first-attempt success
Evidence Spotlight
Nurse-Performed Ultrasound-Guided IV Access in Critically Ill Patients: Does Training Improve First-Attempt Success?
Peripheral IV placement is routine in critical care, but obtaining access can become significantly more challenging in critically ill patients. Edema, obesity, chronic disease, and other factors can make traditional vein visualization and palpation difficult.
Repeated attempts are more than an inconvenience. They contribute to patient pain, consume clinical time and resources, and may ultimately lead to escalation to central venous access.
A randomized controlled trial by Nishizawa and colleagues examined whether trained ICU nurses using ultrasound guidance could improve peripheral IV success in patients with difficult intravenous access.
Why This Study Matters
Much of the early literature surrounding ultrasound-guided peripheral IV placement focused on emergency departments and physician-performed procedures. The authors wanted to evaluate whether the same benefit could be demonstrated when critical care nurses performed the procedure in ICU patients with difficult access.
The study was conducted in a mixed ICU at a Japanese private teaching hospital. Sixty adult patients with difficult peripheral IV access were randomized to either ultrasound-guided placement or standard-of-care placement. Thirty patients were assigned to each group.
Importantly, difficult access wasn't limited to veins that simply looked challenging. Most participants entered the study after two unsuccessful traditional attempts. Edema was by far the most common reason for difficulty, affecting 73.3% of patients in the ultrasound group and 86.6% of those receiving standard care.
Training Before Technology
One of the most interesting aspects of this study is the training program.
None of the participating ICU nurses had previous experience performing ultrasound-guided IV placement. Before independently performing the procedure, nurses completed standardized education consisting of:
A one-hour lecture covering ultrasound physics, relevant anatomy, and US-guided technique
A knowledge quiz
Hands-on practice using a phantom gel model
Sonographic upper-arm anatomy practice
Five successful phantom insertions
Three successful ultrasound-guided insertions on live ICU patients under physician supervision
Only after completing these requirements were nurses permitted to perform US-guided IV placement independently.
This distinction is important: the intervention wasn't simply giving nurses access to an ultrasound machine. It was providing access to ultrasound alongside structured education, supervised practice, and competency development.
What Did They Find?
The primary outcome was first-attempt success.
The difference was substantial:
Ultrasound-guided placement: 70% first-attempt success
Standard-of-care placement: 40% first-attempt success
This 30-percentage-point difference was statistically significant (P = .0379).
After two attempts, successful access had been achieved in 73.3% of the ultrasound group compared with 46.6% of the standard-care group. Although clinically notable, this secondary outcome did not reach statistical significance (P = .0651).
What About Complications?
Extravasation occurred after 13.6% of successful ultrasound-guided placements compared with 28.5% of successful standard-care placements. However, this difference was not statistically significant (P = .394), so the study cannot establish that ultrasound reduced extravasation.
Neither group experienced hematoma, obstruction, or bloodstream infection during the study.
The authors also highlighted catheter length as an important consideration. Because ultrasound-guided access often involves deeper basilic or cephalic veins, the training program encouraged the use of longer catheters when appropriate. They suggested this may have contributed to the relatively low number of extravasations in the ultrasound group, although the study was not designed to prove that relationship.
The Bigger Lesson: Competency Requires More Than a Lecture
Perhaps the most useful part of this study for organizations developing USGIV programs is what happened before patient enrollment.
The nurses didn't receive a brief demonstration and then begin practicing independently. Their education combined didactic instruction, simulation, anatomy recognition, supervised clinical procedures, and demonstrated successful insertions.
Interestingly, the authors acknowledged that even this may not have represented complete mastery. Some participating nurses still lacked confidence and requested verbal guidance from physicians during procedures. The authors suggested that additional hands-on experience might have produced even higher success rates.
That reinforces an important principle in procedural education:
Initial competency and procedural mastery are not the same thing.
A training program can establish the foundation, but proficiency continues to develop through deliberate clinical experience.
Limitations to Consider
This was a relatively small study involving only 60 patients at a single ICU in Japan. All participating nurses had at least five years of clinical experience, which may limit how well the results translate to less-experienced clinicians.
The patient population also differed from populations commonly described in U.S. difficult-access literature. Edema was overwhelmingly the most common cause of difficult access, while relatively few participants had obesity and none had a history of IV drug use.
The study was open-label, nurses were permitted to receive verbal guidance from ICU physicians, and the sample size was too small to draw strong conclusions regarding complications. The authors appropriately called for larger studies to validate their findings.
Practice Takeaway
This study provides randomized evidence that appropriately trained nurses can successfully perform ultrasound-guided peripheral IV placement in critically ill patients with difficult vascular access.
But the more important lesson may be how that capability was developed.
Ultrasound equipment alone does not create a vascular access program. Effective implementation requires structured education, hands-on simulation, supervised clinical practice, competency assessment, and continued experience.
For healthcare organizations seeking to improve difficult vascular access, investing in clinician competency may be every bit as important as investing in the ultrasound itself.
APA 7 Reference
Nishizawa, T., Matsumoto, T., Todaka, T., Sasano, M., Kitagawa, H., & Shimabuku, A. (2020). Nurse-performed ultrasound-guided technique for difficult peripheral intravenous access in critically ill patients: A randomized controlled trial. Journal of the Association for Vascular Access, 25(2), 34–39. https://doi.org/10.2309/j.java.2020.002.001
