Pediatric Nursing Article - Biomedical Device to Improve PVA Success by Hess

7/27/2019 Pediatric Nursing Article - Biomedical Device to Improve PVA Success by Hess

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1 %( Practice Applications of Researc

A Biomedical Device to Improve PediatricVascular Access success

Holly A . HessPurpose: To evaluate the effectiveness of a vein-viewing device on the success of venipunctures performed by staff nurseson a pediatric surgical unit.Method: This prospective, non-randomized study examined pediatric inpatients from the age of newborn to 17 years requir-ing vascular access at a tertiary care center in northeast Florida. The number of attempts, age of the patient, and timerequired to establish successful vascularaccess using a vein-viewingdevice were self-reportedby nursing staff (experimen-tal group, n = 91, mean age 9 years, range 3 days to 17 years) as well as staff, patient, and parental comments about thedevice.These data were compared to baseline data (control group, n = 150, mean age 5.7 years, range 1 1 days to 17years)previously collected on the same unit without using the device. The outcome variables were first-attempt success rate, thenumber of attempts per patient, and the time to procedure completion.Findings: When comparing the two groups, the first-attempt success rate increased from 49.3% to 80.2% the mean num-ber of attempts per patient decreased from 1.97 to 1.29, and the percentage of procedures completed in 15 mhutes or lessincreased from 52.8% to 86.7%. Results were statistically significant for all outmme variables behveen the two groups andalso when re-analyzed in subgroups controlling for age.Conclusions: Use of a vein-viewing device significantly improved first-attempt venipuncture success rate, decreased thenumber of attempts per patient, and decrease.cl procedure time for th e study population. The device was welF received bypatients, families, and staff.

hether for laboratory testing or peripheralintravenous (PW) access, venipuncture is anecessary and nearly universal interventionin the pediatric patient (Rulechek,McC:l(fikcy, Titler, Sr Denehey, 1994; Singer, Ilichman,Kowalska, k Thode, 1999). Though a cornerstone of med-ical treatment, venipuncture remains one of the most com-mon and severe sources of pain and anxietyexperiencedbyhospitalized children (Crowley, 2003; Curnmings, Reid,Finley, McGrath, & Ritchfe, 1996 Geodcnoughet a!. 1999;Gupta et al., 2006; Wong & Baker, 1988).Although the technical goal of pediatric vascular accessshould be success on the first attempt, this is often not thecase. In fact, intravenous success rates of staff nurses inpediatric patients are reported to be between 44%and 53%(Frey, 1998; Lininger, 2003). Many factors affect vascularaccess success or failure, and several are summarized inTable I.

Holly A. Hess, BSN, RM, CRNI, is a Pediatric Vascujar Access Nurse"WolfsonChildren'sHospita!, Jackso~ville, L.Acknowledgment: The author would F~keto acknodedge the editorralass~stancefPamefaTurner;PhD, APRN,CPN, EA-BC,andDanrelleS.Walsh,MD, ACS.

Table I .FactorsAffecting Vascular Access SuccessEFai ure

Physical, * Poor vein quafity, (blown, rolling, sclerotic,phlebotic, fragile, smalf), Uncocperative patient: Dark skin: * ObesityPhysiorogic

I Hypotension' * Peripheralvasmonstriction' (acidosis, sexis, cold,vasopressors, fear,anxfety)* Anemia* Polycythemia

AgeYears experience as anRNYears experiencenserting IVsNumberof IVs nsertedper weekSeA-rated 1V skillsSpecialty certification

-. . . -.- -- . . - --- -. - A . - . -Sources: Alexander & Corrigan, 2004; acobsoi & Winslow,2005.The Practice Applicationsof Researchsection presents reports of research that are clinically focusedand discuss the nursinga~~l icat ionf the findinas. If vou are interested n author auidelines andlor assistance, contact PediotrYc Nursina: East HollyAvenuePitman, N

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Practice Applications of Research

