Vascular access, such as blood sampling and peripheral intravenous (PIV) catheter insertion, is a common experience for the hospitalized neonate and child that requires procedural skill by the inserter. Despite its frequent occurrence, each patient presents with unique underlying conditions, along with an often-acute need for access. Venipuncture and vascular access are considered basic nursing skills, but can also be complex, time-sensitive, and technically difficult procedures that need to be performed successfully within a limited time.1 Due to limited communication abilities, unpredictable behavior, activity levels, and small vessel sizes, the venipuncture and PIV insertion is even more complex for neonates and children.2
Vascular access is a painful procedure that can have lifelong implications for neonates and children if not managed properly. Additionally, needle fear associated with PIV and venipuncture procedures is prevalent in children, and may increase with age if not managed.3 Knowing the distress vascular access can cause, it is important to emphasize care and comfort during vascular access device procedures to support the neonate and child and family during a necessary but frequently painful experience. The American Society for Pain Management Nursing position statement4 highlights this necessity, stating that health care professionals have a responsibility to collaborate, advocate, and intervene to provide optimal comfort management before, during, and after procedures for patients of all ages.
Despite vascular access being a common procedure, there are wide variations in practice. The clinicians performing the procedure can be health care professionals ranging from bedside nurses to physicians. Workforce models vary, with some institutions using a subgroup of skilled clinicians who specialize in vascular access to provide this service, and others training every health care provider with the expectation that he or she can become proficient and maintain competency in PIV insertion. The standard procedure for insertion varies among providers and can use a variety of means, from vein visualization tools to the use of ultrasound depending on resources and provider skill set. Overall, research has suggested that clinicians who place PIVs frequently, such as those in dedicated vascular access services, demonstrate better success rates and fewer attempts at venipuncture for IV placement.5,6 However, a recent Cochrane Systematic Review7 highlighted that there is inadequate evidence to support the widespread benefit of dedicated vascular access teams.
The Infusion Nursing Society (INS) Standards of Practice for Infusion Therapy highlight that the health care organization is responsible for ensuring clinician competency initially (before providing patient care) and on an ongoing basis.8 However, the metrics for assessing competency can be difficult to determine, and there is a wide variation in each organization's training program. Via this survey, the Association for Vascular Access (AVA) Pediatric Special Interest Group (PediSIG) aimed to provide an assessment of the current state of neonatal and pediatric vascular access practice, including any variation in practice affecting clinical outcomes, to inform future research, education, and workforce innovation.
Methods
Aims
The aims of the study were to examine the current state of workforce models, training, and clinical practices surrounding neonatal and pediatric vascular access. This information can then be used to inform practice development opportunities.
Study Design
A cross-sectional survey was developed to describe current practice of clinicians who provide vascular access for neonatal and pediatric patients.
Participants
Clinicians who are currently practicing and who have a position caring for neonatal and/or pediatric patients were invited to complete the online survey.
Instruments and data collection
The PediSIG Assessment of Venipuncture Education and Support (PAVES) survey was developed by expert clinicians in the AVA PediSIG Executive Leadership Council. Following a review of the existing literature on neonatal and pediatric vascular access, questions were developed and prioritized via robust discussion. The survey was piloted through the PediSIG Council and assessed for feasibility (including time for completion), clarity of questions, and data collection ease. The final survey consisted of a combination of 51 multichoice and open-ended questions. Key themes for the survey were listed in the following categories: demographics of clinician, role of clinician, vascular access team (VAT) demographics, initial training of clinician, competency of clinician, clinical practice, pain control, and procedural support. Participation was voluntary, and responses were collected anonymously. The survey was collated via the Survey Monkey™ (SVMK, San Mateo, CA) platform. The survey was distributed via the AVA PediSIG membership mailing list, and PediSIG members were asked to forward on as appropriate to colleagues. Social media (i.e., Facebook, Twitter) was used to further promote the survey via the AVA platforms. The survey was open for 6 months, from January to June, 2018.
