Evaluation of a Unique, Nurse-Inserted, Peripherally Inserted Central Catheter Program
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Vascular Access Program, Hospital for Sick Children, Toronto, Ontario, Canada
Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
Department of Image-Guided Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
ABSTRACT
Background. Concerns regarding the safety and success of peripherally inserted central catheters (PICCs) placed at the bedside in the pediatric population initially precluded the development of a nurse-inserted PICC program at our pediatric center. Previously, all PICCs were inserted by interventional radiologists (IRs) with fluoroscopic guidance. A new nurse-inserted PICC program was initiated with collaboration between PICC nurses and IRs.
Methods. Three nurses participated in the project. Patients who met preestablished selection criteria were approached. All insertions were performed with sterile technique on the fluoroscopy table, with IRs available to support the PICC nurse. Veins were accessed visually or through palpation. Final tip position was confirmed in all cases with contrast material administration and fluoroscopy. Additional fluoroscopy was performed only if placement difficulties were encountered. All patients were monitored prospectively.
Results. Ninety-nine patients (age: 3–18 years; average age: 13.6 years) met the selection criteria. Two patients underwent primary insertion by an IR. The remaining 97 patients underwent an insertion attempt by a nurse. Sixty-nine PICCs (71.1%) were placed successfully by a nurse, 15 (15.5%) required minor assistance from an IR, and 13 (13.4%) were inserted by an IR after an unsuccessful nurse attempt. No insertion complications were noted. Insertion difficulties included difficulty advancing the catheter (19.6%), difficulty cannulating the vein (6.2%), and tip malposition (2.1%). Postinsertion complications occurred for 27.8% of PICCs, and 13.4% required removal before the end of therapy.
Conclusion. This novel, pediatric nurse-inserted PICC program has a good safety profile, high success rate, and low postprocedural complication rate.
Key Words: peripherally inserted central catheter central venous catheter nurse
Abbreviations: PICC, peripherally inserted central catheter TPN, total parenteral nutrition IV, intravenous IGT, image-guided therapy IR, interventional radiologist
Peripherally inserted central catheters (PICCs) allow for middle- to long-term courses of intravenous (IV) therapy in the hospital and at home, blood sampling, and reductions in venipunctures. The purpose of this study was to evaluate a new, nurse-inserted, PICC program for children at a tertiary care pediatric center.
The nurse-inserted PICC program at our pediatric academic health sciences center grew out of an identified need to provide long-term IV access for children. Since 1992, interventional radiologists (IRs) at our hospital inserted PICCs under fluoroscopic guidance. However, patients who required vascular access devices were prioritized along with other patients who were dependent on the expertise of the IRs for image-guided procedures. This led to the perception by health care providers that PICC insertions were difficult to arrange. Consequently, health care providers turned to the IV team nurses for assistance with middle- to long-term vascular access.
Although nurses in the NICU inserted PICCs at the bedside, there was no similar option in the rest of our hospital. In the past, IV team nurses were able to offer midline catheters as the best alternative to short, peripheral, IV catheters. However, midline catheters are not ideal for patients who require blood sampling, treatment with vesicant drugs, long-term treatment with irritant drugs (eg, vancomycin or cloxacillin), or blood transfusions. The experience with midline catheters at our pediatric center also suggests that they are not optimal for total parenteral nutrition (TPN). In our recent review of data for 142 children with midline catheters, 52.3% of children who were receiving TPN through midline catheters could not complete therapy with this device because of complications.
Our solution to the problem of timely PICC insertions outside the NICU focused on the development of a pediatric nurse-inserted PICC program with several unique features. Other centers reported their experiences initiating PICC programs, but most involved either bedside nurse insertions or exclusively IR insertions in a fluoroscopy suite. Few studies reported experiences in pediatric programs.1–4 Concerns have been raised about the high rate of malpositioned catheters inserted at the bedside, where the tip does not sit at the junction between the superior vena cava and the right atrium.5 The success rate of IRs for PICC insertion is high, primarily because of the use of ultrasonography and fluoroscopy to observe the vein and to position the catheter appropriately. In expanding our program, there was an incentive to maintain a high insertion success rate while ensuring the safety of the procedure. Rather than initiating nurse insertions at the bedside, we developed a hybrid program combining the advantages of a nurse-inserted PICC program and an IR PICC service. We thus expanded our vascular access service by incorporating the new nurse-inserted PICC program in the hospital's image-guided therapy (IGT) suites.
Our nurse-inserted PICC program is a collaborative effort between the division of IGT and the vascular access/IV team. All catheter insertions are performed in the IGT fluoroscopy suite. Three nurses with extensive experience in IV access volunteered to participate in the project and received practical training from one of the manufacturers of PICC catheters. Four IRs supervised the nurses in PICC insertion.
The aim of this prospective descriptive study was to evaluate the success of a novel, nurse-inserted, PICC program. The evaluation of the program focused on the insertion success rate of the PICC nurses and on periprocedural and long-term complication rates for PICCs.