Background Figure 1.Nurscs with more experience and those with spccialty TheVeinviewer by Luminetxtraining and certification, such as intravenous ( IV) tcarns,will be more succcssftil in starting IVs (Jacobsen & Winslow,2005).Howcvcr, many Facilities do not employ IV teams,and nursing unit staff typicaIly havc a variety of skill andexpcriencc levels. M any patient-rclntcd factors can alsocontribute to t h e challenges of pediatric vascular acccss.Small vein diameter and lack of cooperation are amo ng themost common factors, rcsulting in mulleipIc attempts(Alexander & Corrigan, 2004). Dark skin and obesity makevisualizing veins more difficult. Lengthy or frequent hospi-talizations, multiple medications, an d disease processes(such as dehydration or sepsis) m ay further complicate vas-cular acccss. Tn addition, multiple unsuccesrful attemptsmakc future attempts mare difficult by damaging veins andcausing vessel and tissue bruising. Although many of theseinjuries ar e minor and self-limiting, for chiIdrcn whorequire multiple IYs and/or lab draws during a hospitaliza-tion, vascular access will be made more difficult simply bythe reduction of viable sites until tissue damage and vesselinjury have resolved.Fach venipuncture attempt is a sourceof additional painan d emotional distress (Ri jttebier k Vertornmen, 1998;Fradet, McGrath, Kay, Adams, 15Lrrke, 1990; Humphrey,Boon, van Linden van den I-leuvail, & van de Wiel, 1992;Kennedy, L u h m a n n , Lj r Zempsky, 2008; Van Cleve,Johnson, 6r Pothier, 1996). Repcatcd ncedlestick expcri-ences in children can even lead to avoidance of medicalcare as adults (Pate, Rlount, Cohcn, Sr Smith, 1996). Inaddition, the impact of the pediatric venipuncture is notlimited to children. Famiry members and health careproviders also experience distress when observing childrenundergoing vascular access procedures (Smith, Shah,Goldman, Ei Taddio, 2007). Conversely, improving theexperience of thc child has a positive impact on both thefamily and health care providers. In a rcccnt study, nurseswho Iielped improve t he vascular acccss experience in chil-dren reported improved job performance and job satisfac-tion (Papa, Morgan, & Zernpsky, 2008).Repeat attempts to achicvc successful vascular access arecostly both in supplies and labor expenses. Costs are multi-plied by increased procedure time and the use of addition- Mote: Lumifletx changed its !lame in May 2010 Ito Christiea1 staff members needed to restrain children. A study at an Digital Systems, Inc., and there is a generation of theurban pediatric teaching hospital reporting a 441)c, first- Veinviewer device available from Christie Digital Systems, Inc.attempt success tate ( N = 656) tor PTVs performed by staff The study presented in this article was conducted using thenurses demonstrated a labor and supply cost for unsuccess- Veinviewer device by Luminetx shown here.ful 1V attempts of $10,392 for a two-week period (Frey,1998).~t the study facility, a ISQ-~ &ertiary care pediatric illuminators have becn used for many years in thc neona-hospital in northeast Florida, it is the responsibility of the tal population, and more recently, have been modified forbedside nurse t o obtain lab draws and s tart PIVs. However, in all ages Watsogridakis, Scshadri, SulIivan, 8the Pediatric Vascular Access Team (PVAT), whose primary Waltzman, 2008; Krueger, 2007).responsibility is to place and maintain peripherally inserted The Veinviewer (Luminctx Corporation, 2006) is anoth-central catheter [PICC) lines, scrvcs as a resource $0 assist er biomedical device designed to facilitate vascular accesswith patients who have a history of diffjclllt access or who by using near-infrared light directed On the patient's skin tohavc had unsuccessful attempts by th e nursing staff. As a detect the Presence of hcm~k dobinsee Figure 1) .A camera*resuIt of being consulted to assist with vascular access, the computer, and projector ar e used to analyze and project a n

PVAT became interested in improving the success rate of image of t he veins back onto the patient's skin. The veinsvenipunctures performed by the nursing staff. will appear as black lines against a grecn background (seeBiomedical dwices can be a way to improve vascular Figure 2). The Veinviewer emit5 no heat or radiation, andaccess success and have been used as an "equalizer" in a n does not comc into Contact with the patient's skin.attempt to compensate for cithcr patient or staff-related The purpose of this study was- to evaluate the effective-variables that make vascular access more challenging. For nCSS of the VeinVi~wcr n the Success rate of veIIipunChlresexample, u ltrasound-guided peripheral vascular access has performed by staffnurses pediatric patients measured bybeen shown in adult studies to be very successful (Blaivas, the 1) Percent of first-attempt success^ 2) number of2005; Costantino, Parikh, Satz, & Fojtik, 2005). Trans- attempts Per Patient, and 3) time needed to complete theprocedure.


