Vascular Access Device Insertion

Establishes standards for the safe insertion of all vascular access devices, including peripheral intravenous catheters, central venous access devices, and arterial catheters, with requirements for aseptic technique, ultrasound guidance, and complication management.

policies•Jan 2025•Vascular Access Procedures

Vascular Access Device Insertion Policy

1. Policy Statement

It is the policy of this organization that the insertion of all vascular access devices (VADs) shall adhere to evidence-based foundational standards encompassing sterility, manufacturer compliance, aseptic technique, and patient education, and that clinicians shall employ appropriate insertion bundles, visualization technology, and complication management protocols to ensure patient safety and procedural success across all VAD types and clinical settings.

2. Purpose

This policy exists to:

  • Establish foundational insertion standards applicable to all vascular access device types
  • Define requirements for peripheral intravenous catheter and midline catheter insertion, including bundle implementation, DIVA assessment, attempt limitations, and immediate removal indications
  • Establish standards for central venous access device insertion, including central line bundle elements, ultrasound guidance, PICC-specific requirements, complication management, and tip location verification
  • Define personal protective equipment and sterile precaution requirements for arterial catheter insertion
  • Ensure patients and caregivers receive appropriate education prior to VAD insertion

3. Scope

This policy applies to:

  • All licensed clinical personnel performing vascular access device insertion in any care setting
  • All vascular access device types, including short peripheral intravenous catheters (PIVCs), long PIVCs, midline catheters, peripherally inserted central catheters (PICCs), tunneled and nontunneled central venous catheters, implanted vascular access ports, and arterial catheters
  • All care settings within this organization where vascular access device insertion is performed, including acute inpatient, ambulatory, procedural, perioperative, intensive care, and emergency settings
  • Adult, pediatric, and neonatal patient populations

4. Policy Requirements

4.1 Foundational Insertion Standards

4.1.1 Sterility and Single Use. Each catheterization attempt shall employ a new, sterile vascular access device. This requirement includes the needle used for venipuncture or arterial puncture and any introducer components. Device reuse between attempts is contraindicated due to contamination risk and potential structural compromise.

4.1.2 Manufacturer Compliance. Vascular access devices shall not be altered outside the parameters specified in the manufacturer’s directions for use. Modifications to device length, materials, or configuration may compromise device integrity and patient safety and are prohibited.

4.1.3 Tip Location Verification. For all central venous access devices (CVADs), appropriate tip location shall be verified prior to initiating infusion therapy. Acceptable confirmation methods include fluoroscopy, electrocardiography-based tip location systems, and other validated verification techniques.

4.1.4 Patient and Caregiver Education. Prior to insertion, patients and caregivers shall receive education regarding the rationale for VAD placement and what to expect during the procedure.

4.2 Peripheral Intravenous Catheter and Midline Catheter Insertion

4.2.1 Institutional Protocols and Bundle Implementation

4.2.1.1 Institutions shall develop and implement local peripheral intravenous catheter (PIVC) insertion bundles to improve insertion success rates and reduce complications. Site-specific protocols shall incorporate evidence-based practices. Standardized bundle approaches have demonstrated measurable improvements in patient outcomes.

4.2.2 Difficult Intravenous Access Assessment

4.2.2.1 When patient assessment reveals no visible or palpable veins, early referral to an infusion or vascular access specialist shall be initiated.1 Delayed escalation contributes to patient discomfort, treatment delays, and vascular damage from repeated unsuccessful attempts.

4.2.2.2 Population-specific difficult intravenous access (DIVA) assessment tools shall be utilized to identify patients who may benefit from specialist intervention or visualization technology.2

4.2.3 Pain Management

4.2.3.1 Insertion-related pain shall be addressed through appropriate pain-relieving measures. Clinical protocols shall incorporate both pharmacological and non-pharmacological interventions to minimize patient discomfort during venipuncture.

4.2.4 Visualization Technology

4.2.4.1 Visualization technology shall be employed to enhance peripheral vein assessment, identification, and selection, particularly for patients with difficult intravenous access. Ultrasound guidance is the standard for improving insertion success in challenging cases.

4.2.4.2 For pediatric patients, dynamic needle tip positioning during ultrasound-guided peripheral venous catheterization shall be utilized when available. This technique involves continuous visualization of the needle tip during advancement, allowing real-time trajectory adjustment, and has demonstrated improved first-attempt and overall success rates.

4.2.5 Long Peripheral Intravenous Catheter Selection

4.2.5.1 Long PIVCs are indicated when standard PIVC criteria are met but the target vessel is difficult to palpate or visualize without technological assistance.

4.2.5.2 When the vessel cannot be adequately assessed through visual inspection or palpation alone, ultrasound guidance shall be used to facilitate catheter placement.

