

Thank you, everyone.

- Thank you.

We will explore improved care efficiency and patient satisfaction with ultrasound guidance for difficult PIV insertions, identify implementation challenges of a nurse-led program, and review a collaborative approach for initiating implementation. Includes a brief demonstration.

What You'll Learn

  • High success for difficult-access patients, efficiency of staff time and resources and greater satisfaction
  • Collaborative approach to gaining support and initiating implementation within your institution
  • How to identify challenges to implementation
  • Strategies and tools for implementing the skill within your emergency department
  • Identifying goals for the future of ultrasound-guided PIV within emergency department care
Lisa Groulx
Presenter: Lisa Groulx, BScN, MN, RN, ENCC
Position: Emergency Clinical Educator – Professional Practice Lead, Guelph General Hospital, Guelph, Ontario, Canada

Lisa Groulx started her career in 2006, as an emergency staff nurse at Guelph General Hospital in Guelph, Ontario, Canada. She is now the Emergency Clinical Educator - Professional Practice Lead. She followed her passion for continuous education and learning in the clinical nurse setting, and obtained a master’s degree in nursing (teaching focus) in 2017. After recognizing the value of ultrasound-guided PIVs in difficult-access cases, Lisa led the development of a UGPIV training program for nurses at Guelph General Hospital. Her evidence-based, collaborative approach resulted in high interest and participation among ED nurses. As a result, the nurse-led UGPIV program has begun making a positive impact on nursing practice and patient satisfaction.

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This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.