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A Biomedical Device to Improve Pediatric Vascular Access SuccessFigure 2.Visualization of an Infant's Veins Using theVeinViewer

Table 2.Number of Data Sets by Age". - .. . -

Control 91 21 3Experimental 3f 25 35 91

MethodsSample

All patients o n the study unit bctwecn the agcs of ncw-born through 17 ycars w h o required vascular access wereeligible for the study. Baseline data without the use of a vas-cular assist device was rccordcd from August 2006 throughJanuary 2007 and were designated as the control group val-ues. Subsequently, the experimental group data (with theuse of thc VeinViewer) were collected over a 10-month peri-od from April 2007 through January 2008. The rangc ofages in the control group was 3 days to 17 years (mean 5.7ycars). Thc range of ages in the experimental group was I1days to 17ycars (mean 9 years). Tablc 2 shows group com-parisons with respect to age.Because a paticnt oftcn has several vascular accessattempts during a hospitalization, multiple data entrypoints could be recorded on one patient throughout his orher l~ospital tay. One-hundred and f i f t y data ( 1 1 = 150)setswcrc obtained for the control group. After the introductionof th e Veinviewer, data colIection for the cxpcrimcntalgroup continued unti! an observed increase of first-attemptsuccess rate from 49.3'X) to 80.2% was noted, resulting in 91.data sets ( n = 91).Patients were excluded from the study if the study pro-tocoI was not followed or if any of the access attempts werenot performed by the unit nurse. The hospital'sInstitutional Review Committee approved the study.Participation in the study requfred provision of informedparental consent and child assent for 6 to 17 years of age.

Data CoilectionThe data collection tool consisted of a seIt-report formthat wa s kept in the treatment room where most vascularaccess procedures take pIncc. A patient's nurse was asked torecord t h e patient's age (in days, weeks, months, or yeass),the numbcr of attempts needed to achieve succcss, thenumber of nurscs involved in thc proccdurc, and theamount of time needed to complete the procedure

(grouped in categories of less than 15 minutes, 15 to 30minutes, or ovcr 30 minutes). ln addition, the collectiontool permitted the nurse to provide personal, patient, orfamily impressions of the device.Procedure

Over a three-month period, nurscs on a 24-bed pediatricsurgical unit received instruction on the basic operation ofthe VeinViewer an d coaching on its use by supcrviscdvenipunctures. Upon initiation of the study, nurses wereexpected to use the VeinViewer for the first three vcnipunc-turc attempts. The use of the VcinViewer was optional i ffurther attcmpts were rcquircd. N o differentiation wasmade between venipunctures to obtain specimens for labo-ratory tests an d those to establish intravenous access for theadministration of fluids or medications. The first-attemptsucccss, number of attcmpts per patient, and time neededto complete the procedure were coIlected on both the con-trol group (prior to the use of the VeinVicwcr) and theexperimental group (using the Veinviewet).Data Analysis

Data from th c control and cxperimcntal groups werecompared and analyzed using the Statistical Package for theSocial Sciences (SPSSv. 16, for Windowsm, Microsoft, Tnc,2007). The outcome variables were:The percent of first-attempt success.The Incan number of attempts per patient.T h e amount of time required to complete the proce-dure.In addition, staff, patient, anc l family comments wcrccollected and gro~~pedy themes.

ResultsThe first-attempt success rate increased from 49% in thecontrol group to 80% in the cxpcrirncntal group, (X2Ill =22.71, p


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Practice Applications of ResearchTable 3.Summary of Results by Group

Control 150 49% 1.97 52.8% 5.7Experimental 91 80% 1.29 86.7% 9.0Significance X2(l)= 22.71 (227.8) 5.198 XZ(1) = 28. 7 (191.1) -4.056p < 0.001 p < 0.001 p < 0.001 p < 0.0001

Figure3. pesccived institutionaI, investigator, or peer expectations.Success of First Attempt by Age Group Although the control and experimental data were collectedon th e same pediatric surgical unit with a fairly consistenttype of patient population, no attempt was made to match

S O Lessthan6-1 Greater than

6 ears Years 12 years

I14- Experimental eJ--.ontrol100 able is the length a n d type of experience of the nurse pcr-

Fifteen additional data sets were excluded because theprotocol was not followed as stated. However, examiningdata from that group revealed even when nurses initiallychose not to use the VeinViewer on the first attempt, 9 of12 patients (7S1W)) were successfully accessed using thedevice on the second or third attempt.Thirty-two extemporaneous comments from the nurses,paticnts, an d families were recorded. Themes tha t emergedincluded a) increased ease of venipuncture with the devicein those patients who had prior venipuncture experienceswithout an assistive device, b) increased ability to visualizeveins, and c) overall appreciation of the technology. Eighty-three percent of nursing comments were positive, such as,"Unable to see veins without Veinviewer," and "[I] foundveins [I] couldn't see otherwise." One hundr2d percent ofpatientlfamily comments were positive and included "Ittook eight sticks last admit, this time it took one," and"He's usually a very hard stick." Children tended to expressappreciation of the technology of the device with com-ments such as, "This thing is great," and 'Tretty awesome."

patients by diagnosis or co-morbidities, which could affect

-, 90$ so+" -.