Data analysis
Descriptive statistics have been used to report the survey results (counts, percentages; mean, standard deviation [SD]; median, interquartile ranges [IQR]) relevant to data characteristics and distribution. Associations between clinical outcomes (clinician report of peripheral intravenous cannulation [PIVC] attempts) and workforce and training were assessed using χ2 test. Variables with a P < 0.05 were considered significant. Missing data are described throughout the Results tables (Tables 1–6). The analysis was undertaken using Stata (version 13; StataCorp, College Station, TX).
| N | % | |
|---|---|---|
| Country | n = 242 | |
| United States of America | 226 | 93.4 |
| Australia | 10 | 4.1 |
| Canada | 3 | 1.2 |
| Mexico | 2 | 0.8 |
| Oman | 1 | 0.4 |
| Type of institution: | n = 237 | |
| Pediatric hospital | 139 | 58.6 |
| University hospital | 39 | 23.2 |
| Private hospital | 39 | 16.5 |
| Clinic | 4 | 1.7 |
| Title of respondent: | n = 242 | |
| Vascular access team member | 100 | 41.3 |
| Registered nurse | 65 | 26.9 |
| Clinical nurse specialist | 16 | 6.6 |
| Nurse manager | 16 | 6.6 |
| Assistant nurse manager | 5 | 2.1 |
| Other | 40 | 16.5 |
| Role: | n = 207 | |
| Vascular access clinician | 89 | 43.0 |
| Manager | 23 | 11.1 |
| Nurse educator | 15 | 7.2 |
| Resource nurse | 28 | 13.5 |
| Other | 52 | 25.1 |
| Patient population: | n = 207 | |
| Neonatal | 147 | 71.0 |
| Pediatric | 187 | 90.3 |
| Adult | 76 | 36.7 |
| Number of pediatric beds: | n = 209 | |
| <100 | 72 | 34.4 |
| 101–200 | 56 | 26.8 |
| 201–300 | 33 | 15.8 |
| >300 | 37 | 17.7 |
| None | 11 | 5.3 |
| Number of neonatal intensive care beds: | n = 206 | |
| <20 | 34 | 16.5 |
| 21–40 | 46 | 22.3 |
| >41 | 103 | 50.0 |
| None | 23 | 11.2 |
| N | % | |
|---|---|---|
| Vascular access model: | n = 209 | |
| Initial vascular access attempted by the bedside nurse, then escalated to expert resources as needed | 85 | 40.7 |
| Difficulty assessed initially; difficult venipuncture automatically escalated to expert clinician, nondifficult attempted by bedside nurse | 80 | 38.3 |
| Vascular access team provides all vascular access | 25 | 12.0 |
| Junior medical doctor/Resident provides vascular access | 4 | 1.9 |
| Other | 15 | 7.2 |
| If no VAT in place, who performs the vascular access functions? | n = 89 | |
| Bedside registered nurse | 72 | 80.9 |
| Charge/nurse leader | 33 | 37.1 |
| Medical doctor | 32 | 36.0 |
| Nurse practitioner | 27 | 30.3 |
| Resident | 22 | 24.7 |
| Clinical nurse specialist | 17 | 19.1 |
| Other | 17 | 19.1 |
| Number of FTE positions dedicated for vascular access: | n = 209 | |
| 0 | 25 | 12.0 |
| 1–2 | 30 | 14.3 |
| 3–5 | 37 | 17.7 |
| >5 | 77 | 36.8 |
| Don't know | 40 | 19.1 |
| Licensure of the clinician providing vascular access service: | n = 209 | |
| Registered nurse | 201 | 96.2 |
| Nurse practitioner | 17 | 8.1 |
| Medical doctor | 10 | 4.8 |
| Emergency medical technician | 7 | 3.3 |
| Other | 9 | 4.3 |
| Title of the person providing vascular access service: | n = 209 | |
| Registered nurse | 94 | 45.0 |
| Vascular access clinician | 65 | 31.1 |
| IV team member | 45 | 21.5 |
| Medical doctor | 5 | 2.4 |
| Days covered by the service: | n = 209 | |
| Monday | 198 | |
| Tuesday | 198 | 94.7 |
| Wednesday | 196 | 93.8 |
| Thursday | 198 | 94.7 |
| Friday | 196 | 93.8 |
| Saturday | 155 | 74.2 |
| Sunday | 141 | 67.5 |
| None | 14 | 6.7 |
| Holiday coverage: | n = 209 | |
| Yes | 147 | 70.3 |
| Hours covered by the service: | ||
| 0700–1100 | 202 | 96.6 |
| 1100–1500 | 201 | 96.2 |
| 1500–1900 | 174 | 83.2 |
