Abstract
Objective:
Comprehensive education and training programs are urgently needed to improve vascular access outcomes in the emergency department (ED). This study aimed to demonstrate the success of a formalized vascular access program in developing competent ED clinicians in traditional and ultrasound-guided insertion methods.
Methods:
This was a retrospective observational study exploring the success of trainees in obtaining competency in peripheral vascular access at an academic suburban ED with 120,000 annual visits. Eligible participants included healthcare workers that enrolled in the Operation STICK vascular access program and perform vascular access procedures as an aspect of their clinical practice. Competency in vascular access included both traditional and ultrasound-guided (US) peripheral intravenous catheter (PIVC) insertions. Competency was defined as demonstration of successful insertion of one traditional and one US PIVC in compliance with checklist. The primary objective was competency. Secondary objectives included trainee time to competency, trainee number of line encounters, and changes in program competency achievements over time.
Results:
From October 15, 2021, to April 15, 2023, 141 clinicians participated in peripheral vascular access training via the Operation STICK model, which included 72 (51.1%) nurses, 52 (36.9%) ED technicians, and 17 (12.0%) healthcare personnel with other medical training. Clinicians overall reported an average of 5.6 years of experience inserting peripheral intravenous catheters (PIVCs) and 23 (16.3%) had experience with using ultrasound. About 122 (86.5%) clinicians successfully completed the program and demonstrated competency in traditional and ultrasound-guided techniques. Time to competency varied over time, with a median of 124 days in the early phase, 32.5 days middle phase, and 10.6 h over 9.5 days in the later phase of the program (p < 0.001).
Conclusions:
Achieving competency in PIVC insertion necessitates a focused effort on refining and systematizing education and training approaches. Recognizing the inherent challenges present in ED settings, it is feasible to effectively and efficiently train emergency clinicians to be expert in both basic and advanced PIVC placement techniques through participation in a well-organized vascular access training program.
Keywords
Introduction
Establishing vascular access through the placement of a peripheral intravenous catheter (PIVC) is a commonly performed invasive procedure in the hospital setting.1–3 In the emergency department (ED), these devices are used to obtain blood samples, perform imaging examinations with intravenous contrast, infuse fluids, and deliver lifesaving medications. While foundational and core to treatment, obtaining vascular access can be challenging, particularly in the setting of a growing difficult intravenous access (DIVA) population, and leads to numerous painful needlesticks, failed attempts, and delays in treatment. 4 With 30%–50% of the population being DIVA patients,5,6 establishing PIVC access can be an impossibility for the average inserter, traumatize the patient, and leave a hefty financial burden for the hospital in the form of wasted personnel time, need for additional supplies, and cost of complications. 7 Even once intravenous access is established, complications are pervasive, with up to 63% failure rates. 8 For the high volume of patients admitted through the ED, fewer PIVC failures and complications provide better patient outcomes and experience.8,9
Major contributors to poor vascular access outcomes are the lack of adoption of robust education and competency programs in healthcare facilities and educational institutions alongside no clear standards on PIVC insertion training and competency requirements.10,11 Of 611 healthcare institutions surveyed, the majority (54%) of institutions reported spending between 1 and 5 h on peripheral intravenous education, while 38% reported spending less than 1 h.10,11 As the majority of ED patients require a PIVC, inadequate education and training for PIVC placement, such as location and device selection, leads to high PIVC failure rates among this population.12–18 Further, many clinicians receive on-the-job training on a clinical shift via the “see one, do one, teach one” model leading to substantial variability in practice. 19 These shortfalls are compounded as there is typically an ill-defined or limited escalation process for more complex DIVA patients. 20
Provision of training and instruction on high-level insertion skills that include visualization technologies is particularly challenging in the fast-paced, high-stress, and often chaotic setting of the ED. Further, the situation is complicated by staffing shortages and high acuity throughout the COVID-19 pandemic and post-pandemic phases. To address these challenges, the authors have developed an efficient, self-sustaining program called Operation STICK. This program standardizes PIVC insertion and redefines how clinicians’ approach PIVC access in the ED by integrating best practice recommendations for traditional PIVC insertions and PIVC insertions with the aid of visualization technology. The acronym “STICK” serves to promote key tenets, support the knowledge needed to optimize PIVC insertion, and help clinicians become proficient in PIVC insertion (Figure 1). This study aimed to demonstrate the success of a comprehensive vascular access training model in developing competent clinicians.