METHODS
Patients and Study Design
All children were inpatients or outpatients at our hospital, which is a tertiary care, pediatric, academic, health sciences center. The program was initiated in December 2001, and data for all patients who met the inclusion criteria between December 2001 and June 2003 were reviewed. Patient criteria for inclusion in the nurse-inserted PICC program were established before the initiation of the project and reflected patients who were midline catheter candidates. Inclusion criteria included cooperative patients >3 years of age, a history of <3 previous central venous catheters in the superior vena cava, and palpable or easily observed brachial or cephalic veins. Patients with a particular medical condition that necessitated general anesthesia for a procedure were excluded. However, patients who otherwise fulfilled the criteria but received general anesthesia for another procedure were included. The evaluation of the program received approval from the hospital research ethics board.
Physicians, bedside nurses, and IV team nurses identified candidates for the nurse-inserted PICC program. Once identified, the patients were triaged by a specially designated resource nurse within the vascular access program and were then assessed by a PICC nurse, to ensure that inclusion criteria were met.
We evaluated all patients who consented and underwent an attempted PICC insertion performed by a nurse. Data were gathered prospectively until the catheter was removed or until the end of the observation period in July 2003 (the minimal follow-up period was 21 days). Periprocedural and postprocedural complications were recorded. PICC nurses assessed inpatients daily and tracked catheter function and site condition. They performed all weekly site dressing changes on inpatients. Patients discharged from the hospital with a PICC in situ were monitored by telephone by the PICC nurse. Inpatient catheter maintenance included heparinization with 150 units of heparin (100 U/mL solution) every 24 hours for all catheters that were accessed intermittently. Catheters with continuous infusions did not receive heparin. Outpatients received daily PICC care by a home care nurse, who followed the same heparinization and dressing policies. Problems with outpatient PICCs were addressed by the hospital's PICC nurses after contact by the patient's family or by the home care nurse. The PICC nurses provided preinsertion and postinsertion education to patients and families and performed all inpatient dressing changes.
Variables included demographic characteristics such as patient age, gender, diagnostic category, and reason for PICC insertion. Dwell time was calculated as the difference between the insertion and removal dates. "Successful" insertions included nurse insertions that did not require assistance from the IR (other than confirmation of the tip position with fluoroscopy after completion of the procedure). "Successful-assisted" insertions included insertions in which nurses required verbal or hands-on assistance by an IR during the insertion. "Unsuccessful" insertions were those performed completely by an IR after a failed nurse attempt.
Insertion difficulties included problems cannulating the vein, advancing the catheter, or positioning the tip. Insertion complications included bleeding, hemothorax, pneumothorax, arterial cannulation, and arrhythmia. Postinsertion complications included external or internal catheter fracture, thrombosis, catheter-related local or systemic infection, as defined by national infection-control standards,6 catheter occlusion, catheter dislodgment, dermatitis, and mechanical phlebitis.
Descriptive statistics were used to examine the success rate for PICC nurses, insertion difficulty and complication rates, postinsertion complication rates, and average dwell times. Comparisons were made between median dwell times for catheters removed because of complications and those removed at the end of therapy.
Technique
Informed consent is obtained from the parent or guardian by the PICC nurse, and assent is granted by the child. The PICC placement is performed in the IGT suite, with sterile technique. Topical anesthetic is applied to the chosen site (basilic or cephalic vein) before the procedure. All inserters use sterile technique with a combination of topical anesthetic (EMLA [AstraZeneca, Wilmington, DE] or Ametop Gel [Smith and Nephew, Hull, United Kingdom]), skin infiltration with lidocaine, and IV sedation. Veins are accessed either by direct observation or by palpation.
The catheter is flushed with saline solution and trimmed to the correct length, with care being taken not to cut the guidewire inside the catheter. The assistant places the patient in a supine position, with the arm abducted to a 90° angle. The site is cleansed with a chlorhexidine/alcohol preparation and draped, and a tourniquet is applied by the assistant. The vein is accessed visually or by palpation with the peel-away introducer needle at a 25° to 45° angle. The stylet from the introducer is removed, and the catheter is threaded through the peel-away sheath. The tourniquet is released and the catheter is advanced centrally. The patient is asked to tuck her or his chin on the ipsilateral shoulder, to prevent the catheter from going up the jugular vein. At that point, the catheter is confirmed fluoroscopically to be in the lower one third of the superior vena cava. The guidewire is removed from the catheter. The catheter position is then confirmed fluoroscopically, with contrast agent administration, by the IR.
If the catheter does not advance or if fluoroscopy indicates that the catheter has gone into any vein other than the superior vena cava, then the IR advances the catheter over a directing guidewire until central access is obtained and confirmed with contrast agent administration. If access fails with visual landmarks or palpation, then the IR may use ultrasonography with a sterile cover in the same sterile field, without moving the patient. The PICC nurse may then be in a position to continue, or the IR may complete the procedure.
