Patients’ experiences in ultrasound-guided intravenous catheter insertion: A qualitative study

Abstract

Background

Peripheral intravenous catheter (PIVC) insertion is the most performed invasive procedure in healthcare. However, it often presents challenges in patients with non-visible or non-palpable veins, leading to unsuccessful cannulation attempts and associated complications. Ultrasound-guided PIVC insertion is a promising solution for patients with difficult venous access (DIVA). However, there remains a gap in the literature regarding patient experiences with this technique.

Aim

This study aimed to describe the characteristics and experiences of patients referred to a specialised DIVA team for ultrasound-guided PIVC insertion and compare their experiences with previous traditional cannulation.

Method

A qualitative study was conducted at an Australian 980-bed metropolitan tertiary referral centre. Thirteen patients were recruited through purposive sampling and interviewed post-ultrasound-guided cannulation. Data collection was conducted using one-on-one interviews followed by thematic analysis.

Results

The study identified three major themes: the improved patient experience resulting from the expertise of the DIVA team with ultrasound cannulation; the impact of limited equipment and trained personnel on patient experience and outcomes; and the significance of acknowledging patients’ prior cannulation experiences. Participants reported a stark contrast in their experiences between ultrasound-guided and traditional cannulation, with the former significantly reducing physical discomfort, stress and anxiety and improving success rates.

Conclusions

Ultrasound-guided PIVC insertion by trained clinicians significantly enhances the experience for patients with DIVA. However, challenges remain, including the availability of equipment and trained staff. The study highlights the need for policy changes and training in ultrasound-guided cannulation to improve patient care and outcomes. Future research should focus on broader and more diverse populations to validate these findings.

Resumen

Antecedentes

La inserción de un catéter intravenoso periférico (PIVC) es el procedimiento invasivo más frecuentemente realizado en la atención sanitaria. Sin embargo, a menudo presenta dificultades en los pacientes con venas no visibles o no palpables, lo cual causa intentos fallidos de canulación y complicaciones asociadas. La inserción ecoguiada del PIVC es una solución prometedora para los pacientes con acceso venoso difícil (DIVA). Sin embargo, sigue existiendo una brecha en la literatura con respecto a las experiencias del paciente con esta técnica.

Objetivo

El objetivo de este estudio fue describir las características y experiencias de los pacientes derivados a un equipo especializado en DIVA para inserción ecoguiada de PIVC, y comparar sus experiencias con la canulación tradicional previa.

Método

Se realizó un estudio cualitativo en un centro de referencia terciaria metropolitano de 980 camas en Australia. Se seleccionaron y entrevistaron trece pacientes mediante muestreo intencional, tras la canulación ecoguiada. Se recopilaron datos utilizando entrevistas personales seguidas de análisis temático.

Resultados

El estudio identificó tres temas mayores: mejora de la experiencia del paciente, derivada del conocimiento del equipo de DIVA con la canulación ecoguiada; impacto de la limitación del equipo y el personal experto en la experiencia y resultados del paciente; y significación del reconocimiento de las experiencias previas de los pacientes sobre canulación. Los participantes reportaron un contraste marcado en cuanto a sus experiencias entre la canulación ecoguiada y la tradicional, reduciendo la primera el malestar físico y el estrés y la ansiedad, y mejorando las tasas de éxito.

Conclusiones

La inserción ecoguiada del PIVC por parte de clínicos expertos mejora considerablemente la experiencia de los pacientes con DIVA. Sin embargo, las dificultades persisten, incluyendo la disponibilidad del equipo y del personal experimentado. El estudio destaca la necesidad de cambios de las políticas y de la formación en canulación ecoguiada para mejorar el cuidado al paciente y sus resultados. La investigación futura deberá centrarse en poblaciones más amplias y diversas para validar estos hallazgos.

What is known

Peripheral IV catheter placement is challenging in DIVA patients, often causing complications from multiple attempts. Ultrasound improves 1st insertion success, but little research exists on patient experiences with difficult vascular access.