| 1900–2300 | 130 | 62.2 |
| 2300–0300 | 98 | 46.9 |
| 0300–0700 | 96 | 45.9 |
FTE=full-time equivalent; IV=intravenous; VAT=vascular access team
| N | % | |
|---|---|---|
| Formalized training for pediatric and/or neonatal vascular access offered at work: | n = 198 | |
| Yes | 129 | 65.1 |
| If yes, who is qualified to attend the training? | n = 189 | |
| Anyone interested | 29 | 15.3 |
| All clinicians who have completed initial orientation | 42 | 22.2 |
| All clinicians hired | 22.2 | |
| As decided by unit management team | 52 | 27.5 |
| N/A | 58 | 30.7 |
| At what point do they receive their training? | n = 154 | |
| Immediately upon hire | 47 | 30.5 |
| After a set time determined by administration | 38 | 24.7 |
| After core competencies are achieved | 37 | 24.0 |
| When staff member requests to attend | 32 | 20.8 |
| Format of training: | n = 156 | |
| Preceptorship/mentoring at bedside observation with skills demonstration at bedside | 127 | 81.4 |
| Lecture, in person attendance | 90 | 57.7 |
| Simulation, in person | 83 | 53.2 |
| Electronic/video-learning management system | 39 | 25.0 |
| Content included: | n = 153 | |
| Insertion procedure | 149 | 97.4 |
| PIV care and maintenance | 133 | 86.9 |
| Device selection/indications | 129 | 84.3 |
| Documentation | 129 | 84.3 |
| Infusion-related complications | 116 | 75.8 |
| Procedural support/distraction modality | 120 | 78.4 |
| Pain control | 112 | 73.2 |
| Pediatric anatomy and physiology | 112 | 73.2 |
| Training hours: | n = 154 | |
| <4 hours | 69 | 44.8 |
| 5–8 hours | 35 | 22.7 |
| >9 hours | 50 | 32.5 |
| Does your facility require observed competency validation before independent placement of a vascular access device | n = 199 | |
| Yes | 170 | 85.4 |
| What is the number of PIVs to be placed with mentor before placing independently? | n = 199 | |
| 0 | 26 | 13.1 |
| 1–5 | 122 | 61.3 |
| 6–10 | 29 | 14.6 |
| 11–15 | 7 | 3.5 |
| 16+ | 15 | 7.5 |
| What is the annual competency requirement?a | n = 196 | |
| No annual competency required | 93 | 47.4 |
| Observed competency validation | 70 | 35.7 |
| Minimum number of completed procedures | 55 | 28.1 |
| Completion of learning management systems | 39 | 19.9 |
| Verbalized understanding of competency | 28 | 14.3 |
| Attendance at class | 20 | 10.2 |
| In order to maintain competency, does your institution mandate a yearly minimum requirement for number of PIV insertions? | n = 196 | 17.7 |
| Yes | 37 | 18.9 |
FTE=full-time equivalent; IV=intravenous; VAT=vascular access team
| N | % | |
|---|---|---|
| Do you have any formal procedure algorithm or set criteria in place to escalate a patient who requires an expert clinician? | n = 209 | |
| Yes | 99 | 47.4 |
| What resources do you utilize to obtain difficult venous access?a | n = 209 | |
| Vein visualization technology | 152 | 72.7 |
| Ultrasound | 182 | 87.1 |
| Expert clinician | 145 | 69.4 |
| Physician/licensed independent practitioner | 43 | 20.6 |
| Vascular access specialist | 161 | 77.0 |
| At what number of total attempts for a PIV do you escalate to a central line and/or refer to alternative access? | n = 207 | |
| <5 | 84 | 40.6 |
| 5–10 | 21 | 10.1 |
| >10 | 3 | 1.4 |
| No set number | 99 | 47.8 |
| What is the percentage of time that you have exceeded your set algorithm attempts in order to obtain access due to the clinical situation? | n = 158 | |
| Median (IQR) | 10% 5–35) | 81.4 |
IQR=interquartile range; PIV=peripheral intravenous
Multiple responses per participant
| N | % | |
|---|---|---|
| Does your hospital mandate a standard method to secure PIV? | n = 194 | |
