PICCs. Vascular access is the cornerstone in the. It s all about. Vascular safety:

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1 Vascular safety: It s all about PICCs Optimal catheter and vein selection prove vital to patient safety initiatives. By Nancy Moureau, CRNI, BSN Practice challenges Special Vascular access is the cornerstone in the provision of treatment for any acute care setting. More than 90% of patients in hospitals have some form of intravenous (I.V.) device, with 13% being central venous catheters. 1 In the past, once patients with peripheral intravenous (PIV) catheters had no other veins for insertion, subclavian catheters (single, dual or triple lumen) were inserted by physicians. Although subclavian catheters are still used, their popularity with physicians is waning in favor of peripherally inserted central venous catheters, or PICCs. 2 Today, optimal catheter and vein selection are considered vital to patient safety initiatives. When consideration is given for lowest to highest risk for patient safety, the first devices used are PIV catheters, in veins of the hand or arm; next, midline catheters or PICCs, inserted through veins in the antecubital region or upper arm; then subclavian, internal jugular, or other more invasive devices, inserted through the larger veins of the chest or Brick Cox

2 neck. Chest insertion of subclavian, triple lumen, or other catheters places the patient at higher risk of pneumothorax, hemothorax, nerve injury, and other serious injuries. Peripherally inserted central catheters, safely inserted through peripheral vein access, have taken the top spot after PIV catheters as the most popular device for the delivery of I.V. medications or fluids. Why PICCs? So, why are PICCs gaining in popularity? Ease of insertion, low cost, and less serious complications are a few of the reasons for using PICCs in all care settings. Nurses began to insert PIV devices in the 1940s in the United States. Late 1970s and 1980s training programs for PICCs began teaching nurses the intricacies of peripheral central line insertion. By 1990, most Boards of Nursing had accepted central line insertion by nurses, specific to PICCs, as within the scope of practice of a registered nurse. With nurses providing direct patient care, it s much easier to find a nurse to insert a PICC than to locate a physician willing to insert a central line. Insertion charges to the patient are reduced when nurses insert PICCs compared to physician fees. 3 Reimbursement for Medicare is ever changing, with the payment to physicians shrinking more than 40% for central venous access over the past 5 years. Physicians are glad to turn this I.V. device responsibility over to nurses. Along with responsibility for insertion of devices comes greater responsibility for selection, monitoring, and managing of all I.V. interventions. Interventional radiology departments maintain availability for difficult patient insertions, but many times the patient waits for more extensive procedures to be completed before a room is available in radiology. Interventional radiology insertion of PICCs averages about 33% of the total number of PICCs inserted each year. By 2008, an estimated 2.5 million PICCs will be inserted per year in our country and 5 million worldwide, maintaining a steady growth rate of 10% to 20%. 4 Nurses are inserting approximately 60% of all 23

