Category Archives: Vein detecting devices

What do you think…

Q:  We have a 24/7  vascular access team, yet we find that an ultrasound machine  in a medical floor is used for PIV insertion by untrained nurses and residents. The machine is there for other purposes but is being used for hard IV sticks.

A:  There is increasing evidence to show the use of ultrasound or vein finding technology increase success rates particularly in patients with difficult veins to access. The INS standards recommend the nurse to consider using visualization technologies that aid in vein identification and selection (S33). The use of  ultrasound allow the identification of peripheral vessels and guide the insertion procedure.  There are reports that ultrasound guided peripheral IV cannulation is successful more than 90% of cases. In addition, it improves patient satisfaction and safety with fewer sticks.

I think anyone who reads this post will agree that healthcare providers using these technology must be properly trained and/or competency checked off. Just because there is an ultrasound machine available on a medical unit doesn’t entitle anyone to use it without proper training. The operator should be very familiar with the ultrasound machine, the type of transducers used, how to improve ultrasound gain and how to control its outcome. The operator should be especially knowledgeable of the sonographic artefacts that can mislead him/her.

In addition, your facility/institution/organization should have policies and procedures related to the training. competencies and use of ultrasound technology. Check out what your policy is and hope you have one. In some, the use of utlrasound for PIV insertion is limited to vascular access teams and the ED. In your case, with a 24/7 vascular access team, the medical floor should take advantage of your service and expertise.

Thanks for your question. I wish you the best.

References:

  1. Infusion Nurses Society 2011 Standards of Practice.
  2.  Abu-Zidan Fikri M Point-of-care ultrasound in critically ill patients: Where do we stand?J Emerg Trauma Shock. 2012 Jan-Mar; 5(1): 70–71.
  3. Elia F, Ferrari G, et al Standard-length catheters vs long catheters inultrasound-guided peripheral vein cannulation. American Journal of Emergency Medicine (2012) 30, 712–716

 

 

 

 

 

 

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Short Peripheral Catheter Checklist

This great resource in available free to download to INS members from the INS website – SPC  Checklist. SPC means short peripheral catheter, which man y of us call “peripheral IV catheter” or “PIV”. This checklist was part of the IV Safety Task Force position paper project on Recommendations for Improving Safety Practices for Short Peripheral Catheters.

SPC Checklist

Modeled after the CDC checklist for Prevention of Central Line Associated Blood Stream Infections, the SPC Checklist covers assessment, monitoring, removal, and safety strategies.  The checklist is designed to help your efforts in implementing evidence based best practices in SPC insertion, care and maintenance as well as promote IV safety practices.

Download you free copy now, go to www.ins1.org

Disclosures:

1. SPC Checklist: Copyright Infusion Nurses Society used with permission from the Infusion Nurses Society

2. I served as the chairperson of the IV Safety Task Force Committee who developed the position paper and the above checklist. This was a volunteer committee and was not compensated for this project.

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Think Safety, Insert Safely

In June of 2013, I was honored to chair a national task force for the Infusion Nurses Society’s (INS) project on Short Peripheral Catheter Safety (SPC).  Along with five other colleagues, we embarked on a task  to identify the safety and practice issues and  look at ways to promote safety in the insertion and management of short peripheral catheters for all patient populations as well as for the clinician.

Yes, we are concerned with short peripheral catheters or as many clinicians call it “PIV” insertion and maintenance. That simple and common procedure routinely performed by nurses and other clinicians often accompanied by the prevailing thought that simple and routine = complication free.  Unfortunately, many nurses/clinicians underestimate the risks involved in PIV insertion, care, and maintenance until they are faced with infusion-therapy related complications and litigation.

Back in June 2013, I posted an blog entry looking for RNs inserting peripheral IV’s to take a short survey.  I was so thrilled that many  of my blog readers and nursing colleagues have taken the survey. Thank you for taking the time to complete the survey. The survey results were used in the development of  the position paper. This position paper entitled “Recommendations for Improving Safety Practices with Short Peripheral Catheters” is now available on the INS website. (Click here)

On Feb. 4, 2014 on behalf of  INS, I will be presenting a live webinar “Recommendations for Improving Safety Practices With Short Peripheral Catheters” that will discuss the findings of the task force and the statement of INS’ position.  Due to unprecedented demand, the webinar is sold out. But thanks to the support by an educational grant from BD Medical, INS members will be able to view the archived presentation free of charge in the INS Knowledge Center later next week.

When it comes to short peripheral catheters, we encourage nurses/clinicians to…Think safety, Insert safely!

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Twice is enough…

The practice criteria in the INS standard 35 on vascular access site preparation and device placement states:

“No more than 2 attempts at vascular access placement should be made by any 1 nurse, as multiple unsuccessful attempts limit future vascular access, and cause patients unnecessary pain. Patients with difficult vascular access require a careful assessment of VAD needs and collaboration with the healthcare team to discuss appropriate options.”

