Vascular Visualization Technology

Establishes standards for the selection and application of vascular visualization technology—including ultrasound, near-infrared, and visible light devices—to improve vascular access insertion success and reduce complications across all patient populations.

policies•Jul 2023•Vascular Access

Vascular Visualization Technology Policy

1. Policy Statement

It is the policy of this organization that vascular visualization technology shall be systematically assessed for and applied to clinical practice with the goal of increasing first-attempt insertion success, minimizing escalation to unnecessary or more invasive vascular access devices, and reducing insertion-related complications. Selection and application of visualization technology shall be guided by patient-specific factors, clinical context, available technologies, and demonstrated clinician competency. No visualization technology replaces sound clinical judgment or foundational vascular access technique.

2. Purpose

This policy exists to:

  • Define the organization’s expectations for use of vascular visualization technologies in support of peripheral, midline, and central vascular access device insertion.
  • Establish patient assessment criteria for identifying candidates who benefit from visualization technology.
  • Specify standards for ultrasound, near-infrared, and visible light device application across patient populations.
  • Define catheter-to-vessel ratio assessment requirements.
  • Establish infection prevention requirements specific to ultrasound-guided procedures.
  • Define competency requirements for clinicians using visualization technology.

3. Scope

This policy applies to:

  • All licensed clinical personnel performing vascular access device insertions in inpatient, ambulatory, procedural, and home care settings.
  • All clinical areas in which peripheral intravenous catheters, midline catheters, peripherally inserted central catheters (PICCs), central venous catheters (CVCs), and arterial catheters are placed.
  • All vascular visualization technologies in organizational use, including ultrasound, near-infrared, and visible light transillumination devices.

4. Policy Requirements

4.1 Patient Assessment for Visualization Technology

4.1.1 Clinical assessment shall identify patients who may benefit from vascular visualization technology prior to or at the time of insertion. Traditional landmark techniques relying solely on observation and palpation demonstrate increased failure rates in specific patient populations.

4.1.2 Clinicians shall evaluate patients for the following risk factors associated with difficult vascular access (DIVA):

  • Patient age extremes, including neonates and older adults
  • History of frequent venipuncture or extended courses of infusion therapy
  • Disease processes causing structural vessel changes, such as diabetes mellitus and hypertension
  • Variations in skin tone, obesity, or significant subcutaneous tissue
  • Skin alterations from scars, tattoos, or excessive hair at intended sites
  • Fluid volume disturbances—whether overload or deficit—altering vein accessibility

4.1.3 Clinicians shall apply validated DIVA screening criteria appropriate to their patient population when available, and document the clinical rationale for visualization technology use in the patient’s health record.1

4.2 Ultrasound Technology

4.2.1 Ultrasound shall be used for pre-insertion assessment and, when indicated, real-time guidance during vascular access device placement.234 Pre-insertion assessment shall evaluate:

  • Vessel size, caliber (diameter and intravenous path length), depth, flow, and patency
  • Vascular anomalies including occlusion and thrombosis
  • Nearby structures requiring avoidance, including nerves, arteries, and valves
  • Respiratory variation and catheter-to-vein ratio

4.2.2 For initial vessel assessment, the short (transverse) axis provides comprehensive visualization. When the long (longitudinal) axis is preferred for needle insertion in adult patients, the probe shall be redirected to this plane following initial assessment to minimize damage to surrounding structures.

4.2.3 In pediatric patients, the short axis (out-of-plane) technique is preferred for ultrasound-guided insertion. Dynamic needle tip positioning shall be considered as a complement to ultrasound guidance to further improve first-attempt success.

4.2.4 Ultrasound guidance is indicated for internal jugular vein central venous access. The long axis in-plane approach may be used as an alternative to the short axis out-of-plane technique, with evidence supporting improved first-attempt success and reduced posterior wall puncture across neonatal, pediatric, and adult patients.

4.2.5 For arterial catheter insertion, ultrasound guidance shall be applied when feasible. Evidence supports improved first-attempt success rates, fewer insertion attempts, reduced hematoma formation, and lower failure rates compared to palpation alone for radial, axillary, and femoral arterial lines.5

4.3 Visible Light (Transillumination) Devices

4.3.1 Transillumination devices using visible light may be used to assist in locating superficial veins, with recognition of their population-specific limitations.

4.3.2 Visible light devices demonstrate greatest effectiveness in neonates, where subcutaneous tissue thickness permits adequate light transmission. Utility in infants, older children, and adults is limited due to increased subcutaneous tissue thickness and larger limb circumference.

