Date of Graduation

Summer 8-6-2020

Document Type

Project

Degree Name

Doctor of Nursing Practice (DNP)

College/School

School of Nursing and Health Professions

Department/Program

Nursing

Program

Family Nurse Practitioner

First Advisor

Alexa C. Curtis, PhD, MPH, FNP-BC

Second Advisor

Jeremy V. Vergara, DNP, RN, NEA-BC, CENP, CNL

Abstract

Problem

Intravenous (IV) catheter insertion is a necessary skill in the emergency department (ED) for indications such as medications, fluids, and blood transfusions. Occasionally, patients present with difficult IV access (DIVA), requiring multiple insertion attempts and central venous catheter (CVC) placements. Due to the invasive nature of these procedures, patients can experience a great deal of pain and discomfort. Furthermore, although CVCs are necessary in critically ill patients that require hemodynamic monitoring or vasopressor infusions, they can cause several problems. For instance, central-line associated blood stream infections are some of the most common complications and result in increased costs and risks for mortality. Therefore, CVC insertions must be avoided when possible. Surprisingly, one study described that CVCs were actually preventable in 85% of patients with DIVA. Ultrasound-guided peripheral intravenous catheter insertion (USGPIV) is an alternative option for patients with DIVA, and have proven to increase insertion success rates, decrease number of attempts, decrease cannulation times, reduce pain, and improve patient satisfaction.

Context

Due to their bedside training as registered nurses and their additional leadership education at the graduate level, nurse practitioners (NPs) are in a unique position to utilize and champion innovative procedures such as USGPIV insertion to improve patient outcomes. Family nurse practitioners (FNPs) are mainly trained to work in primary care. However, well over half of FNPs that do not work in primary care settings are employed in high acuity EDs (Hoyt & Proehl, 2015). Furthermore, Hoyt & Proehl described that 78% of nurse practitioners had FNP certifications while 10% had acute care nurse practitioner certifications. Due to the presence of FNPs in EDs and the lack of emergency procedural training in primary care curriculum, there is a need for USGPIV education for FNPs that have an interest in working in the ED. The location for this project was online.

Intervention

The intervention involved the development, implementation, and evaluation of a 40-minute pre-recorded USGPIV course video for NPs. Based on the American Institute of Ultrasound in Medicine (2019), the intervention covered the following areas: 1) basic doppler techniques, 2) ultrasound imaging techniques and orientation, 3) techniques for ultrasound guided vascular access, 4) transducer and sterilization techniques, 5) procedure documentation, and 6) competency. Best practices by Gottlieb et al. (2017) were also included, and Sister Simone Roach’s (2002) six attributes of caring behaviors (compassion, competence, confidence, conscience, commitment, and comportment) were incorporated throughout the project. Additionally, information about how to develop and implement an USGPIV program in the ED was discussed. A convenience sample was enrolled from the University of San Francisco Family Nurse Practitioner Program and from the professional career website, LinkedIn.com.

Measures

The primary outcome was the effect of the intervention on participant knowledge of USGPIVs. This was measured by comparing pre- and post-intervention knowledge test scores with a desired improvement goal of 30%. The secondary outcomes measured the effect of learner attitudes of USGPIVs related to the six attributes of caring. Six 5-point Likert items were used for this measure, and the desired goal for these responses was also an increase of 30%. Further participant information including area of practice, desire to work in the ED, and previous USGPIV education were also gathered. Finally, participant satisfaction with the training was assessed.

Results

Out of the 35 candidates that were approached from the University of San Francisco FNP program and LinkedIn.com, 14 responded and were ultimately enrolled. There was a clear difference in the mean test scores before and after the intervention, which was an increase from 48.57 to 95% (46.43%). Therefore, the primary goal of at least a 30% improvement in participant knowledge of USGPIVs was met. The second goal, which was a 30% improvement in attitudes of USGPIVs based on six attributes of caring (Roach, 2002), was also met. The pre-intervention mean responses ranged from 1.29 to 3.86 and significantly increased from 4.36 to 5.00 post-intervention.

Conclusions

This project aimed to provide FNPs with an evidence-based resource to learn about USGPIV insertion and the tools to develop an USGPIV program in their own ED if desired. By using a pre-recorded video, evidence-based information was provided based on the American Institute of Ultrasound in Medicine (2019) guidelines and best practices by Gottlieb et al. (2017), and the six attributes of caring behaviors explained by Sister Simone Roach (2002). The ultimate goals were to achieve a 30% increase in participant knowledge and a 30% mean improvement in participant attitudes of USGPIV, which were both met. Although there were some limitations, including a small sample size, a convenience sample, and limited course delivery options, the data and analysis clearly showed that the intervention was effective. Future iterations of this project should include an in-person class with live demonstrations, hands-on practice, and larger sample sizes.

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