I cringe when I hear patients say it took the nurse ..(X).. number of tries to get an peripheral IV in place where X=more than 2 insertion attempts. One patient told me it took 16 tries and 4 nurses  and still wasn’t able to get a PIV inserted. Some patients take  pride in the fact that they are “difficult sticks” and expect to be stuck numerous times for a PIV insertion. Others equate the unsuccessful attempts by nurses as: “incompetence or inexperience”.   

 When it comes to unsuccessful attempts to insert an IV catheter, two unsuccessful attempts by a nurse is enough. Yes, there will be times when even the most proficient nurse will  be unsuccessful on the first try. This standard applies to all settings even for patients receiving infusions at home and there’s no other nurses available to try.  

two_cents_0 

Here are some IV tips I find helpful when peripheral veins are hard to find.

Palpation: Apply the tourniquet. Use your index finger to palpate the veins. Press directly on the vein with your index finger, assessing for vein softness and volume. Then release the pressure slowly without lifting your finger and feel the vein bounce back to your index finger. Repeat as often to ensure you found a suitable vein. Don’t stick without palpating the vein!

Tapping: Apply the tourniquet. Lightly tapping the skin or area where you see veins will help distend the vessel. Avoid “beating” the skin as it might cause venospasms.

Dry heat: Use dry heat to the proposed site. Application of dry heat increases blood flow allowing for good venous dilatation, thus improved vein visualization.  A study showed dry heat is 2.7 times more likely than moist heat to result in successful IV insertion on the first attempt, have significantly lower insertion times, and more comfortable.

Stroking: Stroking the vein toward the hand allow for venous refill.

Open/Close fist: Open and close fist during vein assessment but keep arm relaxed during venipuncture.Keep arm/hand in low (dangling) position.

Skin Anchoring: An important step to the success of venipuncture. Prevent the movement of veins during venipuncture.(especially for “rolling veins”). Pull skin downward below the point of insertion with the thumb of the non-dominant hand or pull skin above the point of insertion with forefingers or pull skin from underneath the extremity.

Insertion: Select the smallest gauge and shortest length catheter. Position catheter tip bevel up. Approach angle to skin at 10 –15 degree. Deeper veins need greater angle. Superficial require lesser angle. If parallel to the skin surface, will drag the skin as you puncture it. Lower angle once blood return is observed and advance the catheter.

Vein Viewer and Ultrasound: There are devices that can help you find veins. The equipment ranges from transillumination to ultrasound. These are expensive equipment and would require training prior to use. There is increasing evidence that the use of ultrasound for venous access is safe and successful.

Take a deep breath: Both you and the patient! Let the patient know when you are ready to stick and tell them to take a deep breath and blow it out slowly. This will distract them from the stick and help the tension in their arm.

Patience: Take the time to do a vein assessment and vein palpation prior to each attempt, don’t stick only because you can see a blue line. Some veins are located deep in the superficial fascia and the extra “fatty deposits” doesn’t help. Veins won’t change position just because you are in a hurry.

Oh, and do document your unsuccessful attempts at PIV insertion – many nurses don’t.

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Poll Results: Gloves vs no gloves during vein palpation

The poll results are in:

1.  Do you think an RN should wear gloves when palpating for veins prior to venipuncture?
Yes:  47 Votes    42%
No:  65 Votes     58%

112 readers took the poll, and 58% said they think an RN should not wear gloves when palpating veins prior to venipuncture. 47% said they think an RN should wear gloves prior to venipuncture.

Vein  palpation is one of the best methods for assessing veins and it is best done by feeling the vein using your sense of touch via your fingers. Using the tip of your index finger, palpate the vein by gently pressing down on the vein and the feel the vein bounce back to your finger tip. Always feel the vein you are about to puncture – don’t just rely on visualization of the vein. Palpation allows you to assess the characteristics of the vein, the depth, firmness, volume, and size. The use of gloves during palpation may not allow you to feel the veins sufficient enough to obtain a good vein assessment especially in the older adult patient. Here are some comments posted on this poll question:

  • gotta have some alcohol rub on hand for hygiene prior to donning glove, otherwise, the trip to the sink for a wash will make the whole vein hunt, well, not so useful.
  • Circumstances will vary. Follow Standard/Contact Precautions as indicated. Gloves precannulation, if not otherwise required, is optional. Depending on years of experience one may want to palpate first w/o and then with gloves so they are comfortable w/chosen site once gloves have been donned for the cannulation. I’m a 26 year RN. Still believe in that skin to skin contact. It’s about common sense and good hand washing. When I started we didn’t have gloves and threw needles in the garbage!
  •  I check for several veins, then release tourniquet get everything ready… and then re tighten, check again that it is the best… don gloves and site cleanse and cannulate
  • I voted no, but then it occurred to me that if gloves aren’t worn prior to cannulation, they may not be put on at all….
  • Before site care: no gloves. After site care: use gloves.
  • I would have liked to see the question stated different. How many people palpate the vein after they have completed site care? If there are no open areas it is fine to palpate with a bare hand prior to site care but nothing annoys me more than those who will palpate the vein after preparing the site:(
  • Of course! But i nvr do (shhh lol) so much easier to find a vein w out esp on the elderly