Operation STICK acronym and explanations.
Methods
Study design, setting, and participants
This retrospective, single-site, observational study was conducted at an academic tertiary care suburban ED in southeastern Michigan, United States. The ED has an annual census of more than 120,000 visits and 160 treatment beds. Participants in the study consisted of a wide range of ED-based staff, including nurses, technicians, physicians, nurse practitioners, physician assistants, residents, fellows, and medical students. These clinicians voluntarily engaged in a training program named Operation STICK. Participation was not a condition of employment. The study was reviewed by the study site Institutional Review Board and determined not to meet the definition of human subjects research.
Operation STICK curriculum overview
Operation STICK is a formalized and comprehensive peripheral intravenous catheter insertion training program. The program is defined by the incorporation of standardized assessment tools, education, and individualized training, alongside vigilant surveillance of procedural outcomes and documentation. Additionally, it capitalizes on the utilization of appropriate products, advanced technology, optimized inventory control, and high-quality infection prevention practices while being carefully monitored via real-time data tracking. Inaugurated in October 2021, Operation STICK has experienced numerous adaptations and refinements to augment both the efficacy and efficiency of the learning experience it offers. These changes are an integral part of its ongoing commitment to evolve in line with advancements in the field and to continuously strive for quality improvement.
Every participant in Operation STICK takes part in a meticulously structured learning path consisting of pre-workshop modules, in-person workshops, and precepted training. The pre-workshop modules are comprised of modern, interactive video content and self-assessment quizzes. These modules serve as an introduction to venous access, offering a comprehensive review of assessment strategies with special attention to site, vein, and device selection,12,13,21,22 infection prevention measures, 23 fundamental and advanced insertion methodologies,24,25 relevant equipment and supplies, and necessary documentation protocols. The in-person workshop involves two parts: a didactic lecture and simulation of PIVC insertion. The didactic coursework serves to reinforce critical concepts from the pre-workshop video series and is supplemented by integrated simulation training. Notably, all didactic content is rooted in the most up to date evidence and guidelines.23,25,26 The final phase of the learning path involves one-on-one precepting sessions. These incorporate both simulation training and live patient insertions. The insertion process on patients is guided by the preceptor utilizing a PIVC checklist to ensure the meticulous following of the procedure. The trainee is deemed competent once they can sequentially complete all the steps of the process without external prompts, highlighting the individual’s full grasp of the principles and practice of vascular access care. At 6 months post competency, graduates are required to demonstrate continued proficiency via a competency audit. This audit includes traditional and advanced placements. These audits are then conducted annually.
Study definitions
Competency was defined as the occurrence in which a trainee successfully performs one traditional and one advanced PIVC insertion on a live ED patient under the observation of a lead preceptor. To ensure a consistent standard across the department, a proficiency checklist was employed (Figure 2). This checklist is consistent with other validated tools for vascular access training. 27 Trainees were expected to complete all steps in the procedure sequentially without prompting to be deemed competent. Trainees were also required to verbalize knowledge of site assessment by appropriately assigning a vascular access score (VAS) to a potential access site, the key factor in determining if traditional or escalation approach was most suitable (Figure 3). The VAS is a simplified version of validated DIVA scoring tools published in the literature.28,29
Proficiency checklist for Operation STICK.
The vascular access score.
Time to competency was measured as the day from the in-person didactic training session to the day when the trainee was deemed to have reached competency by a lead preceptor.
Clinicians were healthcare providers having direct clinical contact with patients and included nurses, technicians, attending physicians, resident physicians, medical students, and advanced practice providers.