What it contributes

The study offers insights into DIVA patients’ experiences with ultrasound-guided IV catheter insertion, highlighting the importance of clinician skill, equipment access, and patient-centred communication for positive outcomes.

Introduction

The necessity for peripheral intravenous catheter (PIVC) placement in over half of all hospital admissions underscores its status as the most commonly performed invasive procedure in global healthcare settings.^1–3 PIVCs are necessary for administering intravenous fluids and parenteral medications.⁴ However, challenges arise for the estimated one-third of patients who present to the hospital with difficult-to-cannulate veins, complicating peripheral venous access.⁵ Such difficulties often lead to numerous unsuccessful cannulation attempts, inflicting discomfort or severe pain on patients and causing delays in the initiation of critical diagnostic tests and treatments.⁶

Patients presenting with difficult venous access (DIVA, include patients who, upon assessment, exhibit no visible or palpable veins, have a documented history of difficult venous access, intravenous substance abuse, or a BMI greater than 30),^7,8 face high rates of repeated cannulation failures, not only causing discomfort but also escalating into serious complications such as phlebitis, thrombosis, and catheter-related infections.^9,10 These complications frequently contribute to premature PIVC failure, compelling clinicians to seek alternative vessels for peripheral venous access, which is often equally challenging and painful. In extreme cases, the exhaustion of peripheral veins may necessitate the transition to more invasive central venous access methods.¹¹

Point-of-care ultrasound (POCUS) is increasingly being utilised for vascular access, especially in emergency departments and intensive care units worldwide. Ultrasound devices have become more affordable, portable, and versatile, making POCUS more accessible in clinical settings. In Australia, wireless POCUS devices cost approximately $6,000–$7,000 AUD, making them more attainable for procedures such as PIVC insertion, which can significantly address current vascular access challenges.^12,13

PIVC insertion using real-time ultrasound guidance allows the cannulation of deeper veins that cannot be visualised or palpated. This technique has been gradually adopted to improve the success rates of first-time cannulation for patients with difficult-to-cannulate veins.¹⁴ Despite these technological and procedural advancements, there remains a paucity in the scientific literature regarding the experiences of those who suffer from DIVA.¹⁵

In addition to providing a less stressful experience of PIVC insertion in adults, the efficacy of this method, as highlighted in prior studies, suggests its huge potential in paediatric patients and underscores the need for specialised training and substantial experience in vascular access procedures among healthcare staff​​.¹⁶ Prior studies that have explored the distress and challenges faced by patients dealing with difficult venous access emphasise the need for a more patient-centric approach for this vulnerable population​​.¹⁷

Ongoing research is vital to understanding the impact of interventions to improve first-insertion success for patients with DIVA. This research should examine patients’ experiences referred to specialised DIVA teams for ultrasound-guided PIVC insertion. It is crucial not only for gaining insight into patient experiences but also for guiding clinical practices and policy decisions to improve the quality of vascular access care in hospitals, which can lead to improved patient safety, outcomes and satisfaction.

Aim

This study aims to describe the characteristics and experiences of patients referred to a specialised DIVA team for ultrasound-guided PIVC insertion and compare their experiences with traditional cannulation.

Method

Design and setting

This study employed a basic qualitative research design. This method was chosen because it provides an in-depth exploration of personal and sensitive reflections on both positive and negative experiences.¹⁸ The study is reported using the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.¹⁹

The study recruited participants using a purposive sampling methodology and was conducted in three medical and one surgical wards of a 980-bed metropolitan tertiary referral centre in Southwest Sydney, Australia. The hospital serves a diverse population and a large geographic area.

Participants

Patients were identified through referrals made to the after-hours clinical support team (AHCST) for ultrasound-guided peripheral cannulation. The AHCST consists of specialist nurses accredited in ultrasound-guided peripheral cannulation. Referrals to the AHCST are made through the hospital escalation pathway when patients are identified as having difficult access, either on assessment or through failed cannulation attempts (Liverpool Hospital DIVA Pathway).⁶ Following referral and before ultrasound-guided cannulation, a member of the AHCST screened patients to determine whether they met the study’s eligibility criteria.