3 PICC S PICCs, with an average of 1,800 nurse-driven PICC teams and 40% of hospitals with I.V. teams in the 7,569 hospitals throughout the country. 5 The number of nurses considered competent with vascular access management and PICC insertion is ever increasing. Selection and safety Emphasis is now being placed on selection and safety. Early identification of patients requiring more than a few days of I.V. medication makes for more efficient use of vascular access devices and greater safety for the patient in the delivery of treatment. Improved placement options Only in these last two decades have we seen significant change in vascular access placement options. Acute care central catheters were instituted in the mid- to late-60s, with the advent of nutritional I.V. solutions and the need for fluid rescue. Acute care subclavian catheters remained the gold standard until quite recently. Over time more and more antibiotics have gained usage that require additional I.V. access and extended durations of treatment, even continuing into the home. The infusion home care rise of the 80s and 90s created a need for extremity, midline catheters are perfect for shorter term I.V. therapies of less than 1 month. While not used extensively in acute care settings, midline catheters are safely used for patient I.V. therapies within the standards set forth by the Infusion Nurses Society (INS). 9 For therapies requiring irritating medications, total parenteral nutrition, or multiple therapies, PICC lines began to fit the niche for central venous access. PICC line placement increased in popularity throughout the 1990s and into the new century as more research became available demonstrating the lower infection rate ( /1,000 catheter days) and Optimal catheter and vein site selection results in completion of therapy, reduction in discharge delays, better patient satisfaction, and a safer, more efficient process. The Institute for Healthcare Improvement (IHI) issued safety initiatives that include optimal catheter and vein site selection as one of the vital areas needing attention. 6 The IHI 100,000 Lives Campaign provides healthcare facilities with implementation tools to effect safer services to save lives. Vascular access selection is as important to patient medication treatment as bread is to butter; what use is butter if you have no bread to put it on? The same is true for I.V. medications without an I.V. access. Optimal catheter and vein site selection results in completion of therapy, reduction in discharge delays, better patient satisfaction, and a safer, more efficient process. 7,8 more reliable forms of vascular access. Acute Care Subclavian catheters, generally not used longer than 7 to 10 days in any setting, weren t sent into home care. Technological improvements resulted in the creation of midlines and PICC lines with softer materials and easier forms of access. Peripheral access options with midlines and PICCs reduced many of the concerns associated with chest access, yet allowed for dwell time exceeding 30 days. Midline catheter application, not requiring X-ray placement confirmation, found a niche in home care for those medications and solutions of a nonirritating nature. Inserted through the veins of the arm with a terminal tip in the proximal portion of the the need for alternative access bridging the gap between PIV and acute care subclavian devices Low cost of insertion, ability to train existing staff, and low incidence of serious complications have created a situation for PICC usage to increase. Single, dual, and triple lumen PICC lines have found their way into the patient care setting. Dual lumen PICCs are by far the most commonly inserted of all PICC lines, allowing for multiple antibiotic or medication administration. With the number of PICC units increasing, nurses began to look for ways to have greater success on insertion. Initially, peripheral vein insertion success for PICC by nurses ranged 24 Nursing Management May

4 from only 70% to 80%, with some patients having such poor vasculature that PICCs weren t even attempted and they were immediately referred to radiology. 13 Now, portable ultrasound options for vein identification have pushed PICC success levels up to just over 90%. Evidence has demonstrated increased safety for central line insertions performed with ultrasound. This method is recommended by the Agency for Healthcare Research and Quality and the American College of Emergency Physicians for all central line insertions. Ultrasound guidance for central line insertion is being implemented in all levels of practice for both nurses and physicians. Approximately 15% of U.S. hospitals use ultrasound for all central venous placements, with a higher percentage using ultrasound for just PICC placement. Newer technologies have allowed for not only increased success on insertion of PICCs, but greater safety with identification of arteries, vein size, and vein condition. This ultimately leads to better selection of the right vein for the catheter. The evolution of PICC practice is causing those who do insertions to use many different options for access, from portable ultrasound at the bedside to fluoroscopic guidance within the radiology department. The downside Peripheral access requires the inserter to locate veins within the arms or legs of a suitable size to accommodate a catheter. Ultrasound has made it possible to locate veins that weren t visible or palpable. Veins of the arm most commonly used for PICCs are the basilic, brachial, and cephalic veins. Prior to the advent of ultrasound, PICC insertion into the brachial vein was rarely done. Brachial veins lie deep in the center of the mid to upper arm at a level that can t be outwardly visualized or palpated. This makes intentional access without ultrasound very difficult and risky. The brachial veins are paired with the brachial artery and medial nerve. Access into a brachial vein isn t without risk; access into the artery or through the nerve can easily occur with needle access. Those 25

