Quality improvement report
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009923 on 3 October 2019. Downloaded from http://qualitysafety.bmj.com/ on December 12, 2023 at Hosp Severo Ochoa Consortia.
►► Additional material is
published online only. To view,
please visit the journal online
(http://​dx.​doi.o​ rg/​10.​1136/​
bmjqs-​2019-​009923).
1 catheters).
Department of Internal
Medicine, Division of Hospital
Medicine, Albert Einstein
College of Medicine and
Montefiore Medical Center,
Bronx, New York, United States
2
Deparment of Nursing,
Montefiore Medical Center,
Bronx, New York, United States
Correspondence to
Dr Benjamin Galen, Department
of Internal Medicine, Division of
Hospital Medicine, Montefiore
Medical Center, Bronx, NY
10461, United States;
​bgalen@​montefiore.​org
Received 12 June 2019
Revised 11 September 2019
Accepted 15 September 2019
Published Online First
3 October 2019
© Author(s) (or their
employer(s)) 2020. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
To cite: Galen B, Baron S,
Young S, et al. BMJ Qual Saf
2020;29:245–249.
Reducing peripherally inserted
central catheters and midline
catheters by training nurses in
ultrasound-­guided peripheral
intravenous catheter placement
Benjamin Galen ‍ ‍,1 Sarah Baron ‍ ‍,1 Sandra Young,2 Alleyne Hall,2
Linda Berger-­Spivack,2 William Southern1
Abstract significant proportion of central-­line asso-
ciated bloodstream infections (CLABSI).3
Background Training nurses in ultrasound-­guided
peripheral intravenous catheter placement might
CLABSIs prolong hospital stay and are
reduce the use of more invasive venous access devices
associated with an estimated US$2.68
(peripherally inserted central catheters (PICC) and midline
billion excess cost each year in the USA.4
Methods We implemented an abbreviated trainingUsing ultrasound to place a peripheral
intravenous catheter is a technique that
in ultrasound-­guided peripheral intravenous catheter
has gained popularity among physicians
placement for nurses on an inpatient medical unit and
Protected by copyright.
provided a portable ultrasound device for 10 months.
in emergency medicine and critical care
Results Nurses on this unit placed 99 ultrasound-­
medicine, particularly in patients for
guided peripheral intravenous catheters with a high
whom peripheral intravenous catheter
level of success. During the implementation period,
placement is challenging.5 6 Ultrasound-­
PICC and midline catheter placement decreased from a
guided peripheral intravenous catheter
mean 4.8 to 2.5 per month, meeting criteria for special
placement was recommended in recent
cause variation. In the postimplementation period, the
national guidelines for venous access ‘to
average catheter use reverted to 4.3 per month on the
intervention unit. A comparison inpatient medical unit
facilitate placement of peripheral intra-
without training or access to a portable ultrasound device
venous catheters in arm veins that are
experienced no significant change in PICC and midline
difficult to palpate or visualise’.2 Our
catheter use throughout the study period (mean of 6.0
per month). research group recently demonstrated
that ultrasound-­
Conclusions These results suggest that an abbreviated guided peripheral intra-
venous catheter placement is an effective
training in ultrasound-­guided peripheral intravenous
catheter placement for nurses on an inpatient medical
tool to reduce central venous catheter
unit is sufficient to reduce PICC and midline catheters.
use on the inpatient medical units when
performed by an investigating physician.1
Previous research on nursing use of this
Introduction technology was limited by the extensive
Hospitalised patients for whom the tradi- training required for the intervention,
tional technique of peripheral intrave- which may limit adoption on a busy inpa-
78
nous catheter placement is unsuccessful tient medical unit. Therefore, we sought
may undergo peripherally inserted central to evaluate the use of this technology
catheters (PICC) and midline catheters by training nurses in ultrasound-­ guided
(short PICCs) solely for venous access.1 2 peripheral intravenous catheter place-
While PICC and midline catheters might ment in an expedited fashion. Our aim
be necessary in some cases, they are inva- was to determine if potentially inappro-
sive, posing potential risks during place- priate short-­term PICC and midline cath-
ment (eg, bleeding, arterial puncture, eters could be avoided in patients with
haematoma, air embolism, arrhythmia) difficult venous access. We hypothesised
and during their use (eg, catheter-­ that the intervention would be associated
related thrombosis and infection). Infec- with a reduced number of newly placed
tions associated with PICCs represent a PICC and midline catheters because
Galen B, et al. BMJ Qual Saf 2020;29:245–249. doi:10.1136/bmjqs-2019-009923    245
Quality improvement report
some of these catheters would no longer be necessary
following successful placement of ultrasound-­guide
peripheral intravenous catheters.