Inclusion and exclusion criteria

Patients over 18 years of age who were referred to the AHCST for ultrasound-guided peripheral cannulation were eligible to participate in the study. Patients who were minors, who were non-English speaking, had altered mentation concerns such as dementia or were confused or unable to provide informed consent were excluded. Once the patient was deemed eligible, they were approached by a research nurse (not part of the DIVA team) and provided with a patient information sheet and a consent form. The research nurse explained the purpose of the study and provided an opportunity for any questions or clarifications.

Data collection

A research nurse, external to the research team and authors, was employed to assist with data collection. After obtaining consent and before starting the one-on-one interviews, the research nurse collected socio-demographic data. The interviews were guided by a semi-structured interview guide (Table 1) and conducted at least 24 h after the participants had been cannulated in the AHCST unit. Interviews lasted between 30 min and one hour and were conducted at the patient’s bedside or in a private room (if ambulant), maintaining as much privacy as possible, Monday to Friday during regular business hours.

Table 1.

Interview Guide.

In relation to traditional cannulation

Can you describe what it’s like having a cannula inserted?

What did you think of the skills or technique of the clinician who tried to perform your canulation?

How do you think your experience of being cannulated has impacted your overall hospital stay?

In relation to ultrasound-guided PIVC insertion

What about your procedure with the ultrasound guided cannula. Can you explain how you were feeling leading up to that?

What did you think of the skills or technique of the clinician who inserted your cannula using the ultrasound?

How do you think your experience of being cannulated using the ultrasound has impacted your overall hospital stay?

Concluding question

Would you have any suggestions on how to improve the experience or process for patients with difficult vascular access going forward?

All interviews were audio recorded and later transcribed verbatim into text for analysis. The digital audio recording device was kept in plain sight and not concealed throughout the interviews. The participant was informed whenever the device was turned on or off. The sample size was determined based on the point at which no new themes or concepts emerged, indicating that data saturation had been reached.

Data analysis

Descriptive data were computed using SPSS software Version 28 (IBM Corp. Armonk, NY, USA). For the qualitative analysis of responses from the interviews, a thematic approach using the six-step 1) familiarisation of the data, 2) generating initial codes, 3) search for themes, 4) review themes, 5) defining and naming themes, and 6) produce the report, approach.¹⁶ Two members of the research team (PD and JRT) were designated the role of data analysis and given access to the transcripts to become familiar with the data. They were selected based on their qualitative analysis experience, and they were not involved in the data collection nor employed in the AHCST unit, thus mitigating any personal influence on data interpretation. Both PD and JRT undertook the initial coding cycle independently and then reached a consensus through triangulation. In the second coding cycle, to arrive at the final themes, all members of the research team participated.

Ethical approval

Site-specific approval from the respective Human Ethics Committees was obtained (2021/ETH01401). All transcriptions were securely stored in an encrypted database hosted on an Australian institutional platform.

Results

Between March and May 2023, over a three-week period, eighteen patients were screened for eligibility; of those, thirteen participated in the interviews. The reasons for exclusion included refusal to consent to be interviewed (n = 3), testing COVID-19 positive and in isolation prior to the opportunity to interview (n = 1) and being discharged home prior to the opportunity to be interviewed (n = 1). The patients included 6 (46%) female and 7 (54%) male participants with an average age of 53 years. The PIVCs inserted were either 20 gauge (n = 7, 54%) or 22 gauge (n = 6, 46%) and primarily 45 mm long and placed in the forearm. The average number of attempts required for successful cannulation using ultrasound by the AHCST was 1 (Table 2).

Table 2.

Characteristics of patients requiring ultrasound-guided cannulation.

