Improving Peripheral Venous Puncture Outcomes in ICU via Vein Grading Management

Introduction

Peripheral intravenous catheters (PIVCs), also referred to as peripheral venous catheters (PVCs), are the most widely used vascular access devices in clinical practice, with over 80% of hospitalized patients globally requiring their use [1,2]. In the intensive care unit (ICU), where patients often present with compromised physiological functions and complex, rapidly changing conditions, PIVCs play a critical role in emergency fluid resuscitation, enabling timely management of critical conditions and replenishment of lost nutrients and energy [3–5]. A Chinese survey indicated that 60% to 90% of hospitalized patients require PIVCs for treatment [6].

In recent years, advances in intravenous therapy techniques have prompted clinical managers to standardize operational procedures for various venipuncture tools and develop tailored nursing measures for diverse clinical scenarios. However, in actual clinical practice, nurses frequently select veins based on personal experience, with limited consideration of the compatibility between their venipuncture skills and the condition of the patient’s veins [7]. This has contributed to a high failure rate in peripheral venous puncture, ranging from 25% to 35% in clinical settings [8–10]. The condition of the veins is the most direct and critical factor influencing venipuncture success [11], while the nurse’s proficiency in venipuncture skills also significantly impacts outcomes [12].

Although vascular grading matching has become popular in pediatrics [6,13,14], its application in ICU settings remains unexplored. ICU patients typically have more severe conditions compared to those in other departments, often exhibiting symptoms such as edema, shock, and fluid deficiency, which adversely affect vascular accessibility [15,16]. Consequently, nurses face greater challenges in achieving successful peripheral venous puncture in ICU patients, resulting in higher failure rates [17].

To address these challenges, this study introduced a graded matching management system for venous access in ICU patients. This system established venous grading standards tailored to ICU patients and concurrently assessed the venipuncture skills of ICU nurses. By matching nurses with appropriate skill levels to patients with corresponding venous grades, the study aimed to improve the first-attempt success rate of venipuncture, reduce patient discomfort, and improve overall nursing care for non-emergency ICU patients with generally poor conditions.

Material and Methods

STUDY PARTICIPANTS:

This study used a convenience sampling method to recruit ICU inpatients from Peking University People’s Hospital between July 1, 2022, and June 30, 2023. Inclusion criteria were age ≥18 years, needed peripheral venous catheterization, and voluntary participation with signed informed consent (for patients unable to provide consent, family members signed on their behalf). Exclusion criteria were hematological diseases or severe coagulation disorders, and patients undergoing emergency resuscitation. A historical control design was adopted, with patients divided into 2 groups based on the enrollment period. The control group comprised 256 patients enrolled from July to December 2022, while the intervention group included 256 patients enrolled from January to June 2023. A total of 38 nurses participated in the study, including 31 females (mean age: 32.5±5.1 years) and 7 males (mean age: 23.2±1.7 years). The nursing staff consisted of 7 head nurses, 15 registered nurses, and 16 staff nurses. Among them, 23 nurses had more than 5 years of work experience, 9 had 3–5 years, and 6 had less than 3 years.

The study protocol was reviewed and approved by the Scientific Committee and the Ethics Review Committee of Peking University People’s Hospital (Ethics Approval No: 2022PHB198-001). All participants or their legal representatives provided written informed consent prior to enrollment.

INTERVENTION METHODS:

The same model of indwelling needle (B. Braun safety intravenous indwelling needle, 22G) and standardized clinical procedures for venipuncture were used in both groups. The indwelling needle used in this study was manufactured by B. Braun Medical Industries Sdn. Bhd. (Bayan Lepas Free Industrial Zone, 11900 Penang, Malaysia). The parent company is B. Braun Melsungen AG, headquartered in Melsungen, Germany. The product is imported and distributed in China by B. Braun Medical (Shanghai) International Trade Co., Ltd. According to the Infusion Nurses Society (INS) guidelines, 20–22G peripheral intravenous catheters are appropriate for adult patients. In this study, the 22G catheter was primarily used for intermittent intravenous medication administration, fluid resuscitation, blood transfusion, and short-term nutritional support in ICU patients without immediate indications for central venous access. For patients requiring long-term infusion of vasopressors or total parenteral nutrition (TPN), central venous catheterization was performed instead. Peripheral venous vascular grading was performed for all patients in both groups.