4.3.3 Only cold light sources designed specifically for vascular visualization shall be used. Traditional flashlights and other heat-emitting devices are prohibited due to association with thermal burns from prolonged skin contact.

4.4 Near-Infrared Technology

4.4.1 Near-infrared (nIR) light technology may be applied to assist peripheral intravenous catheter insertion, particularly in patients with difficult vascular access. Near-infrared devices reveal vein characteristics including bifurcations, tortuosity, palpable but non-visible veins, and venous valve locations.

4.4.2 Near-infrared technology is particularly valuable in neonatal and infant populations, where evidence demonstrates improved first-attempt and overall insertion success rates, decreased procedural time, and reduced extravasation injuries compared to traditional assessment methods.

4.4.3 In adult populations, nIR technology may improve first-attempt success rates, reduce time to insertion, and decrease extravasation events, particularly in patients with obesity, darker complexions, or difficult access history.

4.5 Catheter-to-Vessel Ratio Assessment

4.5.1 Ultrasound shall be used to measure catheter-to-vessel ratio prior to upper extremity vascular access device insertion whenever feasible.

4.5.2 A catheter-to-vessel ratio of less than 45% shall be the target for all upper extremity catheter placements to optimize catheter function and minimize thrombotic complications. This requirement applies to PICCs and shall be considered for midline catheters placed in equivalent vessels.

4.5.3 When catheter-to-vessel ratio exceeds 45%, the clinician shall reassess device selection, insertion site, or vessel and document the clinical rationale for any exception.

4.6 Infection Prevention with Ultrasound Equipment

4.6.1 Proper aseptic technique during ultrasound-guided procedures is mandatory and shall address ultrasound gel and probe management.

4.6.2 For all procedures involving needle puncture:

  • Single-use sterile gel packets shall be used
  • An appropriate sterile barrier shall be placed over the ultrasound probe prior to the procedure

4.6.3 For pre-assessment involving intact skin without needle puncture, single-use gel without sterile barrier is acceptable unless institutional guidelines specify otherwise.

4.6.4 Probe disinfection shall occur before and after each patient use, following manufacturer guidelines and organizational cleaning and disinfection standards. Probes shall never be used on subsequent patients without documented disinfection.

4.7 Training and Competency

4.7.1 All clinicians using vascular visualization technology shall demonstrate documented competency prior to independent use. Competency programs shall support clinicians across the novice-to-expert continuum.67891011121314

4.7.2 Competency assessment shall address:15

  • Vessel assessment: size, depth, location, and patency
  • Recognition of vascular anomalies and structures requiring avoidance
  • Appropriate technology selection for patient and procedure
  • Probe handling and aseptic non-touch technique application
  • Recognition of potential complications during visualization-guided insertion

4.7.3 Competency documentation shall be maintained in individual personnel records and reassessed at a frequency consistent with organizational policy and scope of practice requirements.16

5. Compliance

5.1 Monitoring. Compliance shall be monitored through:

  • Direct observation audits of visualization technology application
  • Tracking of first-attempt insertion success rates by technology and patient population
  • Audit of catheter-to-vessel ratio documentation for applicable device types
  • Review of probe disinfection logs and supply utilization
  • Competency completion records for all applicable staff

5.2 Key Performance Indicators.

  • First-attempt insertion success rate (target: ≥90% for PICC and CVC; tracked by technology type for peripheral IV)
  • Catheter-to-vessel ratio documentation compliance (target: 100% for PICC insertions)
  • Ultrasound probe disinfection audit compliance (target: ≥95%)
  • Visualization technology competency documentation completion (target: 100%)

5.3 Enforcement. Clinicians found to be applying visualization technology without documented competency shall be suspended from independent use pending reassessment. Failure to perform probe disinfection between patients shall be addressed as an infection prevention violation through the organization’s performance management process.

6. Exceptions

6.1 Emergent vascular access may proceed without visualization technology when clinical urgency precludes its use. The absence of visualization technology shall be documented with clinical rationale, and a post-procedure review shall occur when appropriate.

6.2 Catheter-to-vessel ratio documentation may be deferred in emergent circumstances; however, the insertion rationale shall be documented and device appropriateness reassessed at the earliest safe opportunity.