Data source/variables
The data utilized in this study was diligently maintained and curated by five dedicated program leaders/preceptors. Data was self-input by the participant during the workshop by scanning a unique QR code; this linked to a form that automatically uploaded the information to a centralized file. Participants supplied their contact information, current medical occupation and degree, as well as their prior experience with PIVC insertion—quantified in years—and their history of ultrasound usage in PIVC insertions. After each one-on-one training session, the preceptor digitally recorded the length of the session, 29 quantity and method of insertion, general observations on the trainee’s progression, along with any feedback from the trainee. This data was also automatically uploaded to a centralized spreadsheet (Google).
Objectives
The primary objective was competency. Secondary objectives included time to competency, number of line encounters, and change in competency achievement over time.
Statistical analysis
Descriptive analysis was used to summarize clinician characteristics across three distinct time intervals of the program. Continuous variables were reported as means with standard deviations and medians with interquartile ranges. Categorical variables were expressed as frequencies and percentages. The Chi-square or Fisher’s exact test and Kruskal-Wallis (exact) test were used for categorical variables and numerical variables, respectively. When comparing early, middle, and late phases, the multiple comparison method was applied; the post hoc Holm-Bonferonni procedure was used for categorical variables and the Tukey-Kramer method was used for numerical variables. 30 All tests performed in this analysis were two-sided tests, with p < 0.05 or a confidence interval of 95% indicating statistical significance. Analysis was performed using R software, version 4.1.2 (R Foundation for Statistical Computing) and Excel (Microsoft).
Results
From October 15th, 2021, to April 15th, 2023, 141 clinicians participated in the Operation STICK training program. The early phase of the program (October 1st, 2021–April 15th, 2022) consisted of 52 (36.9%) participants, while the middle phase (April 16th, 2022–September 30th, 2022) and later phase (October 1st, 2022–April 15th, 2023) consisted of 41 (29.1%) and 48 (34.0%) participants, respectively. 51.1% of participants were nurses, 36.9% were ED technicians, and 12.0% had other credentials (physician, physician assistant, nurse practitioner, or medical student). The average number of years of experience with PIVC insertion was 5.6 and 23 (16.3%) of clinicians reported previous experience with using ultrasound (Figure 4). Overall, 122 (86.5%) of clinicians completed the training program, with 78.8% achieving competency in the early phase, 85.4% in the middle phase, and 95.8% in the later phase (p = 0.04). The later phase has a significantly greater proportion of trainees achieving competency compared to the early phase (p = 0.047).
Histogram of trainees self-reported years of experience inserting PIVCs.
The average number of PIVCs insertions required for competency remained steady across the three phases, with an overall average of 8.2 insertions (p = 0.46). The median number of days from didactic to competency decreased over time, from 124 days in the early phase, to 32.5 days in the middle phase and 9.5 days in the later phase (p < 0.001) (Tables 1 and 2). There was a significant difference in the average number of days from didactic to competency when comparing the early and middle phases (p < 0.001) and early and late phases (p < 0.001). Importantly, only 26.3% of trainees reached competency in less than 1 month in the early phase of the program, compared to 78.3% of trainees in the later phase (Figure 5).
Description of participants in the Operation STICK training program.
EDT: emergency department technician; RN: registered nurse; PIVC: peripheral intravenous catheter.
For continuous variables, medians (interquartile ranges, IQRs) and means (standard deviation, SD) were presented. For categorical variables, frequencies (percentage) were presented.
Kruskal-Wallis test.
Chi-squared or Fisher’s exact test.
p < 0.05 between early phase and later phase. ¶
p < 0.05 between early phase and middle phase. ¶
In multiple comparisons test, post hoc Holm-Bonferroni procedure and the Tukey-Kramer method was used for categorical and numerical variables, respectively. p-Values are available in Table 2.
Post-hoc multiple comparisons analysis between early, middle, and late phase.
PIVC: peripheral intravenous catheter.
Post-hoc Tukey’s honest significance test was used in multiple comparisons test for numerical variables.
Post-hoc Holm-Bonferroni procedure used in multiple comparisons test for categorical variables.
Time required to achieve competency by program phase.