RESULTS
Ninety-nine patients requiring PICCs fulfilled the selection criteria. Ninety-seven patients (98%) underwent an initial insertion attempt by a nurse; 1 patient who had undergone a previous PICC insertion by an IR refused a nurse-inserted PICC. Another patient was not included because of an underlying coagulopathy. Reasons for PICC insertion included antibiotic or antiviral therapy (N = 59 [60.8%]), TPN administration (N = 28 [28.9%]), chemotherapy (N = 4 [4.1%]), or other medications (N = 6 [6.2%]). The average age of the children was 13.6 years (range: 3–18 years). There were 52 male patients and 45 female patients. Thirty-seven catheters were used exclusively for inpatients, whereas 60 catheters were used for outpatients.
Noncuffed PICCs (Bard Per-Q-Cath [Bard Access Systems, Salt Lake City, UT]) were inserted by PICC nurses. PICCs inserted by an IR after an initial nurse attempt were either noncuffed (Bard Per-Q-Cath) or cuffed (Cook Critical Care, Bloomington, IN). Nurses inserted 81 single-lumen (3F or 4F) catheters and 3 double-lumen (4F or 5F) catheters. IRs inserted 12 single-lumen (3F or 4F) catheters and 1 double-lumen (5F) catheter. The cephalic vein was accessed in 31 insertions and the basilic vein in 66 insertions. Topical anesthetic alone was used for 81 patients (83.5%). The remaining patients received a combination of topical anesthetic and infiltration of lidocaine (N = 12), IV sedation (N = 2), and general anesthesia (N = 2).
A summary of patient characteristics and insertion attempt outcomes is presented in Table 1. Sixty-nine PICCs were inserted successfully by a PICC nurse, yielding a success rate of 71.1%. Twenty-eight insertions required assistance. Fifteen (15.5%) of those insertions involved minor adjustments, such as repositioning with fluoroscopy, saline flush, and/or guidewire, and the other 13 PICCs (13.4%) were inserted completely by an IR after a failed attempt by the nurse. Insertion difficulties included tip malposition (2.1%), difficulty cannulating the vein (6.2%), and difficulty advancing the catheter (19.6%). No insertion-related complications (bleeding, hemothorax, pneumothorax, arterial cannulation, atrial perforation, or arrhythmia) were observed.
Of 97 PICCs inserted, 82.5% (N = 80) were removed at the end of therapy and 4.1% (N = 4) were still in place at the end of the study. Postinsertion complications are listed in Table 2. Thirteen catheters (13.4%) were removed before the end of therapy because of a catheter-related complication. Another 13 patients (13.4%) experienced complications that required treatment with the catheter in place. These patients experienced mechanical phlebitis (N = 7), dermatitis (N = 3), basilic vein thrombus (N = 1), and line blockage (N = 2). Complications that necessitated removal or exchange of the catheter included catheter occlusion unresponsive to saline flush and thrombolytic agent (N = 4), dislodgment (N = 5), external catheter breakage (N = 3), and suspected catheter-related sepsis (N = 1). Two catheters fractured internally during planned removals at the end of therapy, and snaring procedures were required to retrieve the catheter fragments. All episodes of catheter fracture, dislodgment, thrombus, dermatitis, and blockage occurred with catheters used in the outpatient setting. All phlebitis episodes occurred with catheters used for TPN or chemotherapy. All blockages, dermatitis, fractures, sepsis, dislodgment, and thrombus occurred with catheters not used for TPN. Overall, the complication rate for inpatients was 6.9 cases per 1000 catheter-days and the rate for outpatients was 6.4 cases per 1000 catheter-days. More inpatients completed therapy (97.3%) than did outpatients (81.7%).
A comparison of dwell times showed that the median dwell times for catheters removed at the end of therapy and those still in place at the end of the study were 34.5 days and 38 days, respectively. Although catheters removed because of complications had a shorter median dwell time of 22 days, this was not statistically significant, compared with catheters removed at the end of therapy (P = .65). Dwell times for catheters used for TPN (21.5 days; range: 5–80 days) were significantly shorter than those for non-TPN catheters (39 days; range: 6–199 days) (P = .03). Because all catheters used for TPN were for inpatients, it is not surprising that the dwell times for inpatients and outpatients were also statistically significantly different (inpatients: 21 days; range: 5–80 days; outpatients: 42 days; range: 7–199; P = .002).
DISCUSSION
This study evaluated the initiation of a new pediatric nurse-inserted PICC program and raised several issues that should help direct subsequent development of the program. The ability of an on-site IR to redirect, to reposition, or to troubleshoot with fluoroscopy represents a tremendous advantage. Ongoing evaluation of success rates should show an improvement as novices become more experienced with respect to insertion-related difficulties.
The advantages of our program include the added safety of having nurses insert PICCs in a monitored, controlled environment, rather than at the bedside. The proximity and availability of the IR and fluoroscopy allow for ongoing education and support during this early phase. The ability to troubleshoot when an insertion difficulty is encountered is important. Fluoroscopy use is limited to a contrast check of tip position at the end of the procedure for successful insertions, reducing the radiation exposure of the children, compared with insertions by IRs when limited fluoroscopy guidance is used throughout the procedure. No patient transfers, delays, or compromise of sterility occurred when IR assistance was required. The catheters chosen for this program were noncuffed and required less pain control for insertion. They were selected after consultation with the IRs, to ensure compatibility with guidewires used by the IRs and to allow an easy switch from a nurse insertion to an IR insertion. This program also allowed for comprehensive care of inpatients by one group of nurses. The role of an expert PICC team charged with catheter and dressing care might have influenced the low postinsertion complication rate and will be explored in the future.