| Yes | 106 | 54.6 |
| No | 39 | 20.1 |
| Recommended, not mandated | 49 | 25.3 |
| Are there variations allowed based on patient age? | n = 194 | |
| Yes | 142 | 73.2 |
| No | 34 | 17.5 |
| N/A | 18 | 9.3 |
| What devices do you utilize to secure a PIV?a | n = 194 | |
| Arm board | 177 | 91.2 |
| Securement dressing | 152 | 78.3 |
| Steri-Strips/tape | 100 | 51.5 |
| Burn net or stockinette | 77 | 39.7 |
| Clear plastic dome | 65 | 33.5 |
| Engineered securement dressing | 48 | 24.7 |
| Engineered securement device | 44 | 22.7 |
| Tissue adhesive | 42 | 21.6 |
| Arm cuff | 22 | 11.3 |
| Other | 19 | 9.8 |
N/A=not applicable; PIV=peripheral intravenous
Multiple responses per participant
| N | % | |
|---|---|---|
| Do you have a standardized protocol for vascular access pain management? | n = 181 | |
| Yes | 115 | 63.5 |
| How consistently is it being followed? | n = 181 | |
| Never | 28 | 15.5 |
| Rarely | 11 | 6.1 |
| Sometimes | 51 | 28.2 |
| Often | 68 | 37.6 |
| Always | 23 | 12.7 |
| What percent of the time are pain management modalities being utilized? | n = 181 | |
| Mean (SD) | 59.6% (28.8) | 30.5 |
| What does your institution utilize for pain control for PIV insertion?a | n = 181 | |
| Numbing cream | 155 | 85.6 |
| Vibration device | 77 | 42.5 |
| Vapocoolant | 76 | 42.0 |
| Lidocaine injector | 76 | 42.0 |
| Oral sucrose solution | 155 | 85.6 |
| My institution doesn't utilize options for pain control | 6 | 3.3 |
| Do you have a standardized protocol for vascular access procedural support? | n = 181 | |
| Yes | 110 | 60.8 |
| How consistently is the protocol being used? | n = 181 | |
| Never | 6 | 3.3 |
| Rarely | 6 | 3.3 |
| Sometimes | 31 | 17.1 |
| Often | 61 | 33.7 |
| Always | 27 1 | 4.9 |
| N/A | 50 | 27.6 |
| What percent of the time is procedural support and/or distraction being used by a dedicated staff member? | n = 181 | |
| Median (IQR) | 65% (44–88) | |
| For the majority of vascular access procedures, procedural support and/or distraction is provided by: | n = 181 | |
| Child life specialist | 107 | 59.1 |
| Staff member | 34 | 18.8 |
| Parent/caregiver | 12 | 6.6 |
| Any available | 23 | 12.7 |
| None | 5 | 2.8 |
| What days are covered by your procedural support and/or distraction staff? | n = 181 | |
| 5 days a week, Monday to Friday only | 80 | 44.2 |
| 7 days a week | 101 | 55.8 |
| Does your procedural support and/or distraction staff provide holiday coverage? | n = 181 | |
| Yes | 92 | 50.8 |
| What hours are your procedural support and/or distraction staff available?a | n = 181 | |
| 0700–1100 | 178 | 98.3 |
| 1100–1500 | 172 | 95.0 |
| 1500–1900 | 113 | 62.4 |
| 1900–2300 | 53 | 29.3 |
| 2300–0300 | 26 | 14.4 |
| 0300–0700 | 26 | 14.4 |
| Do you provide any of the following forms of sedation as needed?a | n = 149 | |
| Nitrous oxide | 31 | 20.8 |
| Intranasal Versed | 89 | 59.7 |
| Oral Versed | 89 | 59.7 |
| Anesthesia consult | 69 | 46.3 |
| Other | 48 | 32.2 |
| After how many attempts do you consider escalation to sedation? | n = 159 | |
| No set number | 113 | 71.1 |
| 0 | 9 | 5.7 |
| 1 | 4 | 2.5 |
| 2 | 12 | 7.5 |
| 3 | 7 | 4.4 |
| 4 | 6 | 3.8 |
| 5+ | 8 | 5.0 |
IQR=interquartile range; N/A =not applicable; PIV=peripheral intravenous; SD=standard deviation
Multiple responses per participant
Ethical considerations
Human Research Ethics Committee approval was provided by Griffith University in January 2018 (2018/064); the survey was distributed through the PediSIG membership and industry partner email lists and promoted through the AVA social media sites. The survey was kept open for 6 months.
