How long until you were pretty good at IV starts?

[sweetER]

I am a new grad in ER, and have been on orientation for about two months. I got my required number of IV starts for checkoff purposes pretty quickly, half of which my preceptor coached me through, and now I can't seem to hit a sewer pipe with a 24g. I know practice makes perfect, etc., but I am used to getting things, especially technical skills, pretty quickly. So when I go in and can't get a 20g in a very well hydrated young male with great veins in two sticks and my preceptor goes in a hits it first try, I get SO frustrated. I'm sure it'll get better, but I feel bad for all my patients while I'm getting there... How long did it take before you were pretty good at starting IVs?

[murphyle, BSN, RN]

It probably took me a good six months, total, before I was confident starting lines on adults. My ED preceptors were very good about getting me lots of IV experience, since I told them upfront that I hadn't had a lot in nursing school. (By school policy, we weren't even allowed to attempt venous access as SNs, let alone taught how to do it - hence my MS1 instructors, themselves a pair of old ED nurses, had us sneak down to our clinical hospital's ED in disguise so we could at least learn what veins looked and felt like. Very James Bond. I was 1/1 at that point, and felt pretty good about myself as SNs are wont to do - and then my next attempt was in nursing school preceptorship, when the unit nurses sent me in to start a peripheral line on an SICU disaster who had no veins, whose one and only peripheral was blown, and whose IJ central line was under suspicion of being infected. No, I did not get the stick. Yes, it was a hazing attempt. Farewell, self-confidence, I hardly knew thee.)

Now, a year and change later, I'd say I'm about 80-90% on IV starts on adults, and about 70-80% on kids. (Infants still scare me, but that's another skill I'm improving with practice.) We still have patients for whom I'll go get one of our difficult stick wizards right off the bat - the 90+ y.o. nursing home cases with raging sepsis and no PO intake for the last three days, the bariatric patients who have too much tissue to palpate or for the Vein Viewer to image through, the patients with a good existing hand line but bad AC veins, and I need an 18+ AC to send them to OR or CT angiography - but those cases, too, are getting rarer, and now I'm starting to get asked for difficult stick assistance on other nurses' patients. :)

There was a Web resource I found when I was first starting out, containing all manner of tips and tricks for lining up troublesome IVs. There's some wonderful advice here, including canoehead's about sitting down and taking your time. (Absolutely true, BTW.)

http://www.enw.org/IVStarts.htm

Hope this helps, and good luck!!

[MereBuffNurse, BSN, RN]

It was not until I began my career as an ER nurse that I felt like I had enough practice to begin becoming "good" at IV starts. Prior to that, I worked on a med-surg floor. Most of the patients there already had an IV and if they came out or went bad, we could get away with a 22g.

However, in the ER, most patients require and IV start and it needs to be an 18g or a 20g, and quickly. Practice, practice, practice made me better. I am still learning and still have on and off days.

It also helps to review anatomy to know where veins are so you can look for them. Some people's veins are deeper than others. :)

[iluvivt, BSN, RN]

If were 95 % luck and 5 % skill than I must be one of the luckiest nurses in the hospital. Its assessment and planning and skill. It is just like any other skill....a beautiful mix of talent and practice. Would you say a pro golfer's talent is 95 % luck and 5 % talent?

If you keep on learning and evaluating what may have gone wrong you will continue to grow professionally and get better at it. I know nurses with decades of experince that can hit the broad sideof a barn and those with very little experience have made a dedicated effort to learn and are so much more skilled than the seasoned nurses.

[motivated2nurse]

im 2 years in and still have trouble with the hard sticks, hang in there

[EDNurse74]

Practice, practice, practice. I swear some nurses have magic fingers where they can find veins and put an 18g while I would have used a 24. Now I have my hit and miss weeks. I also have my bloody weeks, which I am going thru now. Every stick I do is messy for some reason. It is the same moon that makes the pts weirder that controls this, I swear!

