Background

Midline catheters are commonly used in patients with poor venous access or those requiring extended peripheral infusions. However, their use is associated with higher costs and potential complications.

Training programs in ultrasound-guided peripheral intravenous catheter insertion reduce the use of midline catheters among hospitalized patients with difficult intravenous access.¹ Educational approaches for ultrasound-guided peripheral intravenous cannulation demonstrate improvements in competence and patient outcomes.²

The INS Infusion Therapy Standards of Practice (Standards) recommend ultrasound guidance for both peripheral intravenous catheter (PIVC) and midline catheter insertion, citing improved success rates and reduced escalation of central venous access.³ At our institution, the vascular access team (VAT) observed a high volume of midline orders, many of which lacked clinical justification. Standard PIVCs placed by unit nurses often fail in patients with difficult vascular access, leading to repeated venipuncture attempts and an increased risk of infection.

Ultrasound-guided peripheral intravenous (UGPIV) catheters, although underutilized, offer a safer and more cost-effective alternative in many cases.⁶ This initiative aligns with principles in “Vessel Health and Preservation: The Right Approach for Vascular Access,” emphasizing early assessment and appropriate device selection to preserve vascular health.⁷

Methods

This retrospective quality improvement study analyzed vascular access data from January 2021 to December 2024. The VAT reviewed all midline orders for clinical justification, considering medication type, duration of therapy, venous anatomy, and potential future access needs. Orders lacking justification were revised in collaboration with providers to substitute UGPIVs when appropriate. Ultrasound-guided PIVCs were placed by trained VAT nurses using ultrasound guidance and standardized aseptic technique.³

The initiative was reviewed by the hospital’s quality improvement committee and deemed exempt from institutional review board oversight; no identifiable patient data were obtained. Data were extracted from VAT logs and the electronic health record, including midline orders and placements, UGPIV placements, device costs, unit-specific utilization, placement time, and complication rates. Descriptive statistics were used to compare trends over time; cost savings were calculated from device cost differentials and avoided midline catheter placements.

Results

Between 2021 and 2024, our hospital observed a significant shift in vascular access practices. Midline catheter orders decreased by 37.71%, whereas UGPIV placement increased by 82.71%. This transition resulted in the avoidance of 2692 midline placements and an estimated cost savings of $511,480 over 4 years.

The device cost comparison was substantial, with UGPIVs priced at $1.53 per catheter compared with $190 for midline catheters. Placement times were shorter for UGPIVs (approximately 5 to 7 minutes) than for midlines (approximately 15 to 20 minutes). These improvements in efficiency and vascular preservation underscore the clinical value of UGPIVs (Table).^4,6

TABLE

Utilization and Cost Savings (2021–2024)

Year	Midline Catheter Orders	Midline Catheters Placed	Midline Catheters Avoided	UGPIV Catheters Placed	Cost Savings
2021	1,854	420	1434	1056	$272,460
2022	913	491	422	1414	$80,180
2023	943	456	487	1969	$92,530
2024	610	261	349	1681	$66,310
Total	4320	1628	2692	6120	$511,480

Abbreviations: UGPIV: ultrasound-guided peripheral intravenous [catheter]

Strengths and Limitations

Strengths of this study include a large, 4-year data set from a real-world hospital setting and multidisciplinary collaboration that facilitated practice change. Limitations include the single-center, retrospective design without a randomized control group and limited, unsystematic patient satisfaction data collection.

Future Research

Future studies should evaluate long-term outcomes of UGPIV use compared with midline catheters in specialized populations such as pediatric and oncology patients. Development and validation of standardized training protocols for UGPIV placement across institutions are also needed.² Multi-center comparative research could expand the evidence base for complication rates, cost-effectiveness, and patient-reported outcomes.

Conclusion

Implementing ultrasound-guided peripheral intravenous catheter placement as an alternative to midline catheters was associated with fewer midline placements, substantial cost savings, preserved upper arm vasculature, and improved efficiency in our hospital. These findings support broader adoption of UGPIVs, with device selection individualized according to patient assessment and the Standards.³

References

1. Amick AE, Feinsmith SE, Sell J, et al. Ultrasound-guided peripheral intravenous catheter insertion training reduces use of midline catheters in hospitalized patients with difficult intravenous access. J Patient Saf. 2022;18(3):e697-e703. doi:10.1097/PTS.0000000000000910

2. Hoskins MJ, Nolan BC, Evans KL, Phillips B. Educating health professionals in ultrasound-guided peripheral intravenous cannulation: a systematic review of teaching methods, competence assessment, and patient outcomes. Medicine (Baltimore). 2023;102(16):e33624. doi:10.1097/MD.0000000000033624

3. Nickel B, Gorski LA, Kleidon TM, et al. Infusion therapy standards of practice, 9th ed. J Infus Nurs. 2024;47(1S Suppl 1):S1-S285. doi:10.1097/NAN.0000000000000532

4. Pare JR, Pollock SE, Liu JH, Leo MM, Nelson KP. Central venous catheter placement after ultrasound-guided peripheral IV placement for difficult vascular access patients. Am J Emerg Med. 2019;37(2):317-320. doi:10.1016/j.ajem.2018.11.021

5. Steege SL, Stout-Aguilar J, Rider C. Using ultrasound-guided PIV insertion in the pediatric population to decrease insertion attempts. J Radiol Nurs. 2021;40(2):157-160. doi:10.1016/j.jradnu.2021.02.002

6. Tran QK, Fairchild M, Yardi I, Mirda D, Markin K, Pourmand A. Efficacy of ultrasound-guided peripheral intravenous cannulation versus standard of care: a systematic review and meta-analysis. Ultrasound Med Biol. 2021;47(11):3068-3078. doi:10.1016/j.ultrasmedbio.2021.07.002

7. Moureau NL, ed. Vessel Health and Preservation: The Right Approach for Vascular Access. Springer. 2024.

Disclosures

The authors declare no conflicts of interest. No funding was received for this manuscript.

Ethical Compliance

All procedures performed in this quality improvement initiative were in accordance with institutional policies and the ethical standards of the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.