	Patients (n = 13)
Males, n (%)	7 (54)
Females, n (%)	6 (46)
Age (y), mean (SD)	53 (16)
BMI, mean (SD)	40.5 (13.7)
Minimum BMI	23.9
Maximum BMI	78.7
Reason for ultrasound-guided cannulation, n (%)
Intravenous Antibiotics	5 (38)
Contrast-enhanced CT	3 (23)
Continuous infusions	3 (23)
Blood product	1 (8)
Pre-operative	1 (8)
Catheter Gauge (n, %)
20 gauge	7 (54)
22 gauge	6 (46)
Catheter length in mm (n, %)
45 mm	12 (92)
64 mm	1 (8)
Cannulation Site (n, %)
Left Forearm	6 (46)
Left Antecubital	1 (8)
Left Leg	1 (8)
Right Forearm	3 (23)
Right Upper arm	2 (15)
Depth of vessel from skin in mm, median (IQR)	10 (10,15)
Minimum depth (mm)	7
Maximum depth (mm)	10
Average number of attempts using ultrasound, mean (SD)	1 (0)

The findings gained from interviews revealed three major themes: Expertise and the use of ultrasound improves the patient experience; lack of equipment and expertise impacts patient experience and outcomes; failure to acknowledge patients’ prior cannulation experience leads to physical and emotional distress and poor outcomes. All study participants indicated that the DIVA team and ultrasound-guided cannulation positively impacted the cannulation experience and overall satisfaction.

Theme 1: Expertise and the use of ultrasound improves the patient experience

Participants recognised the advanced skills of the specialised DIVA team, especially for patients who are difficult to cannulate. Participants noted that non-DIVA clinicians often resorted to repetitive and painful methods.

[They kept] "poking and prodding, poking and prodding trying to get it in". (Patient 3)

This contrasted sharply with the DIVA team's approach, perceived by patients as having better communication and seeming more knowledgeable with better skills.

"Calm, explained everything that was going on, and how they were going to do it all", usually succeeding on the first attempt, or being "Spot on, one attempt". (Patient 13)

Among the 13 participants who underwent ultrasound-guided cannulation, each one successfully received cannulation on the first attempt. This contrasts sharply with their experiences of traditional landmark cannulation, where none of the participants had ever been successfully cannulated on the first try. One participant recalled a particularly distressing experience.

“I had 7 attempts [manual cannulation]. I started to get anxious and at the end I said I don’t want anymore”. (Patient 13)

Participants highlighted that using ultrasound for vein location enhanced the experience for both clinical staff and patients. One participant remarked:

“having the ultrasound gives him [clinician] choice. But when you haven’t got an ultrasound, there’s no choice, you’ve just got to take the best-looking thing you can see”. (Patient 12)

Participants agreed that ultrasound use reduced failed attempts and pain and improved the positioning and durability of the cannula. One participant explained their comparative experience between ultrasound-inserted and previous standard insertions:

“In comparison to the old way [no ultrasound]…I can’t even feel it [cannula]. The other ones [no ultrasound] there was always a bit of swelling there, sometimes a bit of soreness and you can’t move especially when they put them in your joints”. (Patient 12)

Theme 2: Lack of equipment and expertise affects patient experience and outcomes

While unanimously valuing the ultrasound’s advantages, participants also expressed concerns about its availability and the limited number of trained clinicians. One noted,

"the ultrasound may be more expensive, but for the patient, I think they will be less fearful of getting one [cannula]". (Patient 11)

Additionally, there were comments about the need for more trained personnel and sufficient equipment, as one participant said,

"They need more people trained on these [ultrasound]" and another mentioned, "I don’t think they have enough equipment". (Patient 12)

Another participant noted that following his experience with the ultrasound, he would seek this preference in future:

“I’d ask for it, but I know it is not an easy option because you have to get an ultrasound, you’ve got to get the right person with the skillset”. (Patient 13)

This indicated patients’ observation of the probability of having an ultrasound-guided cannulation is limited. Another participant commented:

“I think they could use a few more around here [ultrasound], because you have to wait so long. I was supposed to have heparin yesterday but because they could not find a free machine [ultrasound] I had to wait till tonight to get my medication. So I missed out on all of that time of not having my medication because they could not find a machine”. (Patient 9)

This illustrates how a lack of resources (ultrasound machines) can directly affect patient treatment and outcomes.