[AlmostJesus]

I did appx 120 IV sticks in paramedic school between internship and clinicals (about a year long part time) which put me with a good basis. Now that I have started as a paramedic I feel like I am pretty confident with my IV sticks and I am getting good at tough ones. I have found the #1 trick to getting the IV is preparation. If they are obese, go grab a BP cuff and use that as your tourniquet (inflate to somewhere between their sys and diastolic) and then hang their arms down for awhile to use gravity as your friend. You will then have a LOT easier time with finding a decent vein. With many bariatric patients much of the problem with IVs in them is due to the tourniquet not being able to provide enough pressure (It makes sense) When I dont have a cuff, I have had good success with 2 tourniquets spaced 6 inches apart.

Marking your spot with an indent in the skin with a closed pen before you disinfect works well to mark your spot.

With AC IVs in tough patients take the IV needle and bend it slightly to put the needle at a better angle to get the vein

Always use confidence or even if it crosses the line to cockiness, it puts the patient at ease when you come in saying you WILL start the IV on them and if they ask if you are good at IV sticks say yes. If you miss dont give excuses.

Before long nothing will amp you up more than when you get a tough stick first try. I had a patient on Sunday that insisted that there was only one person - a doctor - who has ever gotten an IV on her first try. I took it as a challenge and used the tricks I have learned from here and while she was mentally prepared for multiple sticks I got it in first time which she was extremely surprised about. - I was pumped.

Hope that helps.

[whichone'spink, BSN, RN]

Do any of you use velcro tourniquets? I've seen one ER tech use those and wondered if using a velcro tourniquet is better than using the tourniquet that comes in the IV start kit.

[AlmostJesus]

I actually have one that I have yet to use, I might take that to work next time and see how it goes. Id imagine that it wouldnt yield that great of results due to the inability to get it as tight as a nitrile/latex tourniquet but I could be wrong

[DebanamRN, MSN, RN]

Takes about a year to become really comfortable. After 4 years I'm pretty good. Some days I get every stick first shot, some days (especially if I've been off for a bunch of days) I can't hit anything. Dehydration makes even the biggest veins uncoorperative. I take my time and don't rush. I also had to learn to feel the vein, not look for it with my eyes. Sometimes I sit down with really hard sticks. And do not let the patient intimidate you by saying "I'm a hard stick, you have to use a butterfly, you won't get it, nobody gets it, moan moan moan (I had to have hi-tech when I had my dtr, and am a really hard stick myself, so I get it, but please, give me a break)." Ask the patient where their veins are. Sometimes they look at you funny, but hey, they know better than you do (my good for blood vein is in my left wrist). I find that this is helpful. If the tech got there first and drew blood, ask the tech where the good veins are. We have a great tech that does this for us and it is very helpful. As your confidence grows, you will learn to look for veins in the upper arm, forearm, inner wrist (ouch), and wherever one presents itself. Hang the arm down, let gravity fill the vein. I have also used the two turniquet technique and hot packs. Sometimes I start with a 24G and after hydration move to a bigger line if necessary. And if they use IV drugs, ask them where their good vein is, if they are honest about their IV drug use they will tell you. Lastly, I chat with my patients while starting IVs, it helps distract them and if they are negative nellies, often helps keep them from tensing up too badly. 20g or 18g are great, but I go with the most practical gauge for that particular patient. And we send them for picc lines sometimes. Sometimes you ain't gonna get it no matter what.

[Ernest]

Only advice I haven't seen that I learned in EMS starting IVs in many types of environments:

as you learn, be a scientist doing research.  Keep everything the same as much as humanly possible.  As you work at improving, change one thing at a time.  Before you know it, you will have your own proven method of starting IVs on easy and difficult sticks. 

Also, be confident even when you need to give it to someone else with a different set of eyes.

[LeChien, BSN, RN]

I've done 3 years in the ED and still only feel average, LOL. Everyone's got their skills they're really proficient at, and IVs are not mine. Don't feel badly or beat yourself up over it. ?

[lcb]

I’m brand new in the ER and an extern so I can’t answer this question, but I will say: If you ever have time, watch a good phlebotomist get a hard stick. They are amazing and have so many tricks. I was struggling searching for a vein the other day…the phlebotomist came and rescued me and I learned so much by watching her.