CE: Teaching IV therapy to pediatric nurses
Specialized training programs alleviate pain for both patients and practitioners.
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After reading the article you should be able to:
1. Discuss the demographics of the peripheral venous access procedures performed on children.
2. Describe the pediatric IV training program developed at Children's Hospital of Pittsburgh.
3. Discuss the results of a recent survey of nurses and pain management and intravenous therapy in children.
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By DANA ETZEL-HARDMAN, RN, MSN, MBA, CPN
DANA ETZEL-HARDMAN is a training and education specialist at Children's Hospital of Pittsburgh of UPNC in Pittsburgh. She has taught IV therapy for eight years during her 28 years as a pediatric nurse. The author has nothing to disclose. STAFF EDITOR: CATHERINE RADWAN
Starting and maintaining intravenous (IV) therapies in children poses unique challenges to the clinicians responsible for their care.1 Pediatric patients differ physiologically, developmentally, cognitively, and emotionally from adult patients, and vary by age groups from infancy to teen. When using any type of infusion therapy in a child, nurses have a great responsibility to keep the patient safe while infusing the appropriate amount of fluids. Children require smaller doses than adults, lower infusion rates, appropriately sized equipment, the right venipuncture site determined by therapy and age, and distractions during administration of care.2
More than 18 million peripheral venous access procedures, including blood draws and IV insertions, are performed on children in U.S. hospitals each year.3 Contrary to common myths, children, especially infants, do feel pain as adults do.4 In a recent survey taken among members of the Emergency Nurses Association, the Infusion Nurses Society, and the Society of Pediatric Nurses, 96% of participants agreed that inserting an IV line into a fearful, anxious child can be challenging and that as a group, nurses can have an enormous positive impact on their patients' experiences with peripheral venous access pain. For example, nearly all survey participants (92%) agreed that patients and their families would benefit from the use of a fast-acting topical local anesthetic (TLA) prior to needle-stick procedures.3
The Special Need for IV Training at Children's Hospitals
The need for IV training may be especially acute in a pediatric hospital, where peripheral IV insertions and blood draws are among the most frequently reported painful events.3 The risks associated with poor IV technique, including pain, are greater in children, due to their unique physiology and psychology. In fact, recent studies have shown that management of pain that is associated with peripheral venous access procedures is inadequate.5,6 Many organizations now are encouraging interventions to reduce the pain associated with IV insertions, including topical anesthetics or injection and nonpharmacological interventions such as distraction techniques.6,7 Many children's hospitals are fortunate to have a child life specialist, with a background in growth and development of children, on staff to assist during a procedure. Together, the child life specialist, the nurse, and the parent can use age-appropriate distracters, such as allowing a toddler to "blow bubbles" during the insertion.
Children's anatomy also can be a major factor when inserting a peripheral IV. The nurse must be able to visualize or palpate veins that are small, fragile, and hard to locate.
Children may not tell you it hurts; or, they may tell you it hurts, but mean they just don't like having it done. It is difficult to explain to a young or developmentally delayed child that what you are attempting to do can make them feel better. Children are curious and many times may try to take the catheter out once it has been placed. "Twiddler syndrome" has been coined in the literature to describe when a child begins to manipulate the venous access device, causing the catheter to become dislodged and infiltrate the site.8 Properly restraining the child and securing the IV is important in the training to lessen IV complications and increase catheter dwell time.9 Additionally, preparing the family and child for the procedure is just as important. IV practitioners also must be attuned to parental involvement, including emotional responses.
At Children's Hospital of Pittsburgh, we find that IV failures usually are due to infiltration of the IV. Also, the observation required by the bedside nurse to assess the IV site for complications can be challenging. Other complications, such as phlebitis, are not as prevalent in children, but we do see hematomas that can occur from perforation of the vessel during insertion or manipulation of the catheter. Our current policy permits only two IV attempts from a first and a second nurse, after which a physician must be notified in order to determine what needs to be done, unless it is an emergency. An IV Team was established in 2005 to assist the bedside nurse with IV insertions, although all nurses still are educated on IV insertion.