4.2.5.3 Vessel depth shall be evaluated when selecting a long PIVC to ensure sufficient catheter length resides within the vein. Evidence demonstrates significant reduction in PIVC failure when at least two-thirds of the catheter length is positioned within the vein.

4.2.5.4 Long PIVCs shall be used in clinical environments with appropriate monitoring capabilities.

4.2.6 Vascular Distention Techniques

4.2.6.1 Appropriate aids shall be employed to promote vascular distention during PIVC insertion. Single-patient-use tourniquets, warming devices, and blood pressure cuffs all serve to dilate peripheral vessels and improve visualization and palpation.

4.2.7 Aseptic Technique Requirements for Peripheral Catheters

4.2.7.1 Adherence to Aseptic Non Touch Technique (ANTT) principles is mandatory for all PIVC insertions.

4.2.7.2 Standard-ANTT for Simple PIVC Insertion. Simple peripheral catheter insertions shall follow Standard-ANTT protocols. Single-patient-use tourniquets shall be employed to prevent cross-contamination between patients. Clinicians shall don a new pair of disposable, nonsterile gloves for each insertion attempt and shall not touch or palpate the insertion site following skin antisepsis. If re-palpation of the vein becomes necessary after skin preparation, sterile gloves shall be used.

4.2.7.3 Surgical-ANTT for Complex Insertions. More complex insertion techniques, such as accelerated or Seldinger approaches, shall follow Surgical-ANTT protocols with enhanced sterile precautions.

4.2.8 Insertion Attempt Limitations

4.2.8.1 PIVC insertion attempts shall be restricted to no more than two attempts per clinician. Multiple unsuccessful attempts cause patient pain, delay treatment initiation, compromise future vascular access options, increase healthcare costs, and elevate complication risk.

4.2.8.2 Following two unsuccessful attempts, the procedure shall be escalated to a clinician with advanced skill level and access to technological support. Alternative routes of medication administration shall also be considered when peripheral access proves challenging.

4.2.9 Midline Catheter Tip Positioning and Baseline Measurements

4.2.9.1 Midline catheter selection shall account for appropriate length to achieve optimal tip location relative to the insertion site.

4.2.9.2 Adult patients: The catheter tip shall be positioned at the level of the axilla.

4.2.9.3 Neonatal and pediatric patients: Upper arm insertion sites utilizing the basilic, cephalic, and brachial veins are preferred. Alternative sites include leg veins (saphenous, popliteal, femoral) with the tip positioned below the inguinal crease, or scalp veins with the tip located in the neck above the thorax.

4.2.9.4 Extremity circumference shall be measured at the time of midline catheter insertion, with the measurement location documented to ensure consistency in subsequent assessments. Circumference monitoring is indicated when edema develops or when signs and symptoms suggest deep vein thrombosis. Documentation shall include the location and characteristics of any edema observed.

4.2.10 Immediate Catheter Removal Indications

4.2.10.1 Suspected Nerve Damage. If the patient reports severe pain during insertion — particularly pain described as electrical shock-like — or experiences paresthesia such as numbness or tingling related to the insertion, the catheter shall be removed immediately. The responsible provider shall be promptly notified for evaluation and documentation.

4.2.10.2 Inadvertent Arterial Puncture. When arterial puncture is identified during peripheral catheter insertion, the catheter shall be removed and direct pressure applied to the site until hemostasis is achieved. Circulatory status of the extremity shall be assessed, and any impairment requires prompt provider notification.

4.3 Central Venous Access Device Insertion

4.3.1 Central Line Bundle Implementation

4.3.1.1 The central line bundle shall be implemented for all CVAD insertions as an evidence-based approach to reducing catheter-associated bloodstream infections and insertion complications.345 Core bundle elements include hand hygiene, skin antisepsis with alcohol-based chlorhexidine solution, maximal sterile barrier precautions, and upper body insertion when clinically appropriate. Registered nurses with appropriate training, competency validation, and organizational credentialing are authorized to insert nontunneled central vascular access devices within their defined scope of practice.6

4.3.1.2 Standardized Checklists. A standardized checklist shall be utilized to ensure adherence to mandatory insertion practices. This checklist shall be completed by an educated healthcare clinician who assists with the CVAD procedure, providing real-time verification of protocol compliance.

4.3.1.3 Standardized Supply Systems. A standardized supply cart or kit containing all necessary components for CVAD insertion shall be available to improve efficiency and reduce the risk of procedural interruption or contamination.

4.3.2 Ultrasound Guidance for Central Venous Access

4.3.2.1 Ultrasound shall be employed when inserting CVADs to improve vessel assessment, enhance insertion success, and reduce insertion-related complications.

