Clinical Trial Summary
The placement of peripheral intravenous lines (IVs) is central to the treatment of patients
in the emergency department (ED). The procedure is used for phlebotomy and administration of
a variety of therapeutic medications and intravenous fluids. This procedure is standard of
care, and IVs are routinely placed by experienced emergency nurses.
Occasionally, the nurse will have difficulty placing an IV line. The most common reason for
this is an underlying medical condition, such as diabetes, severe peripheral vascular
disease, obesity, or a history of intravenous drug use. When a nurse is unable to place an
IV, the options are:
1. Ask another nurse to attempt the line placement
2. Ask a physician to establish access, which usually involves placement of a central
venous catheter, a time-consuming procedure with higher risk of infection than a
peripheral line.
The use of bedside ultrasound has become commonplace in the modern ED, and the Tufts Medical
Center ED possesses its own machine, which is used for a variety of indications including
diagnosis of pregnancy, gall bladder disease, abdominal free fluid or pericardial effusion.
Another key use of bedside ultrasound is the location of blood vessels. In fact, it is now
expected that when placing a central venous catheter the clinician use ultrasound guidance,
as the ultrasound clearly demonstrates blood vessels. The procedure is completely pain-free
and harmless, and costs nothing to perform.
Recently, there has been a growing body of evidence demonstrating that placement of
peripheral IVs can be facilitated by the use of ultrasound. Just as it is useful for central
venous catheters, ultrasound can also clearly show smaller peripheral veins. Multiple studies
have demonstrated that physicians can place IVs with ultrasound guidance.
However, nurses are the de facto experts at placing peripheral IVs as it is a usual procedure
for them to perform and they perform the procedure multiple times a day. In this study, we
will provide a two-hour training program to a cohort of nurses. The training program will
instruct them in the use of single-operator ultrasound-guided IV placement. After training,
once the nurse encounters a patient with difficult IV access (either 2 failed attempts or
history of difficult access), the patient will be consented and randomized to either the
standard of care (whatever the nurse elects to do) or use of the bedside ultrasound.
In the meantime, the research assistant will measure time to IV placement starting from
enrollment, the number of skin punctures that are necessary to place the IV, and then ask the
patient questions about satisfaction with the IV placement and the pain they experienced.
Our hypothesis is that single-operator, ED nurse use of bedside ultrasound will facilitate IV
placement in patients with difficult IV access, saving time and also improving patient
satisfaction and comfort.