Experts recommend that pediatric nurses get special pediatric IV training before trying to access sites they wouldn't use in an adult, such as the scalp or foot. Practitioners should give the patient an age-appropriate explanation of the procedure and perform the IV insertion outside the child's hospital room to keep the room as a safe haven for the patient. Nurses should be honest, telling the child the procedure will hurt, but only for a short time, and that it is all right to cry. They should allow the child to keep a comfort item, such as a stuffed animal or blanket, and encourage the parent to be present.
After choosing a site based on the type and duration of IV therapy and the patient's development level, the practitioner should warm the site, administer a TLA, use a tourniquet appropriate for the child's size, and use a small-gauge catheter. In infants and small children, veins can be located by transilluminating the skin with a bright light. Using a vein viewer, an imaging device that uses near-infrared light to show a "roadmap" of the patient's veins directly on the surface of the skin, can help distract a child and show both patient and parent where the needle will go.10
In many hospitals, the child life specialist can help parent and child cope with the stress of invasive procedures such as peripheral venous access through education, distraction techniques, and support.11
Some hospitals permit only two IV sticks, by a first and a second nurse, after which a doctor must be called for an evaluation, except in situations deemed emergencies. Other experts suggest that specialized staff, such as intensive care nursery, anesthesia, or vascular surgeons, also may be called upon to initiate vascular access for some patients.12
In addition to these patient-care issues, nurses need to know what to document and the particular equipment, procedures, and policies required by the hospital to perform IV therapies according to standards outlined by the Intravenous Nurses Society. 13
Historically, initial IV training at Children's Hospital of Pittsburgh was accomplished through self-learning packets that included printed material and a video on how to start an IV. Trainees were paired with a preceptor, who would give a demonstration, then observe the trainee attending to real pediatric patients. After several successful IV procedures, the preceptor would sign off on the trainee as capable. A formal instruction, accounting for the special considerations necessary to safeguard children undergoing IV procedures, was needed.
Today, our training course consists of two parts. The first part of the course is a two-hour lecture on IV access tools,1 instruction in IV access procedures, and a review of hospital policy. Instructional material for this presentation draws from a number of sources. Anyone setting up an IV class will want to refer to the most current standards by the Intravenous Nurses Society, which discuss anatomical, physiological, and infection-control principles; various treatments and modalities, such as parenteral fluids, blood and blood components, pharmacological agents, nutritional solutions, antineoplastic agents, and pain medications; and finally, the legal and ethical aspects of infusion practice. The lecture part of the course also includes an overview of hospital policy, IV access tools and catheters, and the hospital's guidelines on proper taping and securing of the catheter.
The second part of the class provides a rotation through three training stations: 1) two types of IV pumps, 2) a mannequin arm, and 3) an IV access simulator. This hands-on section reinforces the technical and cognitive aspects of IV procedures. It also illustrates aspects of pediatric physiology and psychology, presents a context for discussing aspects of establishing rapport with patients and their parents, and underscores the fine points of proper documentation. This last point is significant because the course exposes nurses to the hospital's perspective regarding documentation, which, if performed correctly, can supply legal protection for both nurses and institution.
IV access tools
IV pump stations—The IV pump stations give trainees hands-on experience with connecting and adjusting the actual devices we use to control drug flow—an important part of safe and successful IV access. Nurse trainees are shown both mini (syringe)- and large-volume infusion pumps used by the hospital. Large-volume pumps use a weight-based program and the mini (syringe) pumps use smart pump technology to reduce errors in programming. Depending on their experience, trainees spend from 15 to 30 minutes practicing stringing the IV tubing, programming the pumps, and making adjustments.
Mannequin arm station—The mannequin arm station gives hands-on practice in palpating and securing the IV with a clear transparent dressing that allows better visualization of the site. The IV site never should be covered by tape or other securing devices except a clear plastic shield that can be easily removed and that prevents the child from touching the site. Each trainee performs two sticks with two different catheters that are used at the hospital. All nurses need to understand the design and safe practice of these devices.
Simulator station—We use the simulator for realistic practice on starting the IV, including: choosing a site, needle angle, the feel of insertion, and perfecting technique. Each trainee spends about 15 to 20 minutes on the system. In addition, several of its visual aides on anatomy support discussions on child physiology and how to properly document patient care.
The simulator is helpful for the IV course and for informal training. Nurses like hands-on practice, and they can improve both their self-confidence and their IV technique through the repetition.
