What constitutes an IV insertion "attempt"?

[MunoRN, RN]

This is a spin-off from this thread: Student attempted IV 7 times, alone - General Nursing - allnurses®

The common rule to IV attempts is that each practitioner gets two "attempts", and once 1, 2, or 3 practitioners have failed in their two "attempts", the patient is referred to either a vascular access specialist or the LIP.  

So what is an "attempt"?

I've always considered an attempt to be a single poke and advancement of the catheter, although I do allow myself one 're-aiming' of the catheter if the vein rolls and I feel confident I have the vein cornered and can cannulate it with a single change of direction.

Yet when I do get a vascular access RN involved there is far more 'rooting around' than what I do, although so long as they have some basis for this and they end up being successful I can't really argue.  And then there's Ultrasound guided insertion which kind of has to involve some 'rooting around'.  

So what defines an attempt?  If the tip comes back out of the epidermis is that really that different than if the tip is just a few micrometers from the surface?  If so, Why?

[JKL33]

The device I've been most proficient with is the BD angiocath/Autoguard. For the purposes of this discussion only, I will proclaim that I am very good with it, using one very smooth and quick motion to pierce the skin and vein, advance the cath and retract the needle. I rarely have a situation where the catheter doesn't advance during this fluid motion, which IME usually indicates having pierced the skin but missed the vein by one means or another.

So. Because of all that, I've never become a digger in any way, and rarely have to pull the needle back and re-aim. Most diggers I have observed appear to simply be poorly-competent at starting IVs. In watching their process from start to finish one can predict that they're likely to miss the vein even by things such as how they stabilize the skin and vein, or the angle of their approach.

However,

2 hours ago, MunoRN said:

If the tip comes back out of the epidermis is that really that different than if the tip is just a few micrometers from the surface?  If so, Why?

On the occasion that I have to pull the needle back, even if I pull it to within micrometers of being out, I have not considered this an additional attempt. I have associated "attempt" with the piercing of the skin rather than the vein itself.

Having not previously thought about this topic, I would guess ^ this stems from my idea that attempting an IV is a process which, after selecting the site, begins with a first step of cleansing the skin. Also, if the tip were out and the skin needed to be re-pierced I would re-clean and begin with a new catheter according to what I was originally taught. I believe the rationale, right or wrong, would have to do with microbes on the outside of the skin and the cleansing and new needle process for IMs and IVs if the needle is brought out and will need to pierce the skin again.

I trust this will be an interesting discussion. ?

[TheMoonisMyLantern, ADN, LPN, RN]

In my opinion, if you pierce the skin then you made an attempt, hands down.

I don't dig around when I do an IV or draw blood simply because I know that for me anyway that if I don't hit it right away, I'm probably not going to, and I'm not going to cause the patient discomfort of digging around and not be successful.

That said, I'm not the best with IV's and drawing blood. I have never been good at it, despite a lot of practice, and a lot of helpful mentorship over the years, I just never developed a good feel for it. My hit rate is about 50/50, I hate it because I always wanted to be that person that could throw it in from across the room, but it's not my strength... 

Back to digging around, I know some IV experts that will occasionally do that, but they have a high success rate so I don't really think it's harmful in that case.

Good topic!

[Wuzzie]

For me an attempt is any time you pierce the skin. I will redirect twice and if not successful will stop. However, when redirecting I will only pull back half the length of the catheter and if it requires anymore than that I start over because I initially positioned poorly and success is unlikely. Also when I pull back I pause a few beats before redirecting. Anecdotally this appears to decrease the pain overall as opposed to digging. FTR there are not a lot of things that I’m good at. Venipuncture happens to be one of them...and I’m very good at it. 

[Nurse Beth, MSN]

Could the number of attempts simply be defined by the number of catheters used?

[Wuzzie]

8 minutes ago, Nurse Beth said:

Could the number of attempts simply be defined by the number of catheters used?

Not if someone reuses a catheter after it’s been pulled out which sadly I have seen done. ?

[JKL33]

10 minutes ago, Nurse Beth said:

Could the number of attempts simply be defined by the number of catheters used?

I really don't think so because of the possibility of people jabbing in and out, here and there, making completely separate punctures with the same catheter. Which I have seen, thankfully rarely.

[LibraNurse27, BSN, RN]

1 hour ago, JKL33 said:

I really don't think so because of the possibility of people jabbing in and out, here and there, making completely separate punctures with the same catheter. Which I have seen, thankfully rarely.

I have done this twice during urgent IV insertions where the tip of the catheter accidentally came out a small amount during redirecting. Then I freaked out about if for days on end and kept checking that the patient hadn't developed sepsis. Thankfully no harm done, but definitely taught me to be more careful with how far out pulling the catheter during redirection. As stated above, I only redirect a couple times if I feel I can fix the positioning and get the IV, and not if near anywhere that could hit a nerve.

[klone, MSN, RN]

On 1/23/2021 at 3:13 AM, TheMoonisMyLantern said:

In my opinion, if you pierce the skin then you made an attempt, hands down.

That's my definition as well.

[Guest219794]

2 hours ago, LibraNurse27 said:

I have done this twice during urgent IV insertions where the tip of the catheter accidentally came out a small amount during redirecting. Then I freaked out about if for days on end and kept checking that the patient hadn't developed sepsis. Thankfully no harm done, but definitely taught me to be more careful with how far out pulling the catheter during redirection. As stated above, I only redirect a couple times if I feel I can fix the positioning and get the IV, and not if near anywhere that could hit a nerve.

I have seen this done most frequently by docs during central line.  In reality, what is the problem with this?- assuming the second insertion is into a clean site.  One rationale is that the needle is dulled.  Wonder if there is any evidence of that.  Apparently, it is still sharp enough to pierce the skin, and, chances are if a nurse resorts to this, there will be no patient discomfort anyway.

As far as the "2 attempts" rule.  I think of it as a guideline, and try to do what is in the best interests of the patient. 

 

[LibraNurse27, BSN, RN]

On 1/23/2021 at 3:15 PM, hherrn said:

I have seen this done most frequently by docs during central line.  In reality, what is the problem with this?- assuming the second insertion is into a clean site.  One rationale is that the needle is dulled.  Wonder if there is any evidence of that.  Apparently, it is still sharp enough to pierce the skin, and, chances are if a nurse resorts to this, there will be no patient discomfort anyway.

As far as the "2 attempts" rule.  I think of it as a guideline, and try to do what is in the best interests of the patient. 

I made a (panicked) thread about it when it happened. Some people said no big deal, others said infection risk because the needle is touching the skin again and even though the site is prepped it's not sterile, so same needle shouldn't be taken out after it's touched the skin, then inserted into vascular system. They said unlikely to cause sepsis but in rare cases it could or maybe a local infection at the site more likely. I think it's a small risk but any risk is risk so I won't do it again.

[0.9%NormalSarah, BSN, RN]

I consider an attempt to be a poke of the skin. I don’t take a needle out and use the same one to poke again, even if the site has been cleaned again, I would always use a new catheter. And I would consider that another attempt. As for digging around a little, yeah I’ll do it if I feel confident the vein is right there AND I’m sure I haven’t pierced the vein yet. If I got flash and lost it, I’m out because I know I’ve either gone straight through it and will cause an infiltration, or it’s already blown. 

I generally try twice and then ask someone better. I’ve tried a third time in a pinch when everyone else was busy and I desperately needed an IV.