5 PICC S inserting PICCs with ultrasound also learn the Modified Seldinger Technique (MST) insertion method, allowing access with a 21-gauge needle rather than the conventional 19- to 15-gauge over the needle peelaway cannulas. The MST uses the smaller needle to gain access to the vein, followed by insertion of a small 20- to 120-cm wire that guides the introducer/dilator combination into the vein. Use of MST with ultrasound reduces the risk associated with larger needle access to deeper veins. There s some concern that the ability to access the deeper brachial veins may lead to impaired extremity circulation and more serious complications. The need for assessment of circulation is becoming a necessary component of ultrasound assessment prior to PICC insertion. Thrombotic complications from previous PIVs, PICCs, or midlines may result in scarring or loss of flow to an area of the vein. Ultrasound assessment guides the inserter to the best vein, but clinicians must also confirm alternative venous flow in another vein. PICC lines are at a disadvantage due to the relative small diameter and length of the catheter; the greater surface area may result in occlusions. Thrombotic occlusion can occur easily with such small diameter catheters if flushing is neglected. Red blood cells accumulate at the end of the catheter and are pulled into the catheter with blood return checks and laboratory blood draws. Adherence of red blood cells at the tip and within the catheter results in sluggish infusion flow, inability to withdraw blood, and complete occlusion. Flushing following all medication infusion or blood draws is necessary to effectively clear the line of residual medication or blood. Valved catheters and positive pressure end caps have reduced the need for heparin locking, but still require vigorous saline flushing. On the horizon Vascular access is vital to the administration of I.V. medications and solutions. Without I.V. access, patients are unable to receive prescribed treatments and may experience delays in therapy, slower recovery, and extended length of stay in the hospital. Newer technologies aid access into the venous system through ultrasound-guided central venous catheter insertion. PICC lines have become the central line of choice for patients receiving I.V. therapies longer than 5 days. Nurse-driven PICC teams are cost effective and safe, resulting in positive patient outcomes. More and more nurses are working in collaboration with physicians to determine the best vascular access device for the patient, inserting and managing the care, and driving the new age of peripheral and central venous devices. 26

6 With shrinking central venous catheter insertion reimbursement for physicians, nurses are in a position to continue to expand the scope of practice into all central venous access. Worldwide nurses are taking an active role in inserting all central venous catheters and ports as physicians focus on treatment, rather than vascular access insertion. NM REFERENCES 1. Herbst S, Kaplan L, McKinnon B. Vascular access devices: managing occlusions and related complications in home infusion. Infusion. 1998;4(suppl):S1-S Lam S, Scannell R, Roessler D, Smith MA. Peripherally inserted central catheters in an acute-care hospital. Arch Intern Med. 1994;154(16): Cardella JF, Cardella K, Bacci N, et al. Cumulative experience with 1,273 peripherally inserted central catheters at a single institution. J Vasc Interv Radiol. 1996;7(1): Intravenous Catheter Market Projections. Multiple research reports and manufacturer sales input US Census press release. Facts for features. April Institute for Healthcare Improvement. 100,000 Lives Campaign: preventing central line infections how-to guide. September Available at: Accessed April 5, Macklin D, Chernecky C, Nugent K, and Waller J. A collaborative approach to improving patient care associated with vascular access devices. J Vasc Access Devices. 2003;8(2): Nugent K, Chernecky C, Macklin D. Using focus groups to evaluate the patient s involvement in decision making associated with their access device. J Vasc Access Devices. 2002;7(2): Intravenous Nurses Society. Infusion nursing standards of practice. J Intraven Nurs. 2000;23(suppl 6S):S1-S88 and 1998;21(1S):S1-S Moureau N, Poole S, Murdock MA, et al. Central venous catheters in home infusion care: outcomes analysis in 50,470 patients. J Vasc Interven Radiol. 2002; 13(10): Walshe LJ, Malak SF, Eagan J, Sepkowitz KA. Complication rates among cancer patients with peripherally inserted central catheters. J Clin Oncol. 2002;20(15): Safdar N, Maki DG. Risk of catheterrelated bloodstream infection in peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2): Anstett M, Royer T I. The impact of ultrasound on PICC placement. J Assoc Vasc Access. 2003;8(3): ABOUT THE AUTHOR Nancy Moureau is the founder and president of PICC Excellence, Inc., an educational company. She has more than 15 years of experience in insertion and instruction of PICCs. 27