Research also supports simulator validity for IV training. A clinical study found that simulation "was judged to be adequately realistic and highly useful for medical student training."14 The National League for Nursing finds that use of simulation is growing. In its report on educational trends, the league found that use of simulation ranks among the top five of 42 teaching items that received more emphasis in 2003 than in 1998 and that it "is expected to have greater emphasis in 2008."15Advances in Human Simulation Education noted: "[Pediatric simulators are] an obvious asset in the practice and mastery of procedural skills, but the largest benefit of simulation is the simultaneous integration of technical and cognitive skills. The ability to recognize and evaluate threatening situations, choose appropriate interventions, and then perform required technical skills in real time makes pediatric simulation invaluable."16
Integration of technical and cognitive skills
The simulator's pediatric module provides four cases, each introduced with a picture, medical background, and instructions for IV access. Advancing through all four of the module's cases provides practice in accessing the greater saphenous vein of an infant, the dorsal hand/inner wrist of a toddler, the scalp vein of a neonate, and the antecubital vein of a child.
The variety of access points is an important aspect of pediatric care, and the simulator supports both the information and the technique needed to provide that care in a way that other tools do not. The cases give the class an opportunity to examine different sites, their specific anatomies, and the steps needed to access the veins within.
In a virtual-reality environment, trainees can prepare "the patient" for insertion of the IV catheter, apply a tourniquet and arm board (if needed), use proper aseptic technique, choose an appropriate needle size from a menu, select an appropriate site for insertion, palpate, retract "the skin," insert the cannula into the vein, thread the catheter, remove the needle, and respond to a variety of challenges. (See "The Importance of IV Assessment".)
Trainees must discriminate which piece of equipment to use in what order, and they cannot progress with the procedure unless the sequencing is correct. The environment is realistic in a number of ways. When a trainee palpates the skin, the vein "pops up" as expected and alcohol gives a sheen to the skin. The simulator also includes realistic force feedback that lets students feel the "pop" of venipuncture and of advancing the catheter, which helps support safe procedures and proficient technique.
Many students initially have problems advancing the catheter, and the simulator helps them correct their technique. Often they do not understand why they need to use a one-handed or two-handed technique. If a trainee releases the catheter, a hematoma results. This simulated complication quickly highlights the problem so the trainee is able to correct it.
Also, trainees often think that veins are deeper than they really are, and teaching a zero- to 10-degree angle, depending on whether they can see the vein or not, can correct the problem. If a trainee is having problems going too deep, the instructor can show them the simulator's transparent and side views. This visual aid helps them grasp the anatomy, and they immediately begin going in at a lower angle, which corrects the problem.
Skill plus knowledge equals care
Nurses have said that the hands-on training is key, and they like the simulated patients' realistic responses. For example, the simulated "kids" cry. In real life, nurses must deal with stressful situations, such as babies crying and parents who protest. The audio element gives trainees a glimpse of actual pediatric situations that might occur. This bit of virtual reality encourages questions and develops an understanding of what it's like to administer an IV to a child. We find our trainees are more prepared as they take on their new responsibilities.
An IV access-training course, especially for pediatric hospitals, helps nurses, patients, and the hospital. Nurses and patients benefit from the training because the psychomotor and critical thinking skills necessary for placing IVs are first reinforced on virtual patients. Integrating knowledge and technique leads to correct IV procedure that supports better patient care.
1. Intravenous Nurses Society. (2001). Infusion therapy in clinical practice (2nded.). Philadelphia: W.B. Saunders Co.
2. Rosenthal, K. (2005). I.V. Essentials: Kid's stuff: Starting I.V.s in peds. Nursing Made Incredibly Easy, 3(4). Retrieved Oct. 8, 2008. http://www.nursingcenter.com/Library/JournalArticle.asp?Article_ID=592110
3. Anesiva Inc. (May 8, 2008). New survey finds enhanced pain management for blood draw and IV insertions in children would benefit patients, families, and nursing staff. Retrieved Oct. 8, 2008. http://investors.anesiva.com/releasedetail.cfm?ReleaseID=308997
4. American Medical Association. (Sept. 2007). Pediatric Pain Management. Retrieved Oct. 10, 2008. http://www.ama-cmeonline.com/pain_mgmt/printversion/ama_painmgmt_m6.pdf
5. Bhargava, R. & Young, K. D. (2007). Procedural pain management patterns in academic pediatric emergency departments. Academic Emergency Medicine, 14(5), 479-482.