Methods
This was a quality improvement project aimed at
reducing the number of newly placed PICC and midline
catheters on the single inpatient medical unit. The
number of newly placed catheters was extracted for
21 months pre-­implementation, during the 10-­month
implementation of the intervention, and followed for
an additional 7 months after the end of the implemen-
tation period (postimplementation).
Intervention
The study consisted of two components: manda-
tory nurse training in ultrasound-­ guided peripheral
intravenous catheter placement followed by access
to the ultrasound device for use in peripheral intra-
venous catheter placement. The complete curriculum
for training is provided in online supplementary file.
Briefly, after an introduction, bedside nurses on a
single inpatient medical unit were shown an instruc-
tional video on ultrasound-­ guided peripheral intra-
venous catheter placement and then given an in-­ser-
vice on the use of the study device: SonoSite S2 with
vascular probe L25 (FujiFilm SonoSite, Bothell, Wash-
ington, USA). Trainees were then required to practice
ultrasound-­ guided peripheral intravenous catheter
placement using a mannequin with physician over-
sight. After completing two successful 20 or 22 gauge
standard length ultrasound-­ guided peripheral intra-
venous catheter insertions (transverse technique) on
the mannequin, the trainees were considered certified
to use ultrasound for peripheral intravenous catheter
placement on patients. Total training time for each
trainee was <60 min. All 29 full-­time nurses on the
intervention unit were trained. None of the nurses had
prior experience using ultrasound to place peripheral
intravenous catheters. The study device was provided
to the intervention unit for the duration of the imple-
mentation period, and was removed from the unit at the
start of the postimplementation period. Trainer assis-
tance for the placement of intravenous catheters was
available on request. A same-­sized inpatient medical
unit with similar patients was chosen for comparison
and the nurses on this unit underwent no training and
did not have access to an ultrasound device for periph-
eral intravenous catheter placement. The intervention
and comparison units used identical, standard length
intravenous catheters placed in forearm veins during
the entire study.
Measures
To compare the intervention and comparison units, the
number of patient discharges, their lengths of stay and
case-­mix index for each unit during the study period
were extracted from the clinical information system.
246
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009923 on 3 October 2019. Downloaded from http://qualitysafety.bmj.com/ on December 12, 2023 at Hosp Severo Ochoa Consortia.
The primary outcome was the monthly count of newly
placed PICC and midline catheters for the study units
during the study period. Newly placed catheter counts
were obtained from interventional radiology billing
records as interventional radiology is the only service
that places these devices. Number of catheters were
examined for a 21-­month pre-­implementation period,
a 10-­month implementation period and 7 months
after the intervention stopped (postimplementation).
Catheters placed within 2 days of hospital discharge
were excluded from the analysis given the likelihood
that these catheters were placed for postdischarge use
rather than for venous access during hospitalisation.
In addition, we recorded the number of ultrasound-­
guided peripheral intravenous catheters placed by
nursing staff using a logbook affixed to the ultrasound
device. Unsuccessful attempts were noted. Requests
for refresher training in ultrasound-­ guided intrave-
nous catheter placement were also tracked.
Statistical analysis
The characteristics of the intervention and comparison
units were compared using the Mann-­Whitney U test.
The monthly number of PICC and midline catheters
on the intervention unit were recorded and plotted
on a C-­ type statistical process control chart, for
Protected by copyright.
Poisson distribution (‘count’) data, using the Shewart
method.9 10 The mean catheter count during the pre-­
intervention period was used as the centerline, which
was carried forward into the intervention period until
special cause was detected. Upper control limits were
calculated as 3 SD from the mean of each time period.
Criteria for detecting special cause variation were
predefined: 1) six points in a row all below or above
the centerline, 2) six consecutive points either rising
or falling, 3) a single point outside the control limits
and 4) two points out of three close (outer third) to
the control limit. When special cause was detected the
centerline was moved at the first point that defined
special cause and a new mean was established.9 10 The
success rate for ultrasound-­guided peripheral intrave-
nous catheters placed by nurses during the study period
was calculated as a ratio of the number of successful
intravenous catheters/attempted intravenous catheters.