In the control group, conventional intervention methods were applied. Patients did not undergo matching based on nurses’ venipuncture skill levels, and the assigned nurse performed the routine peripheral venous indwelling needle puncture without consideration of venous grading. In the intervention group, a targeted approach was implemented. Patients were matched with nurses whose venipuncture skill levels corresponded to the grading of their peripheral venous vascular condition. This matching ensured that nurses with appropriate expertise performed the peripheral venous indwelling needle puncture based on the patient’s venous grade.

All peripheral venous catheterizations were performed on upper-limb veins, including the dorsal hand venous network, superficial forearm veins, and median cubital veins. Lower-limb veins were avoided due to their higher risk of thrombosis and swelling, and were not used during this study.

ESTABLISHMENT OF PERIPHERAL VENOUS VASCULAR GRADING STANDARDS:

The grading standards for patients’ peripheral venous vessels were initially developed based on the clinical practices of the department and tailored to the specific characteristics of ICU work. To refine these standards, consultations were conducted with 4 ICU nursing experts, all of whom held associate senior titles or higher. Based on their expert recommendations, the peripheral venous vessels of ICU patients were classified into 4 grades (I to IV), as detailed in Table 1. To improve the consistency of vein diameter estimation, nurses used a bedside visual aid card printed with 1 mm and 2 mm reference scales during vein assessment. When visual estimation was difficult – such as in patients with obesity, edema, or unclear anatomy – nurses confirmed the diameter through palpation and, when necessary, by using portable ultrasound. This multimodal approach helped improve objectivity and grading reliability. Higher grades indicated increased difficulty in achieving successful peripheral venous puncture.

ESTABLISHMENT OF NURSING PUNCTURE ABILITY GRADING STANDARDS:

This study integrated the specific characteristics of ICU work to establish a grading system for nurses’ venipuncture abilities, which was assessed based on standardized evaluation criteria. During the intervention period, nurses in the treatment group underwent monthly assessments to re-evaluate their venipuncture abilities and ensure continuous skill alignment.

A dedicated review team was formed for this study, comprising 1 head nurse and 2 senior nurses, each with over 10 years of clinical experience. Beginning at the initiation of the intervention group’s treatment, the review team conducted monthly evaluations of the participating nurses. These assessments were based on standardized operating procedures and clinical evaluations of patients classified as Grade II for venous access. Grade II veins were selected because they represent a clear boundary between easily accessible and difficult-to-access peripheral veins. These veins are generally faintly visible and palpable, offering a moderate level of venipuncture difficulty. This makes them particularly suitable for objectively and consistently evaluating nurses’ venipuncture skills, avoiding both under- and over-estimation of their technical ability. Following each assessment, the nurses’ venipuncture abilities were re-graded, with higher grades reflecting stronger proficiency in venipuncture techniques.

Nurses were classified into 3 levels (N1, N2, N3) based on both simulation-based and clinical assessments. The simulation assessment evaluated adherence to standard procedures and operational fluency using a standardized scoring system. The clinical assessment required nurses to perform first-attempt venipunctures on real ICU patients. Specifically, N1 nurses scored below 80 in the mock assessment and successfully completed first-attempt venipuncture in no more than 1 patient; N2 nurses scored 80–90 and succeeded in 2 patients; N3 nurses scored above 90 and succeeded in 3. If a nurse’s scores were across multiple levels, the lowest level was assigned to avoid over-estimation of clinical proficiency and ensure safety in the matching process (Table 2).

CONSTRUCTION OF THE MATCHING SYSTEM:

To ensure smooth implementation of the assessment registration and graded matching venipuncture process, a matching team consisting of 2 senior nurses, each with over 10 years of clinical experience, was established. The matching system was structured as follows: (1) Admission Assessment Registration: Upon admission, regardless of whether intravenous infusion was immediately required, the responsible nurse assessed the patient’s peripheral venous vessels and recorded the vascular grade. The assessment form was then placed at the foot of the patient’s bed for easy reference.; (2) Daily Assessment Registration: Each afternoon, the matching team conducted assessments of the peripheral venous vessels for patients admitted that day. The grading results were documented on the assessment form at the foot of the bed to ensure up-to-date vascular status information; (3) Graded Matching Venipuncture: When a patient required peripheral venipuncture, the matching team contacted a nurse whose puncture skill level corresponded to the patient’s vascular grade to perform the procedure. Specific requirements included: 1)N1 level nurses were authorized to puncture Grade I to II peripheral venous vessels, N2 level nurses were authorized to puncture Grade II to III peripheral venous vessels, and N3 level nurses were authorized to puncture Grade III to IV peripheral venous vessels; 2) Senior nurses were permitted to perform venipunctures for patients with lower vascular grades, while junior nurses were restricted from operating beyond their designated skill level. Following the venipuncture, the matching team evaluated the results and provided appropriate health education to the patient. The workflow for graded matching venipuncture is illustrated in Figure 1.

STAFF TRAINING:

All nursing staff involved in the study had previously undergone standardized training and assessment in peripheral intravenous therapy, as mandated by the hospital. To ensure ongoing competency, the head nurse of the department conducted monthly random bedside assessments of peripheral intravenous therapy practices. Nurses who did not meet the required standards were required to re-participate in departmental training and reassessment. At the initiation of the intervention, a unified monthly training session was organized to familiarize nurses with the grading standards for peripheral veins. Additionally, an ICU peripheral vein grading standard card was developed, tailored to the characteristics of nursing work, and displayed at the foot of each patient’s bed. This card served as a quick reference to help nurses consistently apply the grading standards, ensuring uniformity in peripheral vein assessments.

OBSERVATION INDICATORS:

The following outcomes were compared between the 2 groups: venipuncture time, retention days, one-attempt success rate, and complication rates. Venipuncture time was defined as the time from the nurse’s initial assessment and selection of the target vein to the successful completion of catheter insertion and secure fixation with sterile dressing. Retention days is the number of days the catheter remained in place. One-attempt success means the venipuncture was successfully completed on the first attempt, excluding cases requiring multiple punctures or repeated attempts at the same site. Complications such as phlebitis, fluid leakage, subcutaneous hematoma, and catheter blockage during the catheterization period were recorded and compared between the 2 groups. The diagnosis of phlebitis was based on the standards established by the American Society of Infusion Nurses [18].

STATISTICAL METHODS:

Statistical analysis was performed using SPSS 22.0 software. Normally distributed quantitative data were described using the mean±standard deviation (χ̄±s) and compared between groups using one-way ANOVA. Skewed distributed quantitative data were described using median (25^th percentile, 75^th percentile) [M (P25, P75)] and compared between groups using the Mann-Whitney U test. Qualitative data were described using frequency (percentage) [n (%)] and compared between groups using the chi-square test or Fisher’s exact test, as appropriate. Unless otherwise specified, the significance level for all statistical tests was set at α=0.05.

Results

COMPARISON OF BASELINE CHARACTERISTICS BETWEEN THE 2 GROUPS:

This study included a total of 512 patients, with 256 patients in the control group and 256 patients in the intervention group. Baseline characteristics, including sex, age, hypovolemic shock, SOFA score, and peripheral venous vascular grading, were compared between the 2 groups. No statistically significant differences were observed in these variables (P>0.05), confirming that the groups were well-balanced at baseline. A detailed comparison of baseline characteristics between the 2 groups is presented in Table 3. In particular, the comparable SOFA scores and venous grading distributions between the 2 groups indicate that patients had similar severity of illness and peripheral vascular conditions at baseline. This supports the validity of subsequent comparisons regarding venipuncture performance and outcomes.

COMPARISON OF PERIPHERAL VENOUS PUNCTURE OUTCOMES BETWEEN THE 2 GROUPS:

The comparison of peripheral venous puncture outcomes between the 2 groups revealed significant differences in key measures. The intervention group had a shorter peripheral venous catheterization time compared to the control group (Z=−3.170, P=0.002). Additionally, the intervention group had a significantly higher first-attempt success rate than the control group (χ2=22.709, P<0.001). No statistically significant differences were observed in other measured outcomes. Detailed results are presented in Table 4.