6. MacLean, S., Obispo, J., & Young, K. D. (2007). The gap between pediatric emergency department procedural pain management treatments available and actual practice. Pediatric Emergency Care, 23(2), 87-93.
7. Registered Nurses for Venipuncture Optimization Through Increased Comfort and Education. (2008). Comfort tips. Retrieved Oct. 16, 2008. http://www.manageivpain.com/comfort_tips/default.aspx
8. Browne, N. T. (2006). Nursing Care of the Pediatric Surgical Patient (2nd ed.). (p. 55). Sudbury, MA: Jones & Bartlett Publishers.
9. Tripathi, S., Kaushik, V., & Singh, V. (2008). Peripheral IVs: Factor affecting complications and patency—a randomized controlled trial. Journal of Infusion Nursing, 31(3), 182-188.
10. University of South Alabama Health System. (July 20, 2007). Revolutionary vein-viewing technology comes to USA Children's & Women's Hospital. Retrieved Oct. 9, 2008. http://www.southalabama.edu/usahealthsystem/pressreleases/2007pr/072007.html
11. Registered Nurses for Venipuncture Optimization Through Increased Comfort and Education. (2008). Hospital 101: 411 from Dr. Sears: Power to the parents: 10 tips to help your child (and you!) cope with a hospital visit. Retrieved Oct. 9, 2008. http://www.manageivpain.com/parents/dr_sears.aspx
12. Trimble, Tom. (2008). I.V. starts—improving your odds! Emergency Nursing World. Retrieved Oct. 8, 2008. http://enw.org/IVStarts.htm
13. Intravenous Nurses Society. (2006). Infusion nursing standards of practice. Journal of Infusion Nursing, 29(1 Suppl), S1-S92.
14. Reznek, M. A., Rawn, C. L., et al. (2002). Evaluation of the educational effectiveness of a virtual reality intravenous insertion simulator. Academic Emergency Medicine, 9(11), 1319-1325.
15. Streubert, S., Helen, J., & Jacobson, L. (March 2005). Trends in registered nurse education 1998 to 2008: A report of a national study on basic RN programs. National League for Nursing.
16. Fiedor, M. L. (2004). Pediatric simulation: A valuable tool for pediatric medical education. Advances in Human Simulation Education, 32(2), Suppl., S72-S74.
17. Ours, J. L. & Dennis, M. M. (2001). Competent I.V. management, Part 1. Nursing Management, 32(7), 19-20.
18. Gardner, S. & Hagedorn, M. (1997). Legal aspects of maternal-child nursing practice. Menlo Park, CA: Addison-Wesley.
THE IMPORTANCE OF IV ASSESSMENT
Infiltration, extravasation, nerve injuries, venous thrombosis, and catheter fractures are the main areas in which nurses are identified as defendants in catheter-related malpractice lawsuits.17 Properly securing and assessing the IV site can provide a defense, as illustrated by this case:
Lack of Assessment
Two-year-old Casey was admitted to a local pediatric unit for dehydration secondary to diarrhea. An IV was started in her foot, and she was given fluids with potassium chloride added when her urinary output was sufficient. Several hours after admission, a nurse noticed that Casey's foot with the IV site appeared discolored. The nurse removed the copious dressings covering the site and the lower leg and found a very large infiltration. Further assessment of this leg showed marked circulatory compromise. Appropriate emergency measures were implemented, and Casey was transferred to a tertiary care center, where she underwent a fasciotomy in an attempt to restore her circulation. She had two additional surgical procedures, and two weeks later was discharged home with extensive physical therapy and plastic surgery follow-up.
Although IV therapy in pediatric patients is associated with several risks, cases like this are difficult to defend. Standards of practice mandate that specific nursing interventions are needed to prevent complications. Agency policy and procedure, the Centers for Disease Control Guideline regarding IV care, and the American Nurses Association Standards of Practice define criteria for nursing accountability in the practice of IV therapy. It is estimated that up to 11% of IV lines have been reported to infiltrate in the pediatric population, causing problems with tissue necrosis, pain, scarring, nerve damage, or amputation. Prolonged hospitalization, corrective surgery, and the need for additional follow-up care complicate the situation. 18