The evaluation of our novel program showed that nurse-inserted PICCs for children could be inserted safely with minimal anesthesia and had a low postinsertion complication rate (13.4%). It also confirmed the experience of others who reported success rates similar to ours among novices. This pediatric nurse-inserted PICC program is unique in several ways. Given our center's experience and needs, expansion of our PICC service needed to maintain established safety and infection-control standards. However, it also needed to allow an expected learning period for novices as they entered the program. A previous study of bedside nurse insertion in an academic center with pediatric and adult patients suggested that success rates of novices approached 74%, whereas more experienced bedside insertion rates could approach 83% when a limited number of novices were trained and allowed to perform insertions at the bedside.7 A similar study among adult patients confirmed a 74% success rate for nurse insertions at the initiation of a PICC program.4 Our program was designed with a similar approach, albeit within the IGT suite rather than at the bedside, and our success rate matches those of previous studies, none of which were exclusively pediatric.
The collaboration between the vascular access nurses and the IGT team (including IRs, technologists, and nurses) also allows for a unique multidisciplinary approach. Vascular access nurses join the team within the IGT suite, and their regular follow-up care of inpatients bridges a gap in postprocedural care. Previously, the IGT team only saw patients within 24 hours after PICC insertion and did not attend to dressing changes or monitor complications regularly, unless children required a contrast study of the catheter or catheter exchange. This program provides children with better continuity of care and offers team members a better understanding of minor complications that do not require catheter removal.
The number of catheters removed because of a complication in our series was low, compared with a previous study of pediatric PICC insertions by Thiagarajan et al2 (13.4% vs 29%). Although almost one half of the patients in that study were <1 year of age, the mean dwell time was 13 days, which suggests that PICCs replaced peripheral IV therapy for a subset of patients. In our series, the median dwell time was 34 days, and our therapy completion rate was >82%, which matches another small study of pediatric PICCs.8 Our success rate with respect to completion of therapy might be explained by the older age group of the patients or by differences in catheter care and catheter size. A significant proportion of catheters (68%) in the study by Thiagarajan et al2 had catheter tips in locations other than the vena cava or right atrium, which also might have led to higher complication rates than among our patients, because there is evidence that noncentrally placed catheter tips lead to more complications.9
The rates and types of complications that we encountered raise some interesting points about catheter care and maintenance. Only 1 suspected catheter-related infection was found, for a patient with a positive central culture for coagulase-negative Staphylococcus; no tip culture was sent at the time of removal. All catheter dislodgments occurred among outpatients, which might reflect the quality of outpatient nursing care or the increased physical activity of these children. Another complication that required catheter removal or exchange was external breakage. The catheter type used by the PICC nurses does not have a repair kit, which limited the lives of catheters that fractured or leaked.
The disadvantages of this program include the logistic issues involved in coordinating the availability of PICC nurses, technologists, and IRs. Although most catheters could be inserted within 1 working day after the request, given the large size of our IGT division, coordination may be more difficult in smaller centers. Moreover, our initial inclusion criteria were quite limiting, with only 15.7% of all PICC insertions in the hospital during the study period qualifying for a nurse attempt. Most of that limitation arose from the complexity of cases treated at our center and our institution's restrictions on sedation. No child with airway risks is given nurse-assisted sedation. We selected the group of patients for whom vascular access nurses were already inserting midline catheters, to minimize the confounding effects of patient cooperation on insertion success rates.
As this collaborative program matures, there will be opportunities to make the selection criteria less exclusive. As the PICC nurses develop expertise in PICC insertion, the need for assistance from the IRs is expected to decrease. This should lead to more successful nurse insertions while maintaining patient safety.
ACKNOWLEDGMENTS
Initial training for the nurses who participated in the program was provided by Bard Canada.
Thanks go to Amina Khambalia for assisting with the data analysis and to Carolyne Pehora and Francine Faubert, PICC nurses.
FOOTNOTES
Accepted Oct 4, 2004.
No conflict of interest declared.