Discussion
This study demonstrated the widespread success of a vascular access training program with an overall competency rate of 86.5% in both traditional and ultrasound-guided insertions over an 18-month period. Comparatively, another large ED-based 5-year study reported a competency rate of just 43.0%. 31 While there are several studies on the topic of training in vascular access, most of the literature do not explicitly report competency rates. Furthermore, Operation STICK’s success is particularly noteworthy given the large number of trainees (141) who participated in the program. In a recent systematic review of education and training for ultrasound-guided PIVCs, 18 ED-based publications were assessed. Most ED-based educational programs reported much smaller number of trainee participants (5–195 trainees), with a median of 25 trainees. While one study reported a larger number of trainees (195) than Operation STICK, the composition of the group was markedly different as 76% of trainees were physicians. Instead of focusing on the physician group who is tasked with PIVC insertion on a limited basis, Operation STICK focused on the generalist clinicians (88% being nurses and technicians) with the main responsibility for PIVC insertion. 32
The critical and expanding role of ED technicians in Operation STICK deserves attention. While nurses typically assume the primary responsibility for establishing vascular access, 33 nearly 40% of trainees in this cohort were technicians. This group was composed of highly skilled, teachable, and motivated clinicians that became the backbone of this program. This is consistent with existing evidence that highlights both nurses and technicians can effectively place ultrasound-guided PIVCs.34,35 Given the drastic nursing staffing shortages in recent times, technicians represent a budding pool of lower-cost providers that have not only excelled in the program but also have assumed important leadership roles in the educational and administrative process. Finally, it is important to understand that advanced vascular access is a core part of the curriculum and is paired with patient care responsibilities. Thus, this program uses an efficient model that elevates ED clinicians to provide specialty-level vascular access insertion care.
The importance of this program originating in the ED cannot be overstated. The ED is frequently a chaotic setting characterized by suboptimal vascular access outcomes.17,18,36 With factors such as a demanding caseload, unpredictable patient flow and overcrowding, substantial operational hurdles, insufficient staffing, high staff attrition, and limited availability of vascular access educational opportunities for staff, the ED is a challenging environment to implement major changes. 37 Despite these obstacles, prioritizing vascular access education and training is critical given that the majority of ED patients require a PIVC. 10 Further, the ED serves as the gateway for over half of all hospital admissions and over 90% of these patients receive a PIVC illustrating that the initial choices made by the ED clinician tasked with placing the PIVC may impact most hospitalizations. 38 Unfortunately, too often ED patients are subject to numerous unnecessary needlesticks given the lack of staff experience and training with basic and advanced PIVC insertion skills.4,10 Further, the act of establishing reliable vascular access in a time-efficient matter is no easy task, especially with a growing DIVA population,39,40 which often necessitates escalation to the use of visualization technologies including illumination, near-infrared and ultrasound devices. 41 As DIVA populations continue to grow, the need for well-trained, specialized front line vascular access staff also grows. Operation STICK directly addressed this problem by training the masses to acquire skills that can better meet the needs of this growing vulnerable population with complex vasculature. This program also demonstrated that despite the numerous challenges present in the ED, implementing a large-scale ED-based training program was practical and can be the solution for other sites.
As the competency criteria for training in advanced vascular access remains ill-defined in the current literature, there is some ambiguity in terms of goals in training. 32 While number-based competency thresholds have been described as the current standard, these recommendations have largely been unvalidated before this study with some existing evidence suggesting the number to achieve competency is likely much higher than current recommendations.42–44 While a number cutoff defines the endpoint, it is important to understand that not all trainees learn at the same pace and hard thresholds generally do not work well. Inevitably, some trainees will demonstrate competency before the set numerical threshold while others may need additional procedures to demonstrate proficiency. Instead, as illustrated by Operation STICK, the competency model should be based on demonstrating successful completion of the steps in the insertion process rather than meeting a number threshold. This strategy helps shift training resources to those that have the greatest needs.