In a sensitivity analysis, we constructed similar statis-
tical process control (SPC) charts including all cathe-
ters placed during each admission (i.e., not excluding
the predischarge catheters).
Results
Characteristics of intervention and comparison units
In the year leading up to this study, the intervention
and comparison medical units had similar numbers
of discharges during the study period (1874 vs 1925,
respectively). The intervention and comparison units
had similar mean lengths of stay (6.58 vs 6.35 days,
p=0.32) and similar mean case-­mix indexes (1.38 vs
1.42, p=0.13).
Galen B, et al. BMJ Qual Saf 2020;29:245–249. doi:10.1136/bmjqs-2019-009923
 Quality improvement report

BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009923 on 3 October 2019. Downloaded from http://qualitysafety.bmj.com/ on December 12, 2023 at Hosp Severo Ochoa Consortia.
Protected by copyright.
Figure 1 (A and B) C-­type statistical process control charts. PICC and midline catheters placed each month on the intervention unit (A) and comparison
unit (B) for the 21-­month pre-­implementation period, 10-­month implementation period (denoted by blue lines) and 7-­month postimplementation period.
The centerline (solid line) was established using the mean of the 21-­month pre-­implementation period and the upper control limit was defined as mean+3σ
(dotted line). Both were recalculated when criteria for special cause variation were met. PICC, peripherally inserted central catheter.

Catheter placements PICC and midline catheters reverted to a mean of 4.3

During the pre-­implementation period, a mean number
of 4.8 PICC and midline catheters per month were
placed on the intervention unit (figure 1A). Starting the
third month of the implementation period, a shift in
the number of monthly PICC and midline catheters was
appreciated and met special cause criteria. The monthly
number of newly placed PICC and midline catheters
was reduced to a mean of 2.5 on the intervention unit
(figure 1A). In the postimplementation period, a second
special cause was detected and the monthly number of
catheters per month (figure 1A). The comparison inpa-
tient medical unit utilisation of PICC and midline cath-
eters remained stable during all phases of the study and
variation in catheters per month (mean of 6.0) did not
reach special cause (figure 1B). In the sensitivity anal-
ysis that included all catheters (ie, not excluding pre-­
discharge catheters), the number of catheters placed
each month did not exhibit special cause variation
throughout the study period (data not shown).

Galen B, et al. BMJ Qual Saf 2020;29:245–249. doi:10.1136/bmjqs-2019-009923 247

Quality improvement report
Nurses on the intervention unit attempted 99 ultrasound-­
guided intravenous catheters during the 10-­month study
period, with 96 (97%) noted to be successful. Trainer
assistance was requested for 15 of these, all in the first 6
months of the 10-­month implementation period.
Discussion
In this study of nurse training and utilisation of ultrasound
to place peripheral intravenous catheters, we found the
intervention was associated with a decrease in the number
of newly placed PICC and midline catheters. A compar-
ison inpatient medical unit experienced no reduction in
the number of PICC and midline catheters placed. During
the implementation period, nurses on the intervention
unit attempted on average about 10 ultrasound-­guided
peripheral intravenous catheters per month, the over-
whelming majority of which were successful. Our find-
ings suggest that nurse training in the ultrasound-­guided
peripheral intravenous catheter procedure and access to
an ultrasound device are valuable quality improvements
on the inpatient medical unit.
Technicians have been successfully trained in
ultrasound-­ guided peripheral intravenous catheter
placement in the emergency department, but there is
little research to guide programme development for
nurses on the inpatient medical unit.11 12 A recent
study of nurses on a medical-­surgical unit and step-­
down unit reported a reduction in non-­ essential
PICC line placements using ultrasound-­guided intra-
venous catheter placement.7 However, this protocol
included 8 hours of didactic training and 12 hours of
hands-­on supervision, which may limit its adoption.
Other programmes have combined ultrasound-­guided
peripheral intravenous catheter training with PICC and
midline training for nurses, which is also time inten-
sive.8 We evaluated an abbreviated training model for
inpatient medical unit nurses to learn and implement
ultrasound-­ guided intravenous catheter placement
and found it to be successful. The finding that trainer
assistance was only requested during the first 6 months
of implementation and for only 15 of 99 intravenous
catheters further suggests that the abbreviated training
model was sufficient.
