Identification of Local Problem
At Kaiser Permanente Fresno Medical Center, Inpatient nurses (IP) frequently encounter challenges in obtaining peripheral intravenous (IV) access for patients with Difficult Intravenous Access (DIVA), particularly those with extended hospital stays. Several additional gaps have been identified:
- Staffing Impact: Extra staff resources, such as Lead Nurses (also known as Rapid Response Nurses), are often required to secure a single IV access, diverting them from other critical responsibilities.
- Supply Utilization: Multiple unsuccessful attempts result in increased use of supplies, including angiocatheters and other IV-related equipment.
- Patient Experience: Patients experience discomfort and dissatisfaction due to repeated failed attempts at IV insertion.
- Treatment Delays: Medication administration is delayed when IV access is not readily available.
Context of the QI Activity
A survey was conducted among inpatient (IP) staff across the Medical-Surgical, Telemetry, and Critical Care Units to assess the need for training. The survey ran for 30 days, and the results were used to develop a proposal for the management team to approve and support the training initiative.
The goal was to determine whether there are enough patients who fall under the DIVA population and whether training IP nurses would be beneficial. A QR code was created to track how often Lead Nurses, Assistant Nurse Managers (ANMs), and PICC Line Nurses were called for IV insertions due to DIVA cases.
Over the 30-day period, there were 132 responses. A total of 137 DIVA cases were identified:
- 96 calls were made to Lead Nurses
- 26 calls to PICC Line Nurses
- 10 calls to other IP resources
On average, five DIVA cases per day required multiple resources to obtain a single IV access. A Peripheral Vein Assessment Tool was used to identify DIVA patients (UK Vessel and Prevention, 2020).
What were the interventions?
- The proposed training was approved by the Nursing Professional Development Director in collaboration with unit managers. We began by conducting huddles with staff from three different inpatient units to identify those interested in becoming superusers. Each department was asked to nominate at least six staff members, prioritizing individuals who had prior training at other hospitals, demonstrated commitment to attending training sessions, were willing to train their peers, and showed proficiency with traditional peripheral IVs (PIVs).
- A two-hour CEU module was pre-assigned to staff members and approved by their managers. This was followed by a four-hour didactic class covering Kaiser Permanente practices, competency sign-off requirements, and an introduction to the ultrasound machine, including techniques for identifying appropriate veins for ultrasound-guided PIV insertion. A vein block that simulates both veins and arteries was used for hands-on practice.
- The final component of the training required superusers to complete five successful ultrasound-guided PIV insertions at the elbow under the supervision of a preceptor. We also encouraged these super users to continue seeking opportunities to practice and refine the skills they acquired.
Costs and Funding Sources
- Staff compensation for training hours was covered as a commitment by unit managers
- The existing ultrasound machine in the critical care unit, designated for nursing use, was sufficient for training purposes, eliminating the need to purchase a new device.
- Supplies such as intravenous catheter kits with appropriately sized needles for ultrasound-guided cannulation were approved and procured by each department.
- A nerve block model for arterial-venous simulation was provided by the education team to support hands-on practice.
Overall Results and Analysis
The training program successfully developed 13 superusers from the ICU, 5 from telemetry units, and 6 from medical-surgical units, ensuring coverage across various shifts. See poster photo for results from the survey.
- Inpatient units are now equipped to manage patients with DIVA, leading to reduced delays in care.
- Post-training feedback revealed that 90% of superusers received positive responses regarding their performance in ultrasound-guided insertions.
- The skills acquired during training have proven valuable, especially in alignment with the updated vascular access policy, which permits the administration of first-line vasopressors through a peripheral IV—provided specific criteria are met.
- This advancement has significantly decreased the reliance on central line placement for vasopressor administration, improving efficiency and patient outcomes.
Limitations
The feedback and results were gathered shortly after the training, while the long-term retention of skills and sustained impact on the patient’s outcomes were not assessed at the time of this presentation. This study did not have a control group to include a comparison of the number of DIVA patients with successful insertion after the training; instead, positive responses were gathered using self-reported feedback from superusers' experiences. Extending training to the IP units also would require each unit to acquire more ultrasound machines for them to avoid delays in having multiple users with one ultrasound. This is part of a future goal for this project.
Lessons Learned
Implementing ultrasound-guided IV training for inpatient nurses at Kaiser Permanente Fresno significantly improved access for DIVA patients, reducing delays in care, minimizing supply waste, and decreasing reliance on specialized staff. While early feedback was overwhelmingly positive, long-term skill retention and the impact on patient outcomes remain areas for future evaluation.
