Jean Addis, RN, Patient Care Manager and Jennifer Puck, MD, Medical Director
Pediatric Clinical Research Center (CRC), Clinical Research Services, UCSF CTSI
Bringing better health to more people more quickly!
Challenge:
Tricky Veins Difficult pediatric peripheral
venous access is a common
and frustrating problem for
research clinicians and
participants alike. Multiple
venous access attempts
increase participant pain and
anxiety, and may threaten
commitment to the research
protocol.
Introduction Investigators conducting
outpatient studies at the
Pediatric CRC brought to our
attention their perception that
some participants were
experiencing a large number
of vascular access attempts.
A clinical research review of
literature reported only 53%
to 76% success rates for first
time pediatric cannulation.
Results
Mos '11 Aug Sep Oct
Phleb 92% 98% 95%
PIV 81% 90% 83%
Conclusion
Increased communication
between patient/family and
care givers for early
recognition of “tricky veins” showed a sustained
improvement for successful
PIV insertions and patient
satisfaction. However, obese
patients continue to be an
issue. We recommend training
staff to utilize ultrasound
techniques for PIV access on
obese participants.
Current Evidence-
Based Practice
Suggests: • Warming extremities
• Assuring oral hydration
• Utilizing visualization devices
• Applying topical anesthetic
• Positioning the extremity below
the level of the heart
• Properly applying the tourniquet
• Preventing vein rolling by
holding tension below needle
insertion site
• Involving Child Life Services
play therapists for distraction
and psychological support
• A PCRC nurse participates on
UCSF Benioff’s Children’s
Hospital Vascular Access
Committee
Baseline Rate Identified To validate investigators’
perceptions of excess
unsuccessful vascular access
attempts the PCRC tracked
number of attempts per
participant for a one month
period. First stick success rates
were 92% for phlebotomy and
81% for peripheral IV placement,
significantly better than published
research statistics. However,
some patients were consistently
requiring multiple attempts.
Goals 1.Implement strategies to obtain
first stick success rates for all
phlebotomy to greater then 90%.
2.Improve the experience of
patients with ‘tricky veins.’
Tricky Veins: Approach to Difficult Venous Access
Methods
Implemented •Create a list of returning
participants with challenging
veins
•Flag returning appointments
for these participants and
develop staff action plan for
vascular access
•Educate participants and
family on methods to
increase first time success
rates and enlist their
cooperation with extremity
warming, hydration, topical
anesthesia, and distraction
techniques
•Limit attempts to one per
clinician, with a maximum of
four attempts, and keep
investigator/ study
coordinators informed
•Engage Child Life Services
•Place the following Label on
the back of appointment
card:
[] Drink a lot of water night
before & day of your
apt. No soda!
[] Bring items like movies,
books, music, or stuffed
animal to help you relax.
[] Ask for our Child Life
Specialist to help distract
during procedure.
[] San Francisco is cold so
bring a warm jacket or
blanket to stay warm.
Being cold makes veins
disappear