2. Do you wear gloves during vein palpation?

  • Only when there is a skin break:   49 Votes   49%
  • Always:                                                     32 Votes   32%
  • Never:                                                        18 Votes   18%
  • Only when I remember:                        1 Votes     1%

100 readers responded to this question. 49% said they wear gloves only when there is a skin break. 32% said they always wear gloves during vein palpation. 18% said they never wear gloves during vein palpation, 1% said they wear gloves during vein palpation only when they remember. One comment was posted

When assessing for vein site, it is recommended to avoid areas of flexion or areas where the skin is not intact. If an area with a skin break is selected for venipuncture, it does make sense to wear gloves, although I would question if it is indeed a good idea to put an IV in that area. Sometimes, the skin break is caused by a previous unsuccessful venipuncture. If this is the case, it is recommended to go to the opposite arm or use the area above and a distance away the previous site attempt . One comment was posted on this poll question:

  • There are times when I can only palpate a vein and not visualize it. In cases like this, if I miss the vein on the first entry, I have to palpate the site again to find where the vein is, but before I apply the transparent dressing, I will clean the area again (allowing the skin to dry). I will always avoid palpating over the site of needle entry.

Thank you to everyone who took the time to participate in this poll survey, your response is greatly appreciated. Always remember, it’s not enough that you “see” a vein, “touch” it to make sure it’s a good enough vein that you can puncture!

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Vein Palpation: gloves vs no gloves – Take a poll

This is one of the frequent question I get when I am teaching a peripheral IV class. Of course, I have an answer (and opinion – no surprise there..:-) ) but before I share mine, please take this very short poll and let me know what you do or what you think.

 

The poll will close at the end of May and  the discussion/results  will be posted shortly after.  Thank you so much and please RT to share!

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INS 2012: Exhibit Hall Experience

At each INS Annual Meeting, I am always looking forward to the exhibit hall. The exhibit hall was huge and to see every booths and exhibits, one needs a strategy to get through without missing any booth or presentation. My strategy is simple and that is…. to go down the numbered aisles and look around for those vendors on my list first, then visit those not on my list next. I am very grateful to all the vendors who were there whether they had something new to show or not because their products contribute greatly to patient care and safety. Their willingness to educate nurses is always appreciated.

Just like last year after the convention, I will highlight a few products. Again, as I always do, here’s my disclaimer -  there were many different products represented there and  as the owner of this blog, I reserve the right to point out the ones that caught my attention. For disclosure purposes, I was not paid to write this post  and have no relationship whatsoever with these companies, nor am I endorsing the products. This is my blog, my opinions and not of the Infusion Nurses Society and is just FYI.

  • Decreasing blood exposure: There’s a big focus on mucocutaneous blood exposure and PIV  as evidenced by several exhibitor’s theater presentations. This is real, yet under reported by nurses. Many manufacturer’s have redesigned their current products to prevent this type of exposure. One of those products is the Introcan Safety 3 , a passive safety engineered device and a closed peripheral IV catheter system to prevent blood exposure.  Check it out…Introcan 3
  • EZ-IV Warming unit: this is intended to warm factory sealed medical pads such as alcohol, povidone-iodine prior to use as prep for venipuncture. The theory here is the use of pre-warmed pads encourage vasodilation, facilitating vein access. Pads on this unit are heated to a maximum temperature of 130 F and a minimum of 121F.  The concept makes sense as heat does promote vein dilation upon application. I tried the heated swab on my arm, and it does give a warm soothing sensation upon application – moist heat at first then as the alcohol evaporates, the warmth goes away. I have good arm veins so I was skeptical whether it really dilated my veins. They didnt have any published studies at their booth and was told that the unit was used at a local hospital in Indianapolis – which is where I happen to live and they liked it. So I checked it out and here’s the pilot study…EZ-IV Pilot Study  Check this product. 
  • Vein Detecting Devices: At the exhibit hall, there were several companies with vein detecting devices.   I blogged about this a few weeks ago…Wouldn’t it be nice...  I have received several emails  from that post asking for my recommendation. As I said before, you need get to know these products first before you purchase it. Here are two products to look at:

One other important point I need to mention before purchasing a vein detecting device is to understand the type the “training” or inservice”  provided by the vendor. Many vendors will say they will provide training, only to find out that it just a hour or two inservice per device. Will that is not enough if you have several nurses who will be using the device?

Photo from INS Website / RichSchmittPhotography

I have  always enjoyed the exhibit hall at any conference. It is good to know the different products and choices available so one can make an informed decision based on the products themselves.

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