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Saturday 15 December 2018
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Sponsored – The importance of vascular access device selection: case study

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Disclaimer

This case study reflects the individual experiences of two healthcare practitioners and does not represent a scientific study or present clinical evidence. Results for other clinicians or institutions will vary. Please consult manufacturer’s instructions for use for relevant warnings, indications, and counterindications.
 

Disclosure

This hospital experience report was sponsored by Becton, Dickinson and Company. FP is an employee of Careggi University Hospital and NCR is an employee of University Hospital of La Coruña. CC is an Engagement Manager for Trinity Partners, LLC, contracted by Becton, Dickinson and Company to conduct the interviews and write the report. 
 
Most hospitalised patients receive some form of vascular access during their hospital stay.1 With a variety of options of vascular access devices (VADs) to choose from, selecting the appropriate VAD is an important part of patient care. VAD selection should be tailored to each patient’s needs, taking into account the length of therapy, number of lumens required, flow rates required, need for blood draws, patient preference, and whether or not the patient will be discharged on therapy.2
 
One important VAD option is peripherally inserted central catheters (PICCs). Technological advances in PICCs over the last several years have introduced a variety of benefits that have resulted in their increased utilisation. PICCs can be utilised for both short- and long-term access to the central venous system. Clinicians have found many uses for PICCs including administration of intravenous therapy (such as antibiotics, total parenteral nutrition, and chemotherapy), power injection of contrast media, central venous pressure monitoring, and blood sampling.3 Interviews with Dr Fulvio Pinelli and nurse Noemí Cortes Ray were conducted to characterise two healthcare practitioners’ adoption of PICCs into their clinical practices and the resulting clinical and economic benefits associated with their use. 
 

Oncology use in Italy

Dr Fulvio Pinelli is an anesthesiologist at Careggi University Hospital, a large university hospital in Firenze, Italy. He splits his time between the oncology department and the vascular access centre. Most of his VAD patients are oncology patients receiving chemotherapy. Pinelli estimates that the vascular access team at his hospital places approximately 2500 VADs annually. Over the past several years PICC use has increased in Pinelli’s hospital. In his opinion, this is largely due to advances in PICC technology and increasing awareness amongst physicians of PICC applicability in the medium-term setting, spanning from days to a few months. 
 
According to Pinelli, three key technological advances have driven PICC adoption in Pinelli’s hospital: the introduction of multi-lumen PICCs, improvements in PICC construction materials, and the development of PICCs that allow for PICC placement at the bedside without radiology. Multi-lumen PICCs have removed a significant barrier to PICC use by allowing simultaneous perfusion and haemodynamic monitoring. “In the past, for intensivists, PICCs were not an option because they were single-lumen, had reduced catheter flow rates, and you either couldn’t do haemodynamic monitoring or it was a time-consuming procedure. But then the design improved. Now we have 2–3 lumen PICCs. 
 
Materials used to construct PICCs have also had a large impact. It’s now polyurethane, so the devices soften in the body, have very good strength and pliability. The other major improvement is power injectability. These [technological advances] all led to the possibility of high flows (versus silicone PICCs and non-power PICCs), multiple infusions, and the possibility of giving contrast media.” 
 
The development of PICCs that use the patient’s cardiac electrical activity to guide placement has also been a significant improvement for Pinelli’s hospital. Pinelli’s hospital uses Becton, Dickinson and Company’s Sherlock 3CG™, which utilises an adult patient’s cardiac electrical activity to position the tip of the PICC in close proximity to the cavoatrial junction (CAJ). Historical practice at Pinelli’s hospital had been to insert PICCs “blind” without real-time tip location visualisation.4 Now Pinelli and colleagues are able to use real-time catheter tip tracking technology to display both catheter direction and orientation, checking to confirm tip termination during the procedure. Pinelli reports that with this technique, “successful placement rate has been shown to be around 99%”.5
 
Altogether, Pinelli reports that these advances have spurred him to, “…spread this culture, to convince even the most reluctant doctors to think about using PICCs in hospital patients.”
 

ICU use in Spain

Noemí Cortés is a nurse working in a large intensive care unit (ICU) within University Hospital of La Coruña, a public university hospital in northwest Spain. Patients in Cortés’ unit are post-surgical critical care patients who come to the ICU after surgery, usually with a centrally inserted central catheter (CICC) from the operating room. 
 
Cortés is a strong proponent of PICCs and has been a champion of PICC adoption in her hospital system. The evolution of PICC adoption in Cortés’ ICU has been driven by nurses, and the nurses are exclusively the personnel to place PICCs.
 