LimitationsA limitation of the study is the use of se2f-reported data

collection allowing the potential for nurses to under- orover-report venipuncture attempts, possibly as a resuit of

successhI venipuncture. Another possible staff-related vari-

Discussion

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77.4/ 28 .+- %'*74.3The results of this study dcmonstratcd that a biomedicaldevice, such as t he Veinviewer, can improve vascular accesssuccess in pediatric paticnts. First-attempt vascutar accesssucccss rates were significantly higher, the number ofattempts per patient was significantly lower, and the per-centage of procedures completed within 15 minutcs signif-icantly increased when nurses used the VeinVicwcr com-pared to not using the VeinViewer. Although the mean ageof the two groups was significantly different, the age of th c

patient was not predictive of success. In addition, nursingstaff, patients, a n d families expressed an overall improvedpatient experiencc during vascular access with the use ofthe VeinViewer.

forming the procedure. Future study is recommended witha larger, randomized sample size, controlling for diagnosis,co-morbidities, a n d nirrsc expcricnce.

ImplicationsThe VcinViewer is an expensive capital investment.Thus, having multiple devices can quickly become quitecostIy. However, thc initial cost of purchasing theVeinViewer must bc weighed against the benefits of signif-icantly improved vascular access success rates: highly signif-icant improvement in clinical outcomes, reduced Iabor andsupply costs; and the enhanced experience expressed by

nursing staff, patients, and families.Clinical benefits of improved first-attempt vascularaccess success in children incrude reduced tear, anxiety, andpain, as well as the preservation of potential venipuncturesites that may be needed for future access. I i i addition,improving the vascular access process increases patient,parent, and nursing satisfaction. Many parents whose chil-dren had prior venipuncture experiences expressed a senseof relief and gratitude that their child experienced fewerattempts with the use of the Veinviewer. Of interest,patients wh o wcre subsequently rehospitalized oftcn askedfor the Veinviewer to be used on the first attempt, even ifit had to be brought from another floor.The financial implications of implementing th eVeinViewer vary, depending on the facility's cost of laborand supplies. However, the overall cost benefits can be esti-mated by applying previously published data on financial


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A Biomedical Device to Improve Pediatric Vascular Access Successimplications related to unsuccessful venipuncture attempts. Gupta, D.. gamal. A, . Dhiraaj.S .Tandon, M., Kumar, M.Singh, R. S.,us in^ Frev's (19981 model. incrcasinr th e success rate from ...Singh,U. 2006). n evaluation of efficacy of balloon inflation on50'~j'io86% k o u ~ hesult in a cost sivings of $720 pe r 100 venous cannulatlon parn In children: A prospective, randomized,1Vs. For a facility that places 1000 1Vs pe r month, t h c a n n u - controlled study Anesthesia and Analgesia, 102(5).372-1 75.a1 net savings would amo unt to $86,400. Humphrey,G B , Boon, C.M , van Linden van den Heuvell,G.F..& vande W~el,H.B. (1992). The occurrence of high levels of acuteIn the study population, use of th c VeinVicwcr signifi- behauloral distress in children and adolescents undergang rou-cantly improved vascular access success by increasing the tine veinpunctures. Ped~airics, ql Pt. I). 7-89.f irst-at tempt success, reduced the num ber of at tem pts Per Jacobsen. A.F.. & Winslow. E.H. (20051. Variables influencino intra-patient, an d reduced the t ime required to s~tccessf ; l l~achieve access. d biomedical device, such a s th eVeinviewer, i s not intended to rcplacc th e cxpcrtisc ofskilled clinicians, but rather, to m aximize t he probability ofsuccessful veniprr ncture. Improving vascular access successby rcducing multiple attempts reduces labor and supplycosts, and creates a better experience for the child, family,and staft.ReferencesAlexander, M.,& Corrigan, A.M. (Eds.).(2004). or e currrculum for mfu-$ion nursrng (3rd ed.).NewYork: lnfus~on urses Soclety.Bijttebier, P., & Vertornmen, H. (7998). The Impact of previous experi-ence an ch~ldren's eactions to venepunctures. Joi~rnal f HealthP~y~h010gl :/11, 39-46.Blaivas,M. (2005).Ultrasound-gu~dederipheral IV insertion in the ED.Amerrcan Journalof Nursing, 705(10),54-57.Bulechek,G.M., cCloskey, J.C., Titler, M.G., & Denehey, J.A. (1994).Nursing intervent~onsused in practrce. American Journa! o fNursing, 9411O),59-64,Costanilno, T.G Parikh, A.K., Satz, W.A., & Fojtik, J.P. (2005).Ultrasonagraphy guided peripheral intravenous access versustraditional approaches In pat~ents w~thdifficult intravenousaccess. Annals of EmeqencyMedrcine. 46(5),56-461.Crowley, J.J. (2003) Vascular access. Technrques m Vascular an dEnterventranal Radrolog~6(4), 176-1Curnrnings, E.A., Reid, G.J.,Finley, G.A., McGrath, P.J., & Ritchie, J.A.(1996).Prevalence and source of pain in pediatric inpatients.PamI 68(1),25-31.Fradet, C., McGmth, P.J., Kay, J., Adarns, S., & Luke, B (1990).prospective survey of react~onso blood tests by children and

