Difficult Access Requires Thought, Training and Technology (DART3)

An implementation study to enhance peripheral intravenous catheter insertion success and reduce insertion-related complications. Co-developing an ultrasound pathway for patients with difficult intravenous access. 

The overarching aims of DART3 are to:

1. Evaluate health service funding and budgeting arrangements for PIVC insertion
2. Co-develop DIVA identification and escalation pathways and implementation strategies (including ongoing education of ultrasound inserters) with the partner hospitals
3. Test the effectiveness of the co-developed pathways and strategies on clinical, cost and implementation outcomes at a health services level.

Background

Peripheral intravenous catheters (PIVCs) are small plastic tubes inserted via needle puncture into the veins (commonly in hand/arm) to administer fluid and medication across all medical specialties. Peripheral intravenous catheters (PIVCs) are the most common invasive medical device in hospitals, needed by almost all consumers of Australia’s 10.6 million hospital admissions each year and predominantly inserted by junior medical and nursing staff.

The problem

PIVC placement can be difficult, painful and time-consuming, 44%-58% first attempt insertions fail, with some patients having 10 or more attempts (needle punctures), the procedure abandoned and/or a higher risk central venous catheter inserted instead. Patients at highest risk are those with Difficult IntraVenous Access (DIVA), due to physiology, pathology or damage from previous medication or PIVCs.

Populations at risk include:

• Extremes of age (premature and elderly)
• Overweight patients
• Chronically ill
• Rural/remote patients without access to advanced practitioners. 

DIVA is defined retrospectively as two or more failed attempts at successful PIVC insertion, however 10-45% of patients require more than three insertion attempts to achieve successful PIVC cannulation. Population trends mean one in three ED presentations, and one in two admitted patients who need a PIVC now meet one or more of these criteria, making this a nationally-important problem. Difficult insertions have substantial costs for patients and hospitals.

The solution

Ample evidence exists to support ultrasound PIVC insertion as the first approach for DIVA patients and this is now recommended in international guidelines. However, implementation in Australia is negligible and our current workforce and systems require purposeful adaptation to implement this capacity. In contrast, central venous catheters (CVCs) are predominantly inserted via ultrasound.

The advantage of ultrasound is exact visualisation of vein depth, diameter and quality including valves, bifurcations, and blood flow. This assists with vein choice and the insertion procedure. Traditionally, PIVC placement uses landmarks - the ‘feel’ of veins through the skin, or ‘seeing’ veins with the naked eye. Using this model, patients only receive ultrasound insertion after multiple failed landmark attempts. This outdated model of care results in pain, waste, and treatment delays or cancellation unless an ultrasound skilled inserter can attend.