REFERENCES
Neuman ML, Murphy BD, Rosen MP. Bedside placement of peripherally-inserted central catheters: a cost-effectiveness analysis. Radiology. 1998;206 :423 –428
Parkinson R, Gandhi M, Harper J, Archibald C. Establishing an ultrasound guided peripherally inserted central catheter (PICC) insertion service. Clin Radiol. 1998;53 :33 –36
Barber JM, Booth DM, King JA, Chakraverty S. A nurse led peripherally inserted central catheter line insertion service is effective with radiological support. Clin Radiol. 2002;57 :352 –354
Funaki B, Zaleski GX. Radiologic versus bedside placement of peripherally inserted central catheters. Radiology. 1998;209 :284 –285
Division of Nosocomial and Occupational Infectious Diseases, Bureau of Infectious Diseases, Laboratory Centre for Disease Control, Health Canada. Preventing infections associated with indwelling intravascular access devices. Can Commun Dis Rep. 1997;23(suppl 8) :1 –16
Cardella JF, Cardella K, Bacci N, Fox PS, Post JH. Cumulative experience with 1,273 peripherally inserted central catheters at a single institution. J Vasc Interv Radiol. 1996;7 :5 –13
Miller KD, Dietrick CL. Experience with PICC at a university medical center. J Intraven Nurs. 1997;20 :141 –147
Racadio JM, Doellman DA, Johnson ND, Bean JA, Jacobs BR. Pediatric peripherally inserted central catheters: complication rates related to catheter tip location. Pediatrics. 2001;107(2) . Available at: www.pediatrics.org/cgi/content/full/107/2/e28(Beth Gamulka, MDCM, Crist)
Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
Department of Image-Guided Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
Department of Diagnostic Imaging, University of Toronto, Toronto, Ontario, Canada
ABSTRACT
Background. Concerns regarding the safety and success of peripherally inserted central catheters (PICCs) placed at the bedside in the pediatric population initially precluded the development of a nurse-inserted PICC program at our pediatric center. Previously, all PICCs were inserted by interventional radiologists (IRs) with fluoroscopic guidance. A new nurse-inserted PICC program was initiated with collaboration between PICC nurses and IRs.
Methods. Three nurses participated in the project. Patients who met preestablished selection criteria were approached. All insertions were performed with sterile technique on the fluoroscopy table, with IRs available to support the PICC nurse. Veins were accessed visually or through palpation. Final tip position was confirmed in all cases with contrast material administration and fluoroscopy. Additional fluoroscopy was performed only if placement difficulties were encountered. All patients were monitored prospectively.
Results. Ninety-nine patients (age: 3–18 years; average age: 13.6 years) met the selection criteria. Two patients underwent primary insertion by an IR. The remaining 97 patients underwent an insertion attempt by a nurse. Sixty-nine PICCs (71.1%) were placed successfully by a nurse, 15 (15.5%) required minor assistance from an IR, and 13 (13.4%) were inserted by an IR after an unsuccessful nurse attempt. No insertion complications were noted. Insertion difficulties included difficulty advancing the catheter (19.6%), difficulty cannulating the vein (6.2%), and tip malposition (2.1%). Postinsertion complications occurred for 27.8% of PICCs, and 13.4% required removal before the end of therapy.
Conclusion. This novel, pediatric nurse-inserted PICC program has a good safety profile, high success rate, and low postprocedural complication rate.
Key Words: peripherally inserted central catheter central venous catheter nurse
Abbreviations: PICC, peripherally inserted central catheter TPN, total parenteral nutrition IV, intravenous IGT, image-guided therapy IR, interventional radiologist
Peripherally inserted central catheters (PICCs) allow for middle- to long-term courses of intravenous (IV) therapy in the hospital and at home, blood sampling, and reductions in venipunctures. The purpose of this study was to evaluate a new, nurse-inserted, PICC program for children at a tertiary care pediatric center.
The nurse-inserted PICC program at our pediatric academic health sciences center grew out of an identified need to provide long-term IV access for children. Since 1992, interventional radiologists (IRs) at our hospital inserted PICCs under fluoroscopic guidance. However, patients who required vascular access devices were prioritized along with other patients who were dependent on the expertise of the IRs for image-guided procedures. This led to the perception by health care providers that PICC insertions were difficult to arrange. Consequently, health care providers turned to the IV team nurses for assistance with middle- to long-term vascular access.
Although nurses in the NICU inserted PICCs at the bedside, there was no similar option in the rest of our hospital. In the past, IV team nurses were able to offer midline catheters as the best alternative to short, peripheral, IV catheters. However, midline catheters are not ideal for patients who require blood sampling, treatment with vesicant drugs, long-term treatment with irritant drugs (eg, vancomycin or cloxacillin), or blood transfusions. The experience with midline catheters at our pediatric center also suggests that they are not optimal for total parenteral nutrition (TPN). In our recent review of data for 142 children with midline catheters, 52.3% of children who were receiving TPN through midline catheters could not complete therapy with this device because of complications.
Our solution to the problem of timely PICC insertions outside the NICU focused on the development of a pediatric nurse-inserted PICC program with several unique features. Other centers reported their experiences initiating PICC programs, but most involved either bedside nurse insertions or exclusively IR insertions in a fluoroscopy suite. Few studies reported experiences in pediatric programs.1–4 Concerns have been raised about the high rate of malpositioned catheters inserted at the bedside, where the tip does not sit at the junction between the superior vena cava and the right atrium.5 The success rate of IRs for PICC insertion is high, primarily because of the use of ultrasonography and fluoroscopy to observe the vein and to position the catheter appropriately. In expanding our program, there was an incentive to maintain a high insertion success rate while ensuring the safety of the procedure. Rather than initiating nurse insertions at the bedside, we developed a hybrid program combining the advantages of a nurse-inserted PICC program and an IR PICC service. We thus expanded our vascular access service by incorporating the new nurse-inserted PICC program in the hospital's image-guided therapy (IGT) suites.