This study has several limitations. First, it was
conducted on a single inpatient medical unit and there-
fore results might not be generalisable to other patient
populations. Second, formal evaluation of individual
nurse’s competency at placing ultrasound-­guided intra-
venous catheters was not conducted, either after the
abbreviated training session or during the implemen-
tation period. The ultrasound device used in this study
is portable, but relatively of high cost. It is not clear if
smaller, less expensive, hand-­held devices would be as
effective. We also did not collect data on complications
to ultrasound-­ guided peripheral intravenous catheter
insertion on the intervention unit, such as extravasation
or thrombosis leading to catheter failure.
248
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009923 on 3 October 2019. Downloaded from http://qualitysafety.bmj.com/ on December 12, 2023 at Hosp Severo Ochoa Consortia.
Conclusions
Placement of peripheral intravenous catheters can be
difficult in some hospitalised patients. PICC and midline
catheters are often used in this situation, even though a
peripheral intravenous catheter would be sufficient. Nurse
training in ultrasound-­ guided peripheral intravenous
catheter placement was successful at reducing PICC and
midline utilisation on one inpatient medical unit.
Contributors All authors contributed to study design,
implementation and manuscript revisions.
Funding This study was supported by a grant from the
Hospitals Insurance Company / FOJP
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally
peer reviewed.
Data availability statement All data relevant to the study
are included in the article or uploaded as supplementary
information.
ORCID iDs
Benjamin Galen http://​orcid.​org/​0000-​0001-​8172-​258X
Sarah Baron http://​orcid.​org/​0000-​0002-​5714-​3139
References
1 Galen BT, Southern WN. Ultrasound-­Guided peripheral
Protected by copyright.
intravenous catheters to reduce central venous catheter use
on the inpatient medical ward. Qual Manag Health Care
2018;27:30–2.
2 Chopra V, Flanders SA, Saint S, et al. The Michigan
appropriateness guide for intravenous catheters (magic):
results from a Multispecialty panel using the RAND/UCLA
appropriateness method. Ann Intern Med 2015;163(6
Suppl):S1–40.
3 Chopra V, O'Horo JC, Rogers MAM, et al. The risk of
bloodstream infection associated with peripherally inserted
central catheters compared with central venous catheters in
adults: a systematic review and meta-­analysis. Infect Control
Hosp Epidemiol 2013;34:908–18.
4 Shekelle PG, Wachter RM, Pronovost PJ, et al. Making
health care safer II: an updated critical analysis of the
evidence for patient safety practices. Evid Rep Technol Assess
2013;211:1–945.
5 Stolz LA, Stolz U, Howe C, et al. Ultrasound-­Guided
peripheral venous access: a meta-­analysis and systematic
review. J Vasc Access 2015;16:321–6.
6 Joing S, Strote S, Caroon L, et al. Videos in clinical medicine.
ultrasound-­guided peripheral i.v. placement. N Engl J Med
2012;366:e38.
7 Reeves T, Morrison D, Altmiller G. A nurse-­led Ultrasound-­
Enhanced vascular access preservation program. Am J Nurs
2017;117:56–64.
8 Gosselin Émilie, Lapré J, Lavoie S, et al. Cost-­Effectiveness of
introducing a nursing-­based programme of ultrasound-­guided
peripheral venous access in a regional teaching hospital. J Nurs
Manag 2017;25:339–45.
9 Benneyan JC. The design, selection, and performance of
statistical control charts for healthcare process improvement.
IJSSCA 2008;4:209–39.
10 Shewhart WA. Economic control of quality of manufactured
product. 501. New York: D. Van Nostrand Company, Inc, 1931.
Galen B, et al. BMJ Qual Saf 2020;29:245–249. doi:10.1136/bmjqs-2019-009923

11 McCarthy ML, Shokoohi H, Boniface KS, et al.
Ultrasonography versus landmark for peripheral intravenous
cannulation: a randomized controlled trial. Ann Emerg Med
2016;68:10–18.
Galen B, et al. BMJ Qual Saf 2020;29:245–249. doi:10.1136/bmjqs-2019-009923
Quality improvement report
BMJ Qual Saf: first published as 10.1136/bmjqs-2019-009923 on 3 October 2019. Downloaded from http://qualitysafety.bmj.com/ on December 12, 2023 at Hosp Severo Ochoa Consortia.
12 Schoenfeld E, Boniface K, Shokoohi H. Ed technicians can
successfully place ultrasound-­guided intravenous catheters
in patients with poor vascular access. Am J Emerg Med
2011;29:496–501.
Protected by copyright.
249