adolescents. Pain, 4q1), 3-60.Frey, A.M. (1998). Success rates for per~pheralV insertion In a chil-dren's hosp~tal.ournal of lnfravenousNursmng, 21(3),160-165.Goodenough,B., Thomas, W., Charnp~on, .D.. Perroft, D.,Taplin, J.E..von Baeyer, C.L., & Z~egler,.B (1999).Unraveling age effectsand sex differences in needle pain: Ratings of sensory Intensityand unpleasantness of venipuncture paln by ch~ldrenand thelrparents. Pam, SQ(1-2),79-10.

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venous catheter ~nsertan ifficulty and failure:An analysi&f 339lntravenous catheter insertions Heart & Lung, 34(5), 345-359.Katsogr!dakls, Y., Seshadri, R., Sullivan, C., Waltzman. M. (2008).Ve~nl~teranstllumination in the pediatric emergency department:A therapeutic ~nterventional rlal. Pedratrrc Emergency Care,24(2),83-88.Kennedy,R.M., Luhmann, J . , & Zempsky, W.T. (2008). Clinical implrca-tlons of unmanaged needle-~nsert~onain and distress in ch~l-dren. Pedratrics 12Z(Suppl 3), 5130-5133.Krueger,A. (2007).Needhelp frndlng a vein? Nurmg 2007, 7(6). 9-41Lininqer, R.A. (2003).Pediatr~c peripheral IV insertion success.Pedratrrc Nursng, 29(5), 51 3 5 4 .Lurnlnetx Corporat~on.20%). Veinviewer user'sguide. Memphis,TN:Author.Papa, A.M., Morgan, R., & Zernpsky, W.T (2008).Competency, com-passion, contentmen t: nurses' attitudes toward parn associatedwith perrpheral venous access in pedratric patients. Poster pre-sented at the Arnerrcan Paw Society's 27th Annual ScientiftcMeeting. May 8-1 , 008, Tampa. FL.Pate, J.T., Blount R.L., Cohen, L.L., & Smith, A.J. (1996). hildhoodmedical experienoe and temperament as predictors of adult func-tmmg In med~cal ltuations. ChrldrenB HeaNh Care, 2Y4), 81-298Singer, A.J., Richrnan, P.B., Kowalska, A,, & Thode, H.C. (1999).Comparison of patient and practitioner assessmentsof pain fromcommonly performed emergency department prmedures. Annalsof EmergencyMedicine.33. 652-658.Smith, R.W., Shah, V , Goldrnan, R.D., &Taddio, A. (2007). aregivers'responses to pain In the~r hildren In the emergency department.Archrues of Pediatrrc Adolescent Medrcme, 76116) 578-582.Van Cleve, L.,Johnson, L., & Polhier, P.(1996). ain responsesof hos-pitalized infants and children to venipuncture and Intravenouscannulation.Journa! o fPedtatr~c ursmg, 1 1(3),161 168.Wong, D.L., & Baker, C M. (1988). arn in children: Comparison ofassessment scales. PediafrrcNurang, 14(1), -1 .

Reprinted from PediatricNursing,2010, Volume 36, Number 5, pp. 259-263. eprinted with permission of the publisher, JannettiPublications, Inc., East Holly Avenue, Bo x 56, Pitman, N 08071-0056; (856) 56-2300; AX (856) 589-7463; Web site:www.pediatricnursing.net; For a sample copy of the journal, please! contact the publisher.

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Pediatric Nursing Article - Biomedical Device to Improve PVA Success by Hess