Our nurse-inserted PICC program is a collaborative effort between the division of IGT and the vascular access/IV team. All catheter insertions are performed in the IGT fluoroscopy suite. Three nurses with extensive experience in IV access volunteered to participate in the project and received practical training from one of the manufacturers of PICC catheters. Four IRs supervised the nurses in PICC insertion.
The aim of this prospective descriptive study was to evaluate the success of a novel, nurse-inserted, PICC program. The evaluation of the program focused on the insertion success rate of the PICC nurses and on periprocedural and long-term complication rates for PICCs.
METHODS
Patients and Study Design
All children were inpatients or outpatients at our hospital, which is a tertiary care, pediatric, academic, health sciences center. The program was initiated in December 2001, and data for all patients who met the inclusion criteria between December 2001 and June 2003 were reviewed. Patient criteria for inclusion in the nurse-inserted PICC program were established before the initiation of the project and reflected patients who were midline catheter candidates. Inclusion criteria included cooperative patients >3 years of age, a history of <3 previous central venous catheters in the superior vena cava, and palpable or easily observed brachial or cephalic veins. Patients with a particular medical condition that necessitated general anesthesia for a procedure were excluded. However, patients who otherwise fulfilled the criteria but received general anesthesia for another procedure were included. The evaluation of the program received approval from the hospital research ethics board.
Physicians, bedside nurses, and IV team nurses identified candidates for the nurse-inserted PICC program. Once identified, the patients were triaged by a specially designated resource nurse within the vascular access program and were then assessed by a PICC nurse, to ensure that inclusion criteria were met.
We evaluated all patients who consented and underwent an attempted PICC insertion performed by a nurse. Data were gathered prospectively until the catheter was removed or until the end of the observation period in July 2003 (the minimal follow-up period was 21 days). Periprocedural and postprocedural complications were recorded. PICC nurses assessed inpatients daily and tracked catheter function and site condition. They performed all weekly site dressing changes on inpatients. Patients discharged from the hospital with a PICC in situ were monitored by telephone by the PICC nurse. Inpatient catheter maintenance included heparinization with 150 units of heparin (100 U/mL solution) every 24 hours for all catheters that were accessed intermittently. Catheters with continuous infusions did not receive heparin. Outpatients received daily PICC care by a home care nurse, who followed the same heparinization and dressing policies. Problems with outpatient PICCs were addressed by the hospital's PICC nurses after contact by the patient's family or by the home care nurse. The PICC nurses provided preinsertion and postinsertion education to patients and families and performed all inpatient dressing changes.
Variables included demographic characteristics such as patient age, gender, diagnostic category, and reason for PICC insertion. Dwell time was calculated as the difference between the insertion and removal dates. "Successful" insertions included nurse insertions that did not require assistance from the IR (other than confirmation of the tip position with fluoroscopy after completion of the procedure). "Successful-assisted" insertions included insertions in which nurses required verbal or hands-on assistance by an IR during the insertion. "Unsuccessful" insertions were those performed completely by an IR after a failed nurse attempt.
Insertion difficulties included problems cannulating the vein, advancing the catheter, or positioning the tip. Insertion complications included bleeding, hemothorax, pneumothorax, arterial cannulation, and arrhythmia. Postinsertion complications included external or internal catheter fracture, thrombosis, catheter-related local or systemic infection, as defined by national infection-control standards,6 catheter occlusion, catheter dislodgment, dermatitis, and mechanical phlebitis.
Descriptive statistics were used to examine the success rate for PICC nurses, insertion difficulty and complication rates, postinsertion complication rates, and average dwell times. Comparisons were made between median dwell times for catheters removed because of complications and those removed at the end of therapy.
Technique
Informed consent is obtained from the parent or guardian by the PICC nurse, and assent is granted by the child. The PICC placement is performed in the IGT suite, with sterile technique. Topical anesthetic is applied to the chosen site (basilic or cephalic vein) before the procedure. All inserters use sterile technique with a combination of topical anesthetic (EMLA [AstraZeneca, Wilmington, DE] or Ametop Gel [Smith and Nephew, Hull, United Kingdom]), skin infiltration with lidocaine, and IV sedation. Veins are accessed either by direct observation or by palpation.
The catheter is flushed with saline solution and trimmed to the correct length, with care being taken not to cut the guidewire inside the catheter. The assistant places the patient in a supine position, with the arm abducted to a 90° angle. The site is cleansed with a chlorhexidine/alcohol preparation and draped, and a tourniquet is applied by the assistant. The vein is accessed visually or by palpation with the peel-away introducer needle at a 25° to 45° angle. The stylet from the introducer is removed, and the catheter is threaded through the peel-away sheath. The tourniquet is released and the catheter is advanced centrally. The patient is asked to tuck her or his chin on the ipsilateral shoulder, to prevent the catheter from going up the jugular vein. At that point, the catheter is confirmed fluoroscopically to be in the lower one third of the superior vena cava. The guidewire is removed from the catheter. The catheter position is then confirmed fluoroscopically, with contrast agent administration, by the IR.