  • POL-003: Evidence-Based Selection and Clinical Monitoring Standards
  • POL-007: Competency and Competency Validation in Vascular Access
  • POL-012: Documentation in the Health Record for Vascular Access
  • ANTT Policy (this collection)
  • Central Vascular Access Device Tip Location Policy (this collection)
  • Catheter-Associated Thrombosis Prevention Standards
  • SOP-VA-010: PICC Insertion Using Surgical-ANTT
  • Association for Vascular Access (AVA) Ultrasound-Guided Vascular Access Guidelines

8. Revision History

VersionDateAuthor(s)Description of Change
1.02023-07-11Intracav-CM01Initial policy creation
1.12025-01-14D. Woo, M. Stern, I.M. WrightUpdated catheter-to-vessel ratio thresholds and pediatric ultrasound guidance; revised competency framework
———Scheduled review date: 2026-07-11

References

  1. 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 ↩︎

  2. Picard C, O’Dochartaigh D, Burnett C, et al. NENA position statement: ultrasound guidance for peripheral intravenous cannulation. CJEN Can J Emerg Med. 2023;46(1). doi:10.29173/cjen212 ↩︎

  3. Spencer TR, Bardin-Spencer A. Ultrasound guidance for vascular access procedures by qualified vascular access specialists or other applicable healthcare clinicians. J Assoc Vasc Access. 2019;25(1):18-22. doi:10.2309/j.java.2019.004.002 ↩︎

  4. Spencer TR, Bardin-Spencer A. Central venous access device insertion by qualified vascular access specialists or other applicable healthcare clinicians. J Assoc Vasc Access. 2020;25(1):52-55. doi:10.2309/j.java.2020.01.001 ↩︎

  5. Bardin-Spencer A, Spencer TR. Ultrasound-guided peripheral arterial catheter insertion by qualified vascular access specialists or other applicable health care clinicians. J Assoc Vasc Access. 2019;25(1):48-50. doi:10.2309/j.java.2019.003.008 ↩︎

  6. Totenhofer R, Luck L, Wilkes L. Point of care ultrasound use by registered nurses and nurse practitioners in clinical practice: an integrative review. Collegian. 2021;28(4):456-463. doi:10.1016/j.colegn.2020.10.002 ↩︎

  7. Pitman JS, Buscemi M, Funk EM, Weaver S, Thompson JA, Falyar C. Incorporating evidence-based ultrasound-guided vascular access (USGVA) standards into the nurse anesthetist armamentarium: a quality improvement project. J Perianesth Nurs. 2023;38(4):564-571. doi:10.1016/j.jopan.2022.11.014 ↩︎

  8. Briggs C, Smith-Steinert R, Bakis M. Continuing education for the certified registered nurse anesthetist: ultrasound-guided peripheral intravenous access. J Contin Educ Nurs. 2021;52(10):489-492. doi:10.3928/00220124-20210913-09 ↩︎

  9. Cormack CJ, Childs J, Kent F. Point-of-care ultrasound educational development in Australasia: a scoping review. Ultrasound Med Biol. 2023;49(6):1375-1384. doi:10.1016/j.ultrasmedbio.2023.02.011 ↩︎

  10. Wong A, Galarza L, Duska F. Critical care ultrasound: a systematic review of international training competencies and program. Crit Care Med. 2019;47(3):e256-e262. doi:10.1097/CCM.0000000000003626 ↩︎

  11. Smith C. Should nurses be trained to use ultrasound for intravenous access to patients with difficult veins? Emerg Nurse. 2018;26(2):18-24. doi:10.7748/en.2018.e1733 ↩︎

  12. Jørgensen R, Laursen CB, Konge L, Pietersen PI. Education in the placement of ultrasound-guided peripheral venous catheters: a systematic review. Scand J Trauma Resusc Emerg Med. 2021;29(1):83. doi:10.1186/s13049-021-00897-z ↩︎

  13. Van Loon FH, Scholten H, Korsten HH, Dierick-van Daele AT, Bouwman AR. The learning curve for ultrasound-guided peripheral intravenous cannulation in adults: a multicenter study. Med Ultrason. 2022;24(2):188-195. doi:10.11152/mu-3322 ↩︎

  14. Amick AE, Feinsmith SE, Davis EM, et al. Simulation-based mastery learning improves ultrasound-guided peripheral intravenous catheter insertion skills of practicing nurses. Simul Healthc. 2022;17(1):7-14. doi:10.1097/SIH.0000000000000545 ↩︎

  15. Blick C, Vinograd A, Chung J, et al. Procedural competency for ultrasound-guided peripheral intravenous catheter insertion for nurses in a pediatric emergency department. J Vasc Access. 2021;22(2):232-237. doi:10.1177/1129729820937131 ↩︎

  16. American Society of Radiologic Technologists. ASRT professional practice resources and decision tree for determining scope of practice. Revised January 30, 2018. https://www.asrt.org/docs/default-source/practice-standards/asrt-practice-resources.pdf ↩︎

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