The Need for Better Training for IV Insertions

A collaboration announced in October 2020 between the Association for Vascular Access (AVA) and B. Braun Medical Inc. seeks to improve clinician training on the placement of PIVCs.

This article was originally published December 16, 2020 on PSQH by John Palmer

Vascular access is the most common invasive procedure performed in healthcare, with more than 380 million peripheral intravenous catheters (PIVC) placed in patients annually in the United States. It’s estimated that up to 70% of PIVCs fail before the completion of treatment and more than 50% of adults describe insertion as moderately painful or worse. Collectively, this can lead to serious implications for patients, including increased costs and length of treatment.

To counter the problem, a collaboration announced in October 2020 between the Association for Vascular Access (AVA) and B. Braun Medical Inc. seeks to improve clinician training on the placement of PIVCs. Together, the organizations will develop and provide a series of online courses free of charge to schools of medicine, nursing, respiratory therapy, and other allied health professionals—the first of which is being currently piloted at several leading nursing schools.

The eLearning modules in testing feature interactive graphics and high-definition videos and focus on key aspects like proper device placement, assessment, and insertion to instill confidence in students of all skill levels.

Editor’s note: The following Q&A resulted from a conversation PSQH had with Judy Thompson, MSNED, RN, director of clinical education for the AVA since early 2018. Her professional experience includes work as a registered nurse in oncology, telemetry, emergency, outpatient surgery, telemedicine nursing, and vascular access.

PSQH: What are the reasons for the failure of so many placed PIVC lines? More than a third of lines places fail, and that seems like an awful lot.

Judy Thompson: It is an awful lot. The main source of failure is the lack of a comprehensive approach to teaching this skill. We expect clinicians to inherently know how to place a needle in a vein. When clinicians are in school, they breeze over this topic and then are expected to go into a facility with only a modest amount of knowledge. Unfortunately, they often don’t have that baseline training. It is not fair to the clinician nor the patient. It is critical that clinicians acquire the knowledge of how to place IVs and then be given opportunities to practice the skill under a trained eye. You can’t be competent in a vacuum without having the knowledge behind the skill or the chance to test the skill.

Another reason lines fail is because of the location we place them; if we place them in areas of flexion, they can move in and out as the patient moves their arm. The easiest place to put a PIV is often not the best place for the patient.

Finally, another reason for failure is lack of visualization equipment such as ultrasound or vein viewers. Staff nurses often are not trained with visualization equipment and only have access to shorter IVs to stick patients. So, the nurse cannot see a vein and then the shorter IV only stays in the vein until the patient moves their arm a few times.

PSQH: What is missing from current PIVC placement training? What are some of the courses or new information that nurses should be taught?

Thompson: PIV insertion, care, and maintenance isn’t taught comprehensively in medical, nursing, or even respiratory therapy school. When it is taught, the entirety of the program is not fully mapped out in a way that is conducive to information retention.

We need to layer the learning; being taught how to put a needle in a patient is not the first thing a medical or nursing student needs to be taught. Instead, information that leads to safe practices must be first, including the anatomy and physiology of the veins, how to engage with the patient, how to avoid skin injuries, and even legal aspects of the practice.

Understanding the care and maintenance of an IV is also critical. It takes about 10 minutes to put in the IV itself, but it will be inside the patient for hours, days, and maybe even weeks. Without proper maintenance, a multitude of issues can and likely will occur. In fact, IV infections are often grossly underreported, simply because not enough facilities check to see if there is one.

Another important aspect that needs to be better understood by clinicians is the type of medicine running through the IV. As clinicians care for patients, we think about the holistic impact of the medicine or the drug-on-drug interactions. But we need to think about the full impact the medicine has on the body, including how it reacts to the vascular system and how the location of the IV impacts dwell and complications.

PSQH: How will changing the standard of care impact the patient experience?

Thompson: Right now, patients expect to be stuck a number of times to get an IV inserted. It is awful that patients accept this. Along with food quality and lack of sleep, PIVs are one of the biggest complaints in healthcare. More comprehensive education will lead to fewer sticks, fewer complications, more positive health outcomes, and an improved patient experience.

PSQH: What are some of the specific details of the new training approach, and how will it increase nurse confidence?

Thompson: The course is being created as if the instructor is speaking to an in-person audience, or an actual classroom. We’ve made a concerted effort to make the content engaging and interactive to ensure students understand these concepts and embed the information.

We have engaged subject matter experts and specialists to teach all areas: an attorney wrote and presents the legal aspects, an infection preventionist brings her expertise, university professors are instrumental in knowledge checks and course design, and much more. We sought out people that are passionate about this topic and who really care about improving the standard of care to teach the course. The goal is to show the students the impact that PIVs have in healthcare. This little device is so terribly underappreciated. Future clinicians must have a greater understanding and respect for PIVs.

The hard part isn’t understanding the needle or the catheter; it’s understanding how the infusate and the patient’s medical history and current condition impact their decision-making before inserting the IV.

PSQH: What are some of the long-term health benefits of proper IV placement?

Thompson: For patients that are chronically ill, we need to worry about their vasculature significantly earlier than we currently do. In the case of a sick infant who is frequently getting IVs, the constant sticks over time can damage the veins so extensively that by the time the infant is an adult, he won’t have any viable veins to stick. Chronic conditions such as short gut, sickle cell, cystic fibrosis, and many others have lifelong consequences when venous access is not planned for or taken for granted. These patients run out of veins, sometimes in early adulthood. Venous access is truly their lifeline.

There are many benefits to proper IV placement, but I think critical thinking, reduction in infection, and increased patient satisfaction are the key issues we should aim to solve.

PSQH: Can you provide any examples of hospitals or training programs that have utilized the new training approaches, and talk about the success that they have had?

Thompson: Our beta test is kicking off right after the new year, and we’re excited to share our results once the program starts to be utilized. We have heard from our partners that the type of curriculum we are offering will absolutely change how students are taught and ultimately the patient experience. As with any major shift in education or training, this is evolution and not revolution, so we don’t anticipate a single solitary swing in the industry. But we do know that this will help influence true change in the years ahead.