If the catheter does not advance or if fluoroscopy indicates that the catheter has gone into any vein other than the superior vena cava, then the IR advances the catheter over a directing guidewire until central access is obtained and confirmed with contrast agent administration. If access fails with visual landmarks or palpation, then the IR may use ultrasonography with a sterile cover in the same sterile field, without moving the patient. The PICC nurse may then be in a position to continue, or the IR may complete the procedure.
RESULTS
Ninety-nine patients requiring PICCs fulfilled the selection criteria. Ninety-seven patients (98%) underwent an initial insertion attempt by a nurse; 1 patient who had undergone a previous PICC insertion by an IR refused a nurse-inserted PICC. Another patient was not included because of an underlying coagulopathy. Reasons for PICC insertion included antibiotic or antiviral therapy (N = 59 [60.8%]), TPN administration (N = 28 [28.9%]), chemotherapy (N = 4 [4.1%]), or other medications (N = 6 [6.2%]). The average age of the children was 13.6 years (range: 3–18 years). There were 52 male patients and 45 female patients. Thirty-seven catheters were used exclusively for inpatients, whereas 60 catheters were used for outpatients.
Noncuffed PICCs (Bard Per-Q-Cath [Bard Access Systems, Salt Lake City, UT]) were inserted by PICC nurses. PICCs inserted by an IR after an initial nurse attempt were either noncuffed (Bard Per-Q-Cath) or cuffed (Cook Critical Care, Bloomington, IN). Nurses inserted 81 single-lumen (3F or 4F) catheters and 3 double-lumen (4F or 5F) catheters. IRs inserted 12 single-lumen (3F or 4F) catheters and 1 double-lumen (5F) catheter. The cephalic vein was accessed in 31 insertions and the basilic vein in 66 insertions. Topical anesthetic alone was used for 81 patients (83.5%). The remaining patients received a combination of topical anesthetic and infiltration of lidocaine (N = 12), IV sedation (N = 2), and general anesthesia (N = 2).
A summary of patient characteristics and insertion attempt outcomes is presented in Table 1. Sixty-nine PICCs were inserted successfully by a PICC nurse, yielding a success rate of 71.1%. Twenty-eight insertions required assistance. Fifteen (15.5%) of those insertions involved minor adjustments, such as repositioning with fluoroscopy, saline flush, and/or guidewire, and the other 13 PICCs (13.4%) were inserted completely by an IR after a failed attempt by the nurse. Insertion difficulties included tip malposition (2.1%), difficulty cannulating the vein (6.2%), and difficulty advancing the catheter (19.6%). No insertion-related complications (bleeding, hemothorax, pneumothorax, arterial cannulation, atrial perforation, or arrhythmia) were observed.
Of 97 PICCs inserted, 82.5% (N = 80) were removed at the end of therapy and 4.1% (N = 4) were still in place at the end of the study. Postinsertion complications are listed in Table 2. Thirteen catheters (13.4%) were removed before the end of therapy because of a catheter-related complication. Another 13 patients (13.4%) experienced complications that required treatment with the catheter in place. These patients experienced mechanical phlebitis (N = 7), dermatitis (N = 3), basilic vein thrombus (N = 1), and line blockage (N = 2). Complications that necessitated removal or exchange of the catheter included catheter occlusion unresponsive to saline flush and thrombolytic agent (N = 4), dislodgment (N = 5), external catheter breakage (N = 3), and suspected catheter-related sepsis (N = 1). Two catheters fractured internally during planned removals at the end of therapy, and snaring procedures were required to retrieve the catheter fragments. All episodes of catheter fracture, dislodgment, thrombus, dermatitis, and blockage occurred with catheters used in the outpatient setting. All phlebitis episodes occurred with catheters used for TPN or chemotherapy. All blockages, dermatitis, fractures, sepsis, dislodgment, and thrombus occurred with catheters not used for TPN. Overall, the complication rate for inpatients was 6.9 cases per 1000 catheter-days and the rate for outpatients was 6.4 cases per 1000 catheter-days. More inpatients completed therapy (97.3%) than did outpatients (81.7%).
A comparison of dwell times showed that the median dwell times for catheters removed at the end of therapy and those still in place at the end of the study were 34.5 days and 38 days, respectively. Although catheters removed because of complications had a shorter median dwell time of 22 days, this was not statistically significant, compared with catheters removed at the end of therapy (P = .65). Dwell times for catheters used for TPN (21.5 days; range: 5–80 days) were significantly shorter than those for non-TPN catheters (39 days; range: 6–199 days) (P = .03). Because all catheters used for TPN were for inpatients, it is not surprising that the dwell times for inpatients and outpatients were also statistically significantly different (inpatients: 21 days; range: 5–80 days; outpatients: 42 days; range: 7–199; P = .002).
DISCUSSION
This study evaluated the initiation of a new pediatric nurse-inserted PICC program and raised several issues that should help direct subsequent development of the program. The ability of an on-site IR to redirect, to reposition, or to troubleshoot with fluoroscopy represents a tremendous advantage. Ongoing evaluation of success rates should show an improvement as novices become more experienced with respect to insertion-related difficulties.