It is important to recognize that with a standardized and comprehensive methodology, the learning curve can be shortened.45,46 It is noteworthy that efficiency and success in training requires a multipronged strategy including actively managing expectations regarding the time commitment needed from the educator and the learner, operationalizing communication methods to link educator and trainee with patient, providing administrative support to enforce the requirements and facilitate training opportunities, and implementing effective and standardized educational and training processes. While many of these components were considered in the initial Operation STICK implementation, there was considerable trial and error and refining of processes as the program evolved over time. Over the study period, approaching efficiency from multiple directions allowed for substantial reduction in time and resources needed in training. For instance, an important step in improving efficiency was removing clinical care obligations when conducting the one-on-one training. As nursing administration carved out dedicated time for training, the trainees and educators could focus solely on learning PIVC skills rather than simultaneously juggle managing other aspects of patient care. As the program evolved, further efficiencies were realized when more time was devoted to simulation training. While trainees were eager to attempt ultrasound-guided PIVC sticks on live patients, it was evident that those with a poor foundation on the simulation vein block often struggled with real insertions. The increased practice on the vein block (10–15 insertions) was associated with improved control of the ultrasound transducer and led to more success with real patients. Table 3 lists some additional major process improvements implemented in the middle and late phase that led to improved training outcomes. Ultimately, the best outcomes were noted in the late phase of the program (October 1st, 2022–April 15th, 2023). Most recently, the competency rate was 95.8% with a median time to competency of 9.5 days with the actual average training time of 10.6 h spread out over several days. While these data highlighted some of the growing pains that are to be expected with any new program, they also serve as a baseline for strategic planning for institutions considering implementing an ED based vascular access program.
Description of major process improvements during middle and late phases.
Limitations
This study is not without limitations. First, while team leaders kept detailed logs of training days throughout the program, the number of hours of training were not recorded meticulously until the later phase. As the data for this objective is limited to the more mature phase of the program, this benchmark may not directly apply to a program in its infancy. Similarly, the quantity of placements by insertion method were not accurately captured until the later phase. However, the data from this time interval serves as a useful barometer. Notably, the vast majority of the training time was spent on advanced insertions, as 47 out of 48 clinicians demonstrated competency for traditional PIVC placement within one insertion; the remaining insertions required for competency (mean = 8.2; mean = 8) were ultrasound-guided. Second, competency data highlights the effectiveness of a training program but does not impart information regarding the impact on vascular access outcomes. Further research is needed to prove improved patient outcomes in parallel with training feats. Finally, results may not be generalizable as this data is exclusive to a single emergency department.
Conclusions
Achieving competency in basic and advanced vascular access necessitates a focused effort on refining and systematizing education and training approaches. Operation STICK is a standardized vascular access program that has been successfully implemented in a large academic tertiary care suburban ED. With continuous improvement, Operation STICK has become an effective and efficient learning pathway meeting the vascular access needs of emergency patients. Further research is needed regarding patient outcomes as they relate to training successes.
Footnotes
Acknowledgements
The authors applaud Alexis Walton, ED technician, for her commitment and effort in making Operation STICK successful as well as her assistance in gathering data for this publication.
Author contributions
AB, NM, SG designed the study, had full access to the data, and take responsibility for the integrity and accuracy of the data analysis. AB, NM, ED, SG contributed to data and statistical analysis. All authors contributed to the writing and editing of the manuscript. All authors contributed to data acquisition, analysis and interpretation, and all reviewed and approved the final version of the manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.
Declaration of conflicting interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: All authors are founders of the Operation STICK vascular access program and are voting members of Operation STICK, LLC. Additionally, AB has research grant support from B. Braun Medical, Becton-Dickinson, Teleflex, Adhezion, Medline Industries, Moderna, and Access Vascular. AB is a paid consultant for B. Braun Medical, Teleflex, Lineus Medical, and Interad Medical. SG is a paid consultant for Lineus Medical, Nexus Medical, PICC Excellence, and Fujifilm Sonosite.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Data sharing statement
The data that support the findings of this study are available via a data access agreement. Please contact the corresponding author (AB) for this request.
Ethical approval
The study was reviewed by the study site Institutional Review Board and determined not to meet the definition of human subjects research.
