Background and Purpose
Peripheral intravenous (PIV) catheters are the most
common devices used to deliver medications, fluids,
blood products, and nutrition. Every year, nearly 2
billion PIV catheters are inserted worldwide.1 Several
factors complicate the successful establishment of a
PIV, including an aging population, increasing numbers
of difficult access patients, and usage of irritating
intravenous medications as well as obesity, IV drug use,
and conditions such as diabetes, cancer, and sickle cell
disease.2 Ultrasound-guided peripheral cannulation has
improved PIV access success for patients with known
difficult-to-access veins3,4—which studies estimate is
nearly 60% of today’s patients.5 As a result, ultrasound-guided
PIV (UGPIV) is increasingly being used to
ensure PIV placement success.6,7 As new devices and
practices emerge, it is necessary to consider gaps in
procedural asepsis, evaluate areas of non-compliance
with policies and apply current guidelines to ensure
ongoing safety for patients.8
The purpose of this study was to investigate
ultrasound-guided peripheral intravenous (UGPIV)
practices to assess if differences existed between
supply usage of transducer/probe covers, glove types,
gel and skin disinfectants of clinicians functioning in
primary vascular access, emergency department, or
other roles.

Methods
A voluntary cross-sectional descriptive survey was
conducted via SurveyMonkey in 2019. Data collection
included demographic information, practice-oriented
information, procedural activities, and supplies used for
UGPIV insertions, and economic indicators of current
and perceived procedural activities associated with
UGPIV. Frequency distributions and results of Fisher’s
Exact test and one-way ANOVA were reported using
R v.3.5.2.

Results
A total of 26,649 surveys were distributed with a response rate of 5.5% (n=1475).
Forty-eight percent of respondents (n=709) indicated that they worked in a
vascular access role, 310 (21%) worked in an emergency department, and 455
(31%) categorized their role as “other.” Survey results indicate aseptic technique
reported as very important (90%), sterile technique less important (56%), sterile
gel important (80%) but used less (64%). Personnel in vascular access roles had
the highest percentage of aseptic glove use, sterile glove use, aseptic gel use, and
sterile gel use with meaningful differences in all variables (P <.0001). There are
substantial and meaningful inconsistencies in supplies and procedures used by
vascular access specialists, emergency department personnel, and other personnel.

• The survey confirms that UGPIV procedures are performed frequently with a high number,
49% (n = 478), of respondents reporting 5–20 procedures per day
• 95% of vascular access (VA) clinicians and 91% of emergency department (ED) nurses believe
successful UGPIV insertion improves patient care
• Results demonstrate a wide variety of supply usage practices between departments with
UGPIV insertions
• Aseptic technique was identified as Very Important by 92% of VA nurses but only 82% Always
use it
• One-third of the vascular specialists used alcohol alone, and 46% of the ED personnel reported
not using alcoholic chlorhexidine for skin antisepsis
• 90% of VA nurses and 88% of ED nurses reported transducer/probe disinfection before the
procedure; Approximately 80% of VA and ED clinicians spend 2 minutes or less disinfecting
the transducer
• 73% of VA nurses and 65% of ER nurses use a transducer/probe cover during the procedure
• Sterile gel was used by 69% of vascular access nurses and 56% of ED nurses, and more than 22% of
survey respondents stated they sometimes used each of the gel categories of multi-use, single gel
packet and sterile gel packet
• Inadequate gel removal was cited as a potential cause of securement and dressing adherence
issues by 41% of VA nurses and 51% of ED nurses
• Majority of all respondents believe UGPIV insertion avoids riskier procedures, such as central
venous access or an external jugular catheter
• These data and survey results represent the first known collection of clinical feedback on
supplies used with the UGPIV procedure, and differences associated with clinician usage in various
departments and care settings.

Discussion
Numerous studies, particularly those using Lean Six Sigma
methodologies and its applications in healthcare, have shown
that standardization reduces risk and improves performance
by systematically removing variation of practice while also
pinpointing areas of waste, ultimately leading to greater efficiency
and cost reduction.9 Responses to this survey demonstrated a
wide variety of insertion techniques and variable supply usage.

In the results of this survey, almost one-third of all respondents
reported no use of ultrasound transducer/probe or transparent
dressing covers. The remaining two-thirds always or sometimes
used the ultrasound probe protection. Some probe covers and
gel-separating dressings may mitigate this contamination risk
by removing gel from the insertion and puncture site. Gel-free
insertion practices have been described in the literature and may
increase procedural safety while reducing costs. These results
suggest the need for investigation of guideline application and
evaluation of compliance within policies for all departments and
care settings to promote standardization of safety practices with
UGPIV insertions.

Conclusion
Inconsistency and lack of standardization exist within UGPIV
practices and supply usage. Yet it is well known that risk is
reduced when procedures are standardized, education is provided,
and compliance is monitored. Indeed, 5 organizations recently
joined forces to publish an intersocietal position paper on the need
for standardizing low-level disinfection practices in the UGPIV
space.10 Patient safety concerns are driving changes supporting
increased vigilance of aseptic technique for ultrasound usage.
Results demonstrate a wide variety of practices indicating the
need for standardization, consistency, and understanding to
safely perform UGPIV insertions. These results are suggestive
of interventions that standardize procedures in keeping with
guidelines and recommendations.

References

1. Alexandrou E, Ray-Barruel G, Carr PJ, et al. Use of Short Peripheral Intravenous Catheters: Characteristics, Management, and Outcomes Worldwide. J Hosp Med. 2018;13(5).

2. Dychter SS, Gold DA, Carson D, Haller M. Intravenous therapy: a review of complications and economic considerations of peripheral access. J Infus Nurs. 2012;35(2):84-91.

3. Galen B, Baron S, Young S, Hall A, Berger-Spivack L, Southern W. Reducing peripherally inserted central catheters and midline catheters by training nurses in ultrasound-guided peripheral intravenous catheter placement. BMJ Qual Saf. 2020;29(3):245-249.

4. van Loon FHJ, Buise MP, Claassen JJF, Dierick-van Daele ATM, Bouwman ARA. Comparison of ultrasound guidance with palpation and direct visualisation for peripheral veincannulation in adult patients: a systematic review and meta-analysis. Br J Anaesth. 2018;121(2):358-366.

5. Armenteros-Yeguas V, Garate-Echenique L, Tomas-Lopez MA, et al. Prevalence of difficult venous access and associated risk factors in highly complex hospitalized patients.J Clin Nurs. 2017;26(23-24):4267-4275.

6. Gottlieb M, Sundaram T, Holladay D, Nakitende D. Ultrasound-Guided Peripheral Intravenous Line Placement: A Narrative Review of Evidence-based Best Practices.West J Emerg Med. 2017;18(6):1047-1054.

7. Stuckey C, Curtis MP. Development of a nurse-led ultrasound-guided peripheral intravenous program. J Vasc Nurs. 2019;37(4):246-249.

8. Moureau NL, Gilbert GE. A Survey of Ultrasound-Guided PIV Practices: A Report of Supply Usage and Variability Between Clinical Roles and Departments. JAVA. 2020;25(3):28-33.

9. Steere L, Ficara C, Davis M, Moureau N. Reaching One Peripheral Intravenous Catheter (PIVC) Per Patient Visit With Lean Multimodal Strategy: the PIV5Rights™ Bundle.JAVA;2019;24(3);31-43.

10. Disinfection of ultrasound transducers used for percutaneous procedures. Intersocietal Position Statement. J Ultrasound Med 2021; 9999:1–8.

 

Disclosure: Many thanks to the clinicians who took the time to fill out the survey and to

Parker Laboratories for editorial support.