Discussion

The ICU is a specialized medical unit responsible for managing critically ill patients. Studies indicate that 60% to 90% of ICU patients require PIVCs [19], making PIVC insertion an important component of the ICU clinical workload. Given the high work intensity and frequent staffing shortages in ICUs, effective hierarchical management is essential. By assigning patients with poorer conditions to experienced and highly skilled nurses, hierarchical management ensures the proper implementation of nursing measures, enhances nursing quality, and improves work efficiency [20]. This study demonstrated that implementing hierarchical matching management of venous vessels significantly reduced the time required for PIVC insertion (Z=−3.170, P=0.002) and improved the overall efficiency of ICU nurses.

The ICU has a high volume of complex and technically demanding tasks, often accompanied by significant clinical risks. Hierarchical matching management provides clinical managers with a clearer understanding of nursing workflows, enabling better allocation and supplementation of nursing staff. This approach not only reduces the overall work intensity for ICU nurses but also highlights the value of highly skilled nurses, enhancing their professional recognition. Simultaneously, it motivates less experienced nurses to improve their skills, offering them opportunities for growth and contributing to the overall development of nursing standards within the department.

Kassahun et al [21] reported that 29.7% of adult patients experience failure during the first attempt at venous puncture. In this study, the implementation of graded matching management significantly reduced the first-attempt failure rate to 13.7%, compared to 31.3% in the control group. To ensure technical consistency and reduce confounding factors, all peripheral venous catheterizations in this study were performed on upper-limb veins. These included the dorsal hand venous network, superficial forearm veins, and the median cubital vein – sites known for their relative accessibility and lower complication risk. Lower-limb veins, such as the great and small saphenous veins, which carry higher risks of thrombosis and edema, were avoided entirely during the study period. This standardization minimized variability in venipuncture difficulty caused by anatomical site differences. Previous research has shown that successful first-attempt venipunctures are associated with a lower risk of adverse events [22]. Repeated venipuncture not only causes physical and psychological distress to patients but also increase the risk of complications due to vascular wall damage [23].

Peripheral venous catheterization is a common yet critical nursing procedure. Improper execution can lead to unnecessary patient suffering, increased medical costs, and even life-threatening complications, potentially resulting in medical disputes [24]. This study introduced a graded matching management system for peripheral venous access, which involved scientifically assessing patients’ venous conditions and assigning nurses with corresponding skill levels to perform the venipunctures. This approach significantly improved the first-attempt success rate (χ2=22.709, P<0.001), enhancing patient trust in nursing staff and increasing overall satisfaction. Additionally, it reduced the incidence of nursing complaints and adverse events, contributing to a safer and more efficient clinical environment.

Although this study did not find statistically significant differences in complication rates such as phlebitis, infiltration, or hematoma between the 2 groups, previous studies have shown that multiple venipuncture attempts can cause mechanical injury to the vascular endothelium and surrounding tissue, thereby increasing the risk of such complications [25,26]. Therefore, improving the first-attempt success rate is not only important for patient comfort and procedural efficiency but may also serve as an effective strategy to minimize vascular-related complications. Graded venous access management allows nurses to select the optimal puncture strategy based on the patient’s vascular condition, minimizing vessel damage and indirectly lowering complication rates. Furthermore, the improved venipuncture success rates enhance patient satisfaction with nursing care, potentially reducing the frequency of nursing complaints. Although this study focused on procedural and nursing-related outcomes, improvements in vascular access practices may indirectly benefit patient prognosis by enhancing treatment efficiency, reducing catheter-related complications, and minimizing care delays in the ICU setting.

However, several limitations should be acknowledged. First, there is currently no unified or scientifically validated standard for grading nurses’ venipuncture abilities. This study relied on departmental clinical practices to grade nurses’ skills, and future high-quality research is needed to establish more reliable and balanced grading criteria. Second, this study was conducted as a single-center, non-randomized controlled trial, which may have introduced selection bias and confounding factors. The chronological grouping of participants could also have influenced the results. Future studies should control for additional independent variables and compare nurse skill grading across groups to further validate the effectiveness of graded venous access managements.

Conclusions

This study demonstrates that implementing hierarchical matching management for peripheral venous access in ICU patients significantly reduces venipuncture time, improves first-attempt success rates, and enhances nursing efficiency. By matching nurses’ skill levels with patients’ venous conditions, the approach minimizes patient discomfort, reduces the risk of complications, and increases overall satisfaction. Overall, graded venous access management is a promising strategy to optimize clinical outcomes and nursing quality in ICU settings.