Results
Participant demographics
There were 242 respondents in total, across 5 countries. Most participants identified themselves as vascular access clinicians working with a VAT. When they were asked to list the name of their team/service there were 190 unique entries. Most common themes were names based on tasks instead of specialty, with IV team and PICC team being the most common name.
Neonatal and pediatric vascular access workforce, training, and competency
Approximately 12% of participants reported having all venipuncture attempts performed by a VAT. Other models included having the bedside nurse attempt initial access or the bedside nurse assessing the difficulty and escalating difficult access to an expert clinician. In terms of workforce, 44% of participants reported having 5 or fewer full-time equivalent (FTE) positions dedicated to vascular access, with around 37% of clinicians stating they had greater than 5. Only 65% reported having a formalized training program, and the most common format for training was a preceptor/mentorship program. For program training, 44.8% of respondents stated that their training was typically less than 4 hours.
For initial competency validation, 85% of respondents said it was required, and 61% stated that they required 1 to 5 observed PIVs to be placed with a mentor before independent insertion was allowed. For ongoing training, 47% reported that they had no annual competency requirements.
Clinical practice
As reported in Tables 4 and 5, less than half of respondents reported a formal algorithm or criteria in place to escalate a patient who needed an expert PIV inserter, and only 53% reported having a set number of PIV attempts before escalating to central or alternate access. On average (median), respondents reported exceeding the algorithm's set number of PIV insertion attempts 10% of the time (IQR 5–35).
There was no significant difference between reported number of FTE in workforce or having a dedicated VAT, and the percentage of time clinicians reported exceeding their attempts per their algorithm or the provision of procedural support. There was a significant association between an organization having more than 5 FTE positions and an organization offering formalized training (χ2 8.46; P = 0.004).
Peripheral intravenous securement was standardized in a little over half of the participants, with the arm board and securement dressing being the most common securement methods.
Procedural support
Over 60% of respondents (n = 115) said they had a standardized protocol for vascular access pain management, with only 12.7% (n = 23) stating that the protocol was always followed and 15.5% (n = 28) reporting the protocol was never followed. The most common forms of pain control were numbing cream and sucrose solution, with 85.6% (n = 155) of respondents selecting those options.
Procedural support was standardized in 60.8% (n = 110) of responses, with only 14.9% (n = 27) of respondents stating procedural support was always used. Approximately 60% of the time procedural support was provided by a child life specialist, and 55.8% of respondents stated they had access to procedural support staff 7 days a week.
When asked what types of sedation were provided, 59.7% of respondents mentioned intranasal or oral midazolam. Almost half (46%; n = 69) stated they would use an anesthesia consult, while 71% (n = 113) reported that they had no set number of attempts before considering sedation.
Discussion
This is the first survey designed to target pediatric vascular access clinicians to assess their current practice. Previous international surveys have been conducted to assess for perspectives of the consumer, relating to PIV practices9 and central venous access device site care.10 There has not been a survey conducted in which current practicing clinicians in neonatal or pediatric vascular access self-assess their vascular access insertion, securement, and procedural support practice.