4.3.2.2 Tunneled, Cuffed CVADs and Implanted Ports. An ultrasound-guided modified Seldinger technique with micropuncture kit shall be used for large-bore catheter insertion. This approach is preferred over venous cutdown or landmark-based percutaneous techniques, demonstrating improved insertion success and reduced postinsertion complication rates in both adult and pediatric populations.

4.3.2.3 Internal Jugular Catheterization. The needle tip shall be maintained in constant visualization throughout the insertion process. Various approaches may be employed, including syringe-free technique, long-axis in-plane visualization, and dynamic short-axis insertion. Evidence consistently demonstrates improved outcomes with continuous needle tip visualization.

4.3.3 Peripherally Inserted Central Catheter Insertion

4.3.3.1 Right-sided PICC insertion shall be considered as the default approach unless contraindicated by patient assessment. Right-sided placement reduces the risk of catheter-related complications, including tip malposition, due to the more direct anatomical course to the superior vena cava.

4.3.3.2 Catheter-to-Vein Ratio. A catheter-to-vein ratio of less than 45% shall be maintained to minimize thrombotic complications and ensure adequate blood flow around the catheter.

4.3.3.3 Subcutaneous Tunneling. When the optimal vein is located at its largest diameter in the upper third of the upper arm near the axilla, subcutaneous tunneling shall be considered. This technique optimizes the needle entry point while positioning the catheter exit site in the middle third of the upper arm, improving catheter stability and reducing infection risk.

4.3.3.4 Baseline Extremity Measurements. Baseline extremity circumference shall be measured upon PICC insertion with documentation of the measurement location. Subsequent circumference assessment is indicated when edema or signs and symptoms of deep vein thrombosis develop.

4.3.4.1 Inadvertent Arterial Puncture — Needle or Small Catheter. When arterial puncture occurs during CVAD insertion with a needle or small catheter, the device shall be removed and direct digital pressure applied until hemostasis is achieved.

4.3.4.2 Inadvertent Arterial Puncture — Large-Bore Device or Dilator. Inadvertent arterial puncture during insertion of a large-bore CVAD or dilator represents a potentially life-threatening complication. In this circumstance, the device shall be left in situ while immediate surgical or interventional radiology consultation is obtained. Treatment options include open operative repair and endovascular management approaches.

4.3.4.3 Cardiac Arrhythmias. Arrhythmias during CVAD insertion typically resolve with repositioning of the guidewire or catheter. Persistent arrhythmias that do not resolve with repositioning require immediate provider notification.

4.3.4.4 Pneumothorax. Suspected pneumothorax requires immediate provider notification and appropriate diagnostic evaluation.

4.3.4.5 Nerve Damage. Potential symptoms of insertion-related nerve damage include diaphragmatic paralysis, hoarseness, impaired muscle strength, and dysfunction of the sympathetic nervous system. These findings require prompt evaluation and documentation.

4.3.4.6 Air Embolism. Air embolism protocols shall be immediately initiated when this complication is suspected, including appropriate patient positioning and supportive care.

4.3.4.7 Catheter Malposition. Catheter malposition requires assessment and repositioning according to institutional protocols.

4.3.5 Central Catheter Tip Location

4.3.5.1 For upper body insertion sites, the CVAD tip shall be advanced to the cavoatrial junction, the lower one-third of the superior vena cava, or the superior aspect of the right atrium.

4.3.5.2 For lower body insertion sites, the CVAD tip shall be positioned in the inferior vena cava above the level of the diaphragm.

4.3.5.3 Prior to initiating infusion therapy, the inserting clinician shall verify tip position using a recognized tip location technique. Acceptable methods include fluoroscopy, electrocardiography-based systems, and other validated approaches.

4.3.6 Complex CVAD Insertions

4.3.6.1 Cardiovascular Implantable Electronic Devices. When a patient has an existing pacemaker, implantable cardioverter-defibrillator, or other cardiovascular implantable electronic device, CVAD insertion shall account for device-catheter interaction. Contralateral placement is preferred to minimize this risk. The integrity of pre-existing cardiovascular implantable electronic devices and leads shall be determined both before and after CVAD insertion.

4.3.6.2 Chronic Kidney Disease Considerations. For patients with chronic kidney disease who require both CVAD insertion and cardiovascular implantable electronic device placement, non-tunneled catheters shall be avoided. Rapid progression to arteriovenous fistula or graft creation is recommended to preserve venous access for future hemodialysis needs.

4.4 Arterial Catheter Insertion

4.4.1 Ultrasound-Guided Assessment

4.4.1.1 Ultrasound shall be utilized to assess arterial access sites and guide catheter insertion. Visualization improves first-attempt success rates and reduces complications associated with arterial cannulation.