Theme 3: Failure to acknowledge patients’ prior cannulation experience leads to physical and emotional distress and poor outcomes

Although communication between the clinician and patient should promote successful cannulation through the identification of past challenges, participants highlighted the failure of the clinicians to’ listen’ to their past experiences.

“what works for them [us the patients]” (Patient 1)

This was highlighted again with another participant, who felt the clinician ignored their request for the less stressful insertion option, indicating a failure to acknowledge a patient’s experience.

“I think if they just listen to the patient because I know I am very hard to cannulate and straight off I say can you use the ultrasound, but they always want to try first [without ultrasound]”. (Patient 10)

A participant who had previous encounters with ultrasound procedures shared an instance where their attempts to communicate past experiences were disregarded. Despite offering valuable insights about their body and veins, which could potentially aid in the procedure’s success, their feedback was dismissed. They expressed their intentions not as a critique of the professional’s skills but as a contribution to understanding their unique situation and for better outcomes. The participant commented,

“I am not telling you how to do your job, but rather I am telling you about my body and my veins, where you would get more success”. (Patient 5)

This experience highlights the importance of healthcare professionals considering patient input, especially from those with prior relevant medical experiences, to enhance cannulation success and patient-centred care.

Ignoring a patient’s previous cannulation experiences can lead to profound consequences. This was vividly illustrated by a young patient who shared their distressing journey. The patient pointed out that enduring multiple cannulations from a young age led to heightened anxiety and stress, not just for them but also significantly impacting their family life. The patient emphasised,

"I’m very young and having multiple cannulas you get anxious, you get stressed and it has complicated my lifestyle, it affects the whole family." (Patient 2)

They expressed a desire for their medical team to consider their past experiences. The patient believed that if their suggestions, particularly about consistently using ultrasound for cannulation, were heeded, it could vastly improve their overall situation. This narrative underscores the importance of patient-centred care, where listening to and respecting patients’ knowledge about their bodies can greatly enhance their treatment experience and overall well-being. This scenario underscores the importance of addressing the physical aspects of medical care and considering and supporting the emotional well-being of patients undergoing difficult cannulation.

Discussion

Our study aimed to investigate the characteristics and experiences of patients with difficult intravenous access (DIVA) who underwent ultrasound-guided PIVC insertion. The results revealed three main themes; concern about the competence of non-DIVA specialists, shortage of available ultrasound machines for peripheral cannulation and clinician failure to acknowledge patients’ previous cannulation experiences to help guide procedural success.

This study’s findings contribute to understanding patient experiences with ultrasound-guided PIVC insertion in difficult venous access (DIVA) cases. The results underscore the importance of clinician expertise, the availability of appropriate equipment, and consideration of patient history in improving patient experience and outcomes.

When used by appropriately trained personnel, ultrasound guidance can improve first-insertion cannulation success. It can reduce the time required to gain venous access, to commence clinical treatment and improve patient satisfaction and overall organisational efficiency.^17,18 The participants in this study unanimously recognised the expertise of the specialised DIVA team and the use of ultrasound. This reflects a need for a paradigm shift to improve cannulation practices for DIVA patients through training and better resourcing. The dramatic contrast between the success rates and patient comfort levels with ultrasound compared to traditional cannulation highlights the effectiveness of this technique. The DIVA team’s approach, characterised by calmness, clear communication, and proficiency, starkly contrasts with the often painful and unsuccessful attempts of traditional cannulation.