In describing aspects of the VAT, there were 190 unique entries for name of team, often not defining the comprehensive lists of duties survey participants reported providing to patients. Because the model pertains to vascular access initiation, many participants reported that the bedside nurse made the first attempt for vascular access with the VAT making the next attempt. Only 25% of respondents reported that a vascular access specialist provided all vascular access needs. Less than half of the respondents reported having 24/7 coverage for vascular access, with a recent global study identifying pediatric vascular access specialist teams as most common in the United States.11 For those who answered that they did not have a VAT, vascular access was provided by the bedside registered nurse according to most of the responses.
Education and training have a significant impact on procedural skill and patient outcomes. Most respondents said that they did have a formalized training programs offered at their hospitals with the primary method of training being preceptorship/mentoring at the bedside. However, most training was reported as being less than 4 hours. Advanced procedural skill acquisition can require a significant time investment. A recent example of this has been the introduction of ultrasound-guided PIV insertion, where procedural competency has been demonstrated to require dedicated education and practice.12,13 Within the current survey, most respondents reported that they required observed competency before independent placement of a vascular access device, with 61% of the respondents reporting that they required 1 to 5 observations. However, there was a wide variation in the requirement for ongoing or annual competency, with a majority reporting no annual competency required. Only about 19% of respondents stated having a mandated yearly minimum of PIV insertions to maintain competency.
Practice variation was also evident in the resources available to support escalation of patients with difficult IV access (DIVA). Less than half of respondents reported having a formal procedure to escalate a patient to an expert clinician. There was a wide variation in practice as to how many total attempts the clinician performed before escalating to a central venous access device or alternative access. Similarly, Schults et al.14 recently reported that only 16% of clinicians (n = 23) globally used a DIVA scale, with resources used for the identification and escalation of children with DIVA unstandardized or inconsistently used. Further study is needed to streamline processes for DIVA identification and escalation to the appropriate clinicians, to improve patient safety and experience.
Peripheral intravenous securement practice was also variable. Only approximately half of the respondents reported that their hospital mandated a standard method to secure a PIV, which leads to a lack of institutional standardization and increased variations in practice and outcomes. There is also a wide variation in methods used for pain relief, with only 63.5% of respondents saying they had a standardized protocol for pain management and only 12% of respondents saying their protocol was always followed. On average, respondents felt that pain management modalities were being used around 60% of the time, with most respondents saying they used numbing cream and oral sucrose solution. A systematic literature review15 suggests that in the neonatal population, oral sucrose with a nonnutritive suck is effective for vascular access procedures with numbing cream also being effective. Of note, the literature review also mentioned that the patient environment was an important factor in order to achieve maximum effectiveness.
Limitations
The main limitation of this survey is that the participants were gathered from a convenience sample supplied by a listserv. Some of the responses could represent the same workplace or VAT, but because this survey assessed a clinician's personal practice, we did not feel a need to limit responses by institution. We also had limited responses from non-United States-based clinicians. Together this limits the generalizability of the survey to other countries, however providing a useful description of the current state of peripheral vascular access at this moment in time.
Conclusions
Our study shows a wide variance in what neonatal and pediatric clinicians are self-reporting as their peripheral vascular access practice. Becoming proficient in PIV insertion in the wide range of neonatal and pediatric patient sizes and developmental levels is challenging. Developing the necessary expertise requires hours of training and mentorship. The majority of training programs were reported as 4 hours or less, with a low number of mentored insertions before the clinician was allowed to operate independently. Despite there being a national standard requiring ongoing competency,8 a little less than half of respondents reported requiring any annual competency.
Evidence shows that neonatal and pediatric patients require pain relief and procedural support.3,4 As pediatric vascular access specialists, we need to ensure that children receive appropriate procedural pain-relieving measures and emotional support for every needlestick experience they encounter. This is necessary to prevent negative long-term effects of health care, including sustained needle phobia, noncompliance with medical treatment, and avoidance of health care as an adult.3 Core standards for pediatric vascular access need to be developed to help guide the neonatal and pediatric clinicians in proper training, procedural support, and access to vascular access specialists to provide the best care for every neonate and child.