4.4.2 Dynamic Needle Tip Positioning

4.4.2.1 Dynamic needle tip positioning shall be employed for arterial catheter insertion. This technique involves maintaining continuous ultrasound visualization of the needle tip during advancement, allowing real-time trajectory adjustment. Studies across adult, pediatric, and neonatal populations consistently demonstrate superior outcomes with this approach compared to conventional techniques.

4.4.3 Personal Protective Equipment and Sterile Precautions

4.4.3.1 Peripheral Arterial Catheters. Insertion of peripheral arterial catheters shall require a cap, mask, sterile gloves, and eyewear. A small fenestrated sterile drape shall be used to create an appropriate sterile field.

4.4.3.2 Central Arterial Access and Pulmonary Artery Catheters. Surgical-ANTT with maximal sterile barrier precautions is required when inserting pulmonary artery catheters and arterial catheters via the axillary or femoral artery. Full sterile gowning, large sterile drapes, and rigorous adherence to aseptic technique are mandatory for these higher-risk procedures.

5. Compliance

5.1 Key Performance Indicators

  • Rate of PIVC insertion attempt compliance (≤2 attempts per clinician before escalation) (target: ≥95%)
  • Rate of central line bundle element completion as documented on standardized checklist (target: ≥95%)
  • Rate of ultrasound guidance use for CVAD insertions (target: ≥90%)
  • Rate of CVAD tip location verification prior to first use (target: 100%)
  • Rate of PIVC insertion bundle adherence (target: ≥95%)
  • Central line-associated bloodstream infection (CLABSI) rate per 1,000 catheter-days
  • Rate of serious insertion-related complications (arterial puncture, pneumothorax, nerve injury) reported and reviewed

5.2 Enforcement

Non-compliance with this policy shall be addressed through the organization’s standard performance improvement and professional accountability processes, including event reporting, documentation review, direct feedback, competency re-evaluation, and escalation to unit leadership or credentialing bodies as appropriate.

6. Exceptions

Exceptions to this policy may arise in emergent clinical situations where strict adherence to standard bundle elements or attempt limitations is not feasible due to immediate patient need. Any deviation shall be documented in the patient’s health record, including the clinical rationale, and shall be reviewed at the earliest opportunity. Exceptions shall not become routine practice without formal policy revision.

  • Vascular Access Device Selection and Insertion Policy
  • Vascular Access Site Preparation and Skin Antisepsis Policy
  • Aseptic Non Touch Technique (ANTT) Policy
  • Hand Hygiene Policy
  • Vascular Visualization Technology Policy
  • Central Vascular Access Device Tip Location Policy
  • Implanted Vascular Access Ports Policy
  • Vascular Access for Hemodialysis Policy
  • Pain Management for Vascular Access Procedures Policy
  • Adverse Event Management and Reporting Policy

8. Revision History

VersionDateAuthorDescription
1.02025-01-20Vascular Access Governance CommitteeInitial policy release
1.12025-10-08Vascular Access Governance CommitteePeriodic review; arterial puncture management for large-bore CVADs clarified

References

  1. Krein SL, Harrod M, Weston LE, et al. Vascular access specialist teams and catheter-related bloodstream infection prevention: a multisite qualitative study. BMJ Qual Saf. 2021;30(8):628-638. doi:10.1136/bmjqs-2020-011806 ↩︎

  2. Paterson RS, Schults JA, Slaughter E, et al. Peripheral intravenous catheter insertion in adult patients with difficult intravenous access: a systematic review. Emerg Med Australas. 2022;34(6):862-870. doi:10.1111/1742-6723.14069 ↩︎

  3. Rupp ME, Majorant D. Prevention of vascular catheter-related bloodstream infections. Infect Dis Clin North Am. 2016;30(4):853-868. doi:10.1016/j.idc.2016.06.001 ↩︎

  4. Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol. 2022;43(5):553-569. doi:10.1017/ice.2022.87 ↩︎

  5. Martillo M, Zarbiv S, Gupta R, et al. A comprehensive vascular access service can reduce catheter-associated bloodstream infections and promote the appropriate use of vascular access devices. Am J Infect Control. 2020;48(4):460-464. doi:10.1016/j.ajic.2019.09.021 ↩︎

  6. Plohal A, Dumont C, Perry C, et al. The role of the registered nurse in the insertion of nontunneled central vascular access devices. J Infus Nurs. 2017;40(6):339-345. doi:10.1097/nan.0000000000000255 ↩︎

Teams can standardize this procedure with version control and compliance tracking.

Learn about qpolicy.ai