These findings align with and extend previous research emphasising the need for specialised training in ultrasound-guided PIVC insertion.^13,14 Prior studies that have explored the experiences of patients with DIVA, identified skill deficit as a key factor in the negative experiences with PIVC insertion, and lack of competency to gain venous access on the first attempt, often led to feelings of dread, anxiety and distress.¹⁹ An international cross-sectional survey by Cooke and colleagues²⁰ on patient perspectives on PIVC insertion was heavily influenced by staff training and competence. Patients emphasised how inadequate training can lead to discomfort and distress and how staff competence is crucial for their safety and comfort.

The advantages of ultrasound-guided PIVC insertion, in comparison to traditional techniques for patients with DIVA, have been previously demonstrated, with 1st insertion success rates being up to two and a half times greater.¹⁷ However, the advantages of ultrasound use are diminished by logistical challenges, particularly the availability of both the equipment and training of personnel. It is common for clinicians to lack sufficient training and preparation before performing traditional PIVC insertion. The issue becomes more challenging for these clinicians when faced with patients who suffer from DIVA. The lack of formal hospital structures (such as DIVA pathways) to support difficult insertions leads to futile insertion attempts, causing pain and distress for those who are likely to be the most vulnerable (the young and the elderly).²¹ Our findings echo previous studies that reported patients being negatively impacted by the lack of DIVA policies, insufficient resources (such as ultrasound machines), and inadequate staff training.²²

Participants’ experiences of delays in treatment due to the unavailability of ultrasound equipment highlight a critical area for improvement in hospital resource management. The call for more trained staff in this technique is a clarion call for continuing education and training in advanced cannulation methods. This situation reflects a broader issue in healthcare where technological advancements are not always accompanied by adequate training and resource allocation.²³

Failure to acknowledge patients’ prior cannulation experiences also brought to light a crucial aspect of patient-centred care. Patients’ narratives reveal a disconnect between their knowledge of their bodies and clinicians’ receptiveness to this information. This gap can lead to not only physical discomfort but also emotional distress, as seen in the experiences of younger patients who have endured multiple cannulations.²⁰ A history of DIVA increases the risk of failing to insert a cannula on the first attempt. Patients who have had trouble with peripheral cannulation in the past are more likely to experience premature PIVC failure. In a recent systematic review of 121 studies on defining DIVA, all of the included literature definitions incorporated a history of difficult venous access as part of the definition or risk assessment.^7,24 This highlights the importance of a more holistic approach to cannulation for DIVA patients, one that respects and incorporates patient history and preferences into treatment plans.

Our study findings have significant implications for clinical practice and policy. They emphasise the need for better ultrasound-guided cannulation training, increased equipment investment, and a shift towards more patient-centred communication strategies. Hospitals and healthcare systems must recognise the multifaceted benefits of ultrasound-guided PIVC insertion, not just in increasing the success rate of cannulations but also in improving patient satisfaction and emotional well-being.

Limitations

Participants were recruited from a single hospital in Southwest Sydney, and their experiences may reflect the practices unique to that setting. If the study were conducted in other hospitals or healthcare systems with different approaches to ultrasound-guided cannulation, patient experiences might differ.

The study’s exclusion criteria, such as non-English speakers and patients with cognitive impairments, might have led to the omission of valuable perspectives. These groups could potentially have unique experiences and challenges with PIVC insertion, which are not represented in this study.

In light of these limitations, this study still provides significant insights and highlights the need for further research with more diverse populations and in different healthcare settings. Such studies could help validate and extend the findings of this research, contributing to a more comprehensive understanding of patient experiences with ultrasound-guided cannulation.

Conclusion

This study highlights the transformative potential of ultrasound-guided PIVC insertion by skilled clinicians in improving patient outcomes for patients with DIVA. It also sheds light on the gaps in current practices, notably the need for more equipment, personnel training, and a patient-centred approach that acknowledges and utilises patients’ personal medical histories. Addressing these gaps will enhance the efficacy of medical interventions and lead to more compassionate and holistic patient care.