ACCESS TO ACCESS

Improving access to ultrasound equipment and ultrasound-guided cannulation training for use in patients with difficult intravenous access

DR OLIVER GEORGE, DR GEORGINA SANDERSON, IZZY ELKINGTON, DR THEA MORGAN & DR RICHARD CRAIG

Background

Peripheral intravenous cannulation is essential for the treatment of many patients in hospital. Establishing intravenous access can be challenging 1. Repeated cannulation attempts and subsequent delays in obtaining intravenous access have significant implications for patient safety and experience 2,3. Patients with difficult intravenous access are frequently escalated to the anaesthetics team within the trust, forming an appreciable contribution to on call duties. In patients with difficult intravenous access, ultrasound-guided cannulation is associated with increased overall success rates and fewer complications compared to standard techniques 3-5

Scale Of The Problem

• Difficult intravenous access referrals to the anaesthetics team were surveyed using a two-part form, the first section completed by the referrer and the second by the individual receiving the referral. Initial data collection demonstrated 4.8 cannulation attempts on average prior to referral.

• Difficulty obtaining intravenous access was associated with delays to medication administration in 79% of cases (FIGURE 1), this included blood transfusions, intravenous antibiotics and fluid resuscitation.

• Further data collection demonstrated that anaesthetists used ultrasound-guidance techniques in 55% of patient referrals.

• Only 20% of referrers had attempted ultrasoundguided cannulation prior to referral (FIGURE 2).

• Of those that had not attempted ultrasoundguidance techniques, 31% had not received training, 31% reported that ultrasound equipment was not available and a further 25% reported both lack of training and availability of equipment (FIGURE 3).

Aim

Reduce delays to intravenous medication administration in patients with difficult intravenous access, and thereby improve patient safety. Our initial results highlight two key areas for improvement: (1) ultrasound equipment availability on the wards and (2) access to ultrasound-guided cannulation training within the trust.

Method

A driver diagram, as outlined in FIGURE 4, provides a framework to explore factors that influence intravenous medication administration in patients with difficult intravenous access. Access to ultrasound-guidance cannulation training and ultrasound equipment form two of the primary drivers, reflecting the two key areas for improvement identified in our initial data collection. A Plan-Do-Study-Act cycle for establishing ultrasoundguidance cannulation training within the trust is illustrated in FIGURE 5.

Identification of patients with difficult intravenous access

Access to ultrasound equipment

Assessment

Documentation & handover

Equipment availability

Postgraduate training

Reduce delays to intravenous medication administration in patients with difficult intravenous access

ACT Following analysis, we plan to: (1) review the interventions and make adjustments as appropriate, and (2) share the results at relevant clinical governance meetings and with key stakeholders (described previously, see PLAN).

STUDY Following completion of further training sessions, we plan to re-analyse difficult intravenous access referrals to the anaesthetic team using the same two-part form as previously and compare these results to baseline. Our main outcome measure is the number of patients with delays to intravenous medication administration due to difficulty establishing intravenous access.

REFLECTIONS & FUTURE DIRECTIONS

Routine use of intravenous access assessment tool on admission

Record alert on patient record

Increase awareness of equipment availability, locations and sign out processes Purchase new equipment / regular equipment checks and services

Undergraduate training

Ultrasound-guidance training for postgraduates

Ultrasound-guidance training

Escalation when unable to obtain intravenous access

Ultrasound-guidance training for undergraduates Multidisciplinary team training

Familiarity with equipment available

Escalation to senior team members

Referral to anaesthetics team

Ultrasound-guidance training for Multidisciplinary team

Opportunities to practice Referrals process

PLAN Using the driver diagram outlined in FIGURE 4, we considered factors that influence ultrasound-guidance training (postgraduate, undergraduate and multidisciplinary team training, and familiarity with equipment available) and identified relevant change ideas. Discussions with key stakeholders included: anaesthetics consultants and trainees, acute medicine consultants, chief nurse, midwives, vascular access practitioners, postgraduate and undergraduate medical education departments.

DO Established weekly ultrasound-guidance training drop-in sessions in Swindon academy:

• Available to postgraduate trainees, undergraduate medical students, nurses, midwives and Allied Health Professionals across all specialties within the trust.

• Portable wireless SONON® 300L ultrasound and standard cannulation model used.

• No previous ultrasound experience required; opportunity to practice and develop skills.

• Purchasing additional equipment for ultrasound training (cannulation and otherwise); same equipment as available on the wards to ensure transferability of experience.

• Low response rates to the surveys limited our data collection. Following discussions with the anaesthetics team and colleagues from each division within the trust, we have adapted our forms to improve future engagement. We are also working with the pharmacy team to collect further data from the electronic prescribing systems regarding intravenous medication delays due to lack of intravenous access to guide further PDSA cycles.

• Future PDSA cycles aim to focus on improving access to ultrasound equipment for clinical use. As outlined in the driver diagram (FIGURE 4), change ideas include:

(1)increasing staff awareness of the current equipment available for ultrasound-guided cannulation within the trust, (2) ensuring consistent availability of equipment and ‘sign out’ processes during the day and out of hours, and (3) purchasing additional equipment as required.

• Key learning points from this Quality Improvement Project include liaising with key stakeholders from each division within the trust and forming a business case for the purchase of additional equipment for training purposes.

BMJ Open 8, (2018). // 2. Fields, J. M., Piela, N. E. & Ku, B. S. Association between multiple IV attempts and perceived pain levels in the emergency department. J. Vasc. Access 15, 514–518 (2014). // 3. Liu, Y. T., Alsaawi, A. & Bjornsson, H. M. Ultrasound-guided peripheral venous access: a systematic review of randomized-controlled trials. Eur. J. Emerg. Med. 21, 18–23 (2014). // 4. Davis, E. M. et al. Difficult intravenous access in the emergency department: Performance and impact of ultrasound-guided IV insertion performed by nurses.