Ultrasound-Guided IV Training Reduces Central Line Placement

Nancy A. Melville

April 27, 2012

April 27, 2012 (Phoenix, Arizona) — The rate of inappropriately placed central venous catheters (CVCs) substantially declines when residents and emergency department (ED) technicians are trained to perform ultrasound-guided peripheral intravenous access (USPIV), according to a study presented here at the American Institute of Ultrasound in Medicine (AIUM) 2012 Annual Convention.

A research team led by Hamid Shokoohi, MD, from The George Washington University (GWU) Medical Center in Washington, DC, evaluated the monthly rate of CVC placement in high- and low-acuity patients from 2006 to 2010.

In 2008, administrators at the GWU Medical Center implemented a program to train residents and ED technicians to use USPIV.

Whereas the ED saw an increase in patients over the study period, from 60,239 in 2006 to 71,431 in 2010, the number of CVCs placed was reduced by nearly 65%, from 426 in 2006 to 152 in 2010.

"In 2006, nearly 13% of patients who received CVC had the line removed and it turned out the patient could be sent home," Dr. Shokoohi reported. "This number dropped to just 1% in 2010."

In addition, most patients who did receive a CVC were admitted to the intensive care unit (ICU).

"This is very important because we assume the people who go to the ICU are the most severe patients who need the CVC for reasons other than simply poor peripheral IV access," said Dr. Shokoohi. "In 2006, only about a third [33.2%] of patients who got CVC were admitted to the ICU; by 2010, this number went up to 82%."

The findings underscore the association between USPIV and CVC reduction in low-acuity patients who need IV access but not central line access, Dr. Shokoohi noted.

"The study demonstrates that the best outcome can be achieved using ultrasound first and replacing an unnecessary invasive CVC procedure with a safe and successful method of obtaining IV access in low-acuity patients with difficult IV access."

Michael Blaivas, MD, FACEP, professor of emergency medicine in the Department of Emergency Medicine at Northside Hospital Forsyth, in Cumming, Georgia, said the findings support the sentiment of many physicians that CVC, and its potential for complications, can be avoided more often than many realize.

"This is a really important study," said Dr. Blaivas, who moderated the session and is chair of the AIUM Emergency and Critical Care Ultrasound Section.

"It's amazing how many of us, over the years, have had the gestalt that the central line is often unnecessary, and documenting that is critical."

USPIV is "simple and extremely effective because it can help you avoid the central line completely. Obviously, many central lines do need to be placed, but as the study indicated, you can avoid it in as many as a third of cases."

Although there is a bit of a learning curve for USPIV, Dr. Blaivas said the training isn't too difficult. "In general, we've found that training can be accomplished with a 2-hour course, lectures, some demonstrations, practice on a phantom, and then trying it out on about 5 patients in a proper setting with the oversight of an expert."

USPIV is used at nearly all academic medical centers in the United States, but its use in other settings needs to be increased, he said.

"The community healthcare providers tend to pick this up less, so they are the next big battleground," Dr. Blaivas said. "The Emergency Nurses Association has put out a statement endorsing this, and I think you will start seeing more and more implementation."

Dr. Shokoohi has disclosed no relevant financial relationships. Dr. Blaivas reports being a consultant to a number of ultrasound device companies, but none related to this study.

American Institute of Ultrasound in Medicine (AIUM) 2012 Annual Convention: Abstract 1239655. Presented March 31, 2012.

April 27, 2012 (Phoenix, Arizona) — The rate of inappropriately placed central venous catheters (CVCs) substantially declines when residents and emergency department (ED) technicians are trained to perform ultrasound-guided peripheral intravenous access (USPIV), according to a study presented here at the American Institute of Ultrasound in Medicine (AIUM) 2012 Annual Convention.

A research team led by Hamid Shokoohi, MD, from The George Washington University (GWU) Medical Center in Washington, DC, evaluated the monthly rate of CVC placement in high- and low-acuity patients from 2006 to 2010.

In 2008, administrators at the GWU Medical Center implemented a program to train residents and ED technicians to use USPIV.

Whereas the ED saw an increase in patients over the study period, from 60,239 in 2006 to 71,431 in 2010, the number of CVCs placed was reduced by nearly 65%, from 426 in 2006 to 152 in 2010.

"In 2006, nearly 13% of patients who received CVC had the line removed and it turned out the patient could be sent home," Dr. Shokoohi reported. "This number dropped to just 1% in 2010."

In addition, most patients who did receive a CVC were admitted to the intensive care unit (ICU).

"This is very important because we assume the people who go to the ICU are the most severe patients who need the CVC for reasons other than simply poor peripheral IV access," said Dr. Shokoohi. "In 2006, only about a third [33.2%] of patients who got CVC were admitted to the ICU; by 2010, this number went up to 82%."

The findings underscore the association between USPIV and CVC reduction in low-acuity patients who need IV access but not central line access, Dr. Shokoohi noted.

"The study demonstrates that the best outcome can be achieved using ultrasound first and replacing an unnecessary invasive CVC procedure with a safe and successful method of obtaining IV access in low-acuity patients with difficult IV access."

Michael Blaivas, MD, FACEP, professor of emergency medicine in the Department of Emergency Medicine at Northside Hospital Forsyth, in Cumming, Georgia, said the findings support the sentiment of many physicians that CVC, and its potential for complications, can be avoided more often than many realize.

"This is a really important study," said Dr. Blaivas, who moderated the session and is chair of the AIUM Emergency and Critical Care Ultrasound Section.

"It's amazing how many of us, over the years, have had the gestalt that the central line is often unnecessary, and documenting that is critical."

USPIV is "simple and extremely effective because it can help you avoid the central line completely. Obviously, many central lines do need to be placed, but as the study indicated, you can avoid it in as many as a third of cases."

Although there is a bit of a learning curve for USPIV, Dr. Blaivas said the training isn't too difficult. "In general, we've found that training can be accomplished with a 2-hour course, lectures, some demonstrations, practice on a phantom, and then trying it out on about 5 patients in a proper setting with the oversight of an expert."

USPIV is used at nearly all academic medical centers in the United States, but its use in other settings needs to be increased, he said.

"The community healthcare providers tend to pick this up less, so they are the next big battleground," Dr. Blaivas said. "The Emergency Nurses Association has put out a statement endorsing this, and I think you will start seeing more and more implementation."

Dr. Shokoohi has disclosed no relevant financial relationships. Dr. Blaivas reports being a consultant to a number of ultrasound device companies, but none related to this study.

American Institute of Ultrasound in Medicine (AIUM) 2012 Annual Convention: Abstract 1239655. Presented March 31, 2012.

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