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