Background
Peripheral intravenous (PIV) access is one of the most routine procedures performed on acutely ill patients. However, obtaining PIV access can be unpredictable and problematic based on patient clinical presentation and environment (Bridey et al., 2018).
Historically, the use of audible ultrasound doppler was used to differentiate blood flow between the carotid artery and internal jugular vein for intravenous access. This technique reduced error in the amount of unintended artery punctures (Ullman & Stoelting, 1978). In the decades to follow, ultrasonography was used more frequently for visualization of nerves, veins, and arteries. In using this technique, ultrasound aided clinicians in increasing successful PIV placements while reducing the amount of central line venous access and surgical cut down insertions in difficult access patients (Keyes, Frazee, Snoey, Simon, & Christy, 1999).
Goal of This Investigation
Recently, the use of ultrasound is becoming more portable and affordable for healthcare providers (Bridey et al., 2018). However, there is scant literature on ultrasound use for PIV access outside of developed countries. Ultrasound use in obtaining PIV access in patients warrants further analysis to examine if obtaining PIV access using ultrasound technique results in better outcomes compared to using a traditional technique. The purpose of this study is to examine if the use of ultrasound technique compared to standard visualization/palpation method yields increased successful PIV access rates in a developing nation emergency department setting.
Methods
Study Design
This will be a systematically allocated, non-blinded, prospective single-site study. The first phase of this study will include data collection of the standard direct visualization group for PIV access. Data collection will include patient demographics, characteristics and outcome metrics. The data collection for the first phase will occur over a two-week period.
The second phase of the study will include education and training for nurses on ultrasound guided PIV placement. This training will occur over a one-week period and consist of a didactic module and hands-on training with ultrasound guided PIV placement. The training material will be tailored to the use of portable ultrasound in an emergency department.
The third phase of the study will include data collection for the ultrasound guided group for PIV access. The data collection for the ultrasound guided group will occur over a two-week period. Phase two and phase three will be driven by the study protocol to maintain scientific equipoise.
In both groups, after three failed PIV attempts of the assigned method, a rescue approach will be attempted by the attending provider per hospital protocol.
Setting
Timing of the study will be five weeks (December 2019-January 2020) at Kilimanjaro Christian Medical Center (KCMC) in Kilimanjaro, Tanzania.
Selection of Participants
Patient inclusion criteria will be any adult patient (>18 years of age) requiring intravenous access during the selected time frame for each phase of the study. Patient exclusion criteria will be the immediate requirement for central venous access. Patients will be enrolled in the study via convenience sampling strategy.
Consent and Ethics
Written approval and/or informed consent of study design will be obtained by the research protocols of KCMC.
Data Collection
The portable ultrasound linear transducer probe will be used in association with compatible smart phone device when conducting this study. In the ultrasound group, the nurse will first search for veins using the ultrasound probe. Once a vessel is found it will also be confirmed by collapsibility and depth in addition to other associated landmarks. The nurse will hold the probe in a transverse plane proximal to the PIV insertion site and begin the PIV attempt. For the standard direct visualization group, the nurse will identify the vessel via visual inspection and palpation before the PIV placement is attempted.
Data Analysis
The allocated sample size of each cohort will be generated on a power analysis of at least 0.8 at a significance level of 0.05. The rescue group will be analyzed on a separate post hoc analysis.
Outcome Measures
Outcome metrics will be measured and compared between both groups. Outcome metrics include successful PIV access rates, time until successful PIV cannulation (‘tourniquet to tegaderm’), time until treatment (‘tourniquet to treatment’), pain and complications associated with the procedure.
PIV success rates will be measured by calculating the number of PIV successful placements divided by number of attempted PIV placements (Bahl et al., 2016). Time until successful PIV cannulation will be measured by calculating a ‘tourniquet to tegaderm’ metric. Time zero will begin when the tourniquet is applied to the patient; and time will end when the tegaderm is placed over the PIV site (Bahl, Pandurangadu, Tucker, & Bagan, 2016).
Time until treatment will be measured by calculating a ‘time to treatment’ metric. Time zero will begin when the tourniquet is placed, and time will end when the associated intravenous intervention is administered. Pain will be measured on a numeric Likert scale from zero (no pain) to ten (severe pain) associated with the procedure (McCarthy et al., 2016).
Successful PIV placement will be confirmed with aspiration and flush of five milliliters (mL) of saline (Ismailoglu, Zaybak, Akarca, & Kiyan, 2015). Complication metrics measured will include infiltration, hematoma, and arterial cannulation associated with the procedure (Van Loon, Buise, Claassen, Dierick-van Daele, & Bouwman, 2018).
Results
Statistical Package of Social Sciences (SPSS) version 16.0 for Windows will be used to analyze the collected data. Patient demographics, characteristics, as well as outcome metrics of each group will be compared. Wilcoxon rank sum test will be used for continuous data. Chi-square (x2) or Fisher exact test will be used for categorical data. P values of less than 0.05 will be considered statistically significant. A post hoc analysis will be performed based on the rescue group.
Discussion
The use of ultrasound has been shown to increase successful rates of PIV access in several patient populations, thus leading to a more efficient administration of emergency interventions (Van Loon, Buise, Claassen, Dierick-van Daele, & Bouwman, 2018). The use of this intervention leads to decrease central venous access attempts, less complications rates, and improved patient satisfaction and outcomes. (Keyes, Frazee, Snoey, Simon, & Christy, 1999) This study will expand the breadth of knowledge of ultrasound through the use of portable ultrasound to an emergency department environment in Tanzania.
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