The advantages of our program include the added safety of having nurses insert PICCs in a monitored, controlled environment, rather than at the bedside. The proximity and availability of the IR and fluoroscopy allow for ongoing education and support during this early phase. The ability to troubleshoot when an insertion difficulty is encountered is important. Fluoroscopy use is limited to a contrast check of tip position at the end of the procedure for successful insertions, reducing the radiation exposure of the children, compared with insertions by IRs when limited fluoroscopy guidance is used throughout the procedure. No patient transfers, delays, or compromise of sterility occurred when IR assistance was required. The catheters chosen for this program were noncuffed and required less pain control for insertion. They were selected after consultation with the IRs, to ensure compatibility with guidewires used by the IRs and to allow an easy switch from a nurse insertion to an IR insertion. This program also allowed for comprehensive care of inpatients by one group of nurses. The role of an expert PICC team charged with catheter and dressing care might have influenced the low postinsertion complication rate and will be explored in the future.
The evaluation of our novel program showed that nurse-inserted PICCs for children could be inserted safely with minimal anesthesia and had a low postinsertion complication rate (13.4%). It also confirmed the experience of others who reported success rates similar to ours among novices. This pediatric nurse-inserted PICC program is unique in several ways. Given our center's experience and needs, expansion of our PICC service needed to maintain established safety and infection-control standards. However, it also needed to allow an expected learning period for novices as they entered the program. A previous study of bedside nurse insertion in an academic center with pediatric and adult patients suggested that success rates of novices approached 74%, whereas more experienced bedside insertion rates could approach 83% when a limited number of novices were trained and allowed to perform insertions at the bedside.7 A similar study among adult patients confirmed a 74% success rate for nurse insertions at the initiation of a PICC program.4 Our program was designed with a similar approach, albeit within the IGT suite rather than at the bedside, and our success rate matches those of previous studies, none of which were exclusively pediatric.
The collaboration between the vascular access nurses and the IGT team (including IRs, technologists, and nurses) also allows for a unique multidisciplinary approach. Vascular access nurses join the team within the IGT suite, and their regular follow-up care of inpatients bridges a gap in postprocedural care. Previously, the IGT team only saw patients within 24 hours after PICC insertion and did not attend to dressing changes or monitor complications regularly, unless children required a contrast study of the catheter or catheter exchange. This program provides children with better continuity of care and offers team members a better understanding of minor complications that do not require catheter removal.
The number of catheters removed because of a complication in our series was low, compared with a previous study of pediatric PICC insertions by Thiagarajan et al2 (13.4% vs 29%). Although almost one half of the patients in that study were <1 year of age, the mean dwell time was 13 days, which suggests that PICCs replaced peripheral IV therapy for a subset of patients. In our series, the median dwell time was 34 days, and our therapy completion rate was >82%, which matches another small study of pediatric PICCs.8 Our success rate with respect to completion of therapy might be explained by the older age group of the patients or by differences in catheter care and catheter size. A significant proportion of catheters (68%) in the study by Thiagarajan et al2 had catheter tips in locations other than the vena cava or right atrium, which also might have led to higher complication rates than among our patients, because there is evidence that noncentrally placed catheter tips lead to more complications.9
The rates and types of complications that we encountered raise some interesting points about catheter care and maintenance. Only 1 suspected catheter-related infection was found, for a patient with a positive central culture for coagulase-negative Staphylococcus; no tip culture was sent at the time of removal. All catheter dislodgments occurred among outpatients, which might reflect the quality of outpatient nursing care or the increased physical activity of these children. Another complication that required catheter removal or exchange was external breakage. The catheter type used by the PICC nurses does not have a repair kit, which limited the lives of catheters that fractured or leaked.
The disadvantages of this program include the logistic issues involved in coordinating the availability of PICC nurses, technologists, and IRs. Although most catheters could be inserted within 1 working day after the request, given the large size of our IGT division, coordination may be more difficult in smaller centers. Moreover, our initial inclusion criteria were quite limiting, with only 15.7% of all PICC insertions in the hospital during the study period qualifying for a nurse attempt. Most of that limitation arose from the complexity of cases treated at our center and our institution's restrictions on sedation. No child with airway risks is given nurse-assisted sedation. We selected the group of patients for whom vascular access nurses were already inserting midline catheters, to minimize the confounding effects of patient cooperation on insertion success rates.
As this collaborative program matures, there will be opportunities to make the selection criteria less exclusive. As the PICC nurses develop expertise in PICC insertion, the need for assistance from the IRs is expected to decrease. This should lead to more successful nurse insertions while maintaining patient safety.
ACKNOWLEDGMENTS
Initial training for the nurses who participated in the program was provided by Bard Canada.
Thanks go to Amina Khambalia for assisting with the data analysis and to Carolyne Pehora and Francine Faubert, PICC nurses.
FOOTNOTES
Accepted Oct 4, 2004.
No conflict of interest declared.
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