Until a few years ago, the vast majority of VADs placed in Cortés’ ICU were CICCs. PICC use was rare, requiring placement by the hospital’s radiology team. When Cortés joined the ICU three years ago, she quickly developed an interest in improving the patient experience and outcomes through optimal VAD use and joined the unit’s newly formed vascular access management program. “PICC use is a topic I got into for professional reasons. It was professional curiosity; we wanted to improve. We realised that many times the vascular access of our patients ended up exhausted. 
 
We recognised the need and value of PICCs, but the only service that could cannulate PICCs was vascular radiology. Critical patients usually need technology for life support and moving out of the unit is very risky and complex.” In addition, ICU patients often require infusions of multiple medications. PICCs allow for multiple simultaneous infusions. “Sometimes we need more than 2–3 central lines because our patients are critical, so they need continuous infusion of noradrenaline, morphine, midazolam, several antibiotics, etc. Using a multi-lumen device allows for just one device for multiple simultaneous infusions.”
 
To help improve vascular access management, Cortés and her colleagues decided to learn to insert PICCs and midline catheters. She and two other ICU nurse colleagues completed private training courses in Spain and abroad. Cortés and her two colleagues then approached the hospital board and requested PICCs for use in the ICU. PICC use in the ICU is now significant (Cortés ICU uses Becton, Dickinson, and Company’s PowerPICC®s), and the number of nursing personnel trained to cannulate PICCs and midline catheters has steadily grown. With 14 nurses now trained in cannulation, Cortés’ ICU now has around-the-clock coverage of personnel trained for PICC cannulation. 
 
Cortés subsequently received additional inservice training from C.R. Bard (which is owned by Becton, Dickinson and Company) and other private courses, and is now an official instructor for cannulation training. She attends vascular access conferences like WoCoVa (World Congress Vascular Access) and drives keeping her practice up to date with the latest in VAD technology and practices. 
 
Cortés’ efforts to champion PICC adoption was not without hurdles, however. “At the beginning, the biggest enemy we had to fight against were the nurses. For many people, it’s difficult to change, to learn new things. [Some nurses] felt like ‘Oh my gosh, another thing to learn, another thing to do, it’s another job for us.’ They thought it was going to increase our work. We had confrontations with some people because of that, but at this moment, most of them have changed their minds. The clinical benefits [of PICCs] were so high that even those [originally skeptical] nurses have changed their minds. They are very happy with the use of PICCs.” 
 

Clinical advantages of PICCs

Cortés and Pinelli are both strong proponents of PICC use in appropriate patient types in their respective settings. In addition to the ability to infuse multiple medications/collect samples simultaneously and the ability to place PICCs at the bedside with advances in placement technique, Cortés and Pinelli outline several other clinical advantages of PICCs.
 

Preserve vein integrity; reduced long-term injury to patient veins

For Cortés, the most important benefit of PICCs is preserving the veins of the patient, and “…not provoking more harm than necessary. Once you have injured the vein, it takes time to heal. Sometimes the damage is too severe, and it may not heal. The most important thing to me is that you are not provoking pain, you are not provoking more injury than necessary.”
 

High patient acceptance/preference (reduced patient discomfort due to fewer punctures)

At the front lines of VAD placement, Cortés reports that in her experience many patients have a high acceptance of and preference for PICCs over other VADs. The continuity of a single VAD across the patient journey and the availability of multi-lumen PICCs may reduce the number of needlesticks for the patient, potentially limiting overall discomfort/pain that comes with multiple cannulisations. 
 

Clinical limitations of PICCs

Like any VAD, there are clinical limitations and contraindications to PICC use. For instance, PICCs should not be used in an emergent situation, as PICCs are not designed to be cannulated as quickly as other VADs. Pinelli also mentions that PICCs should not be used in patients with limited arm mobility. “You need to show that the patient can move his/her arm. Chronic kidney disease is an absolute contraindication because that patient could need to use that arm during dialysis. The risk of thrombosis if a patient can’t move their arm is too high.” PICCs should always be used in accordance with their indication for use.3
 

Economic considerations 

In addition to clinical considerations, Pinelli and Cortés also postulate that PICC use has had a positive economic impact in their hospitals. From a resource perspective, Pinelli and Cortés report that using a single PICC instead of several other VADs may save time and resources that would be needed to place multiple VADs.6 Pinelli further adds that VAD placement by radiologists in his hospital is costly, and the shift to bedside PICC placement circumvents this need and creates cost savings. In his experience, Pinelli says “risk-adjusted cost of PICC use is lower, due to potential complications if a PICC is not used, the cumulative cost of several devices, and staff time. A PICC is more expensive than a CICC, but if you consider the potential cost of … mechanical complications like a pneumothorax, and the cost of time you spend using different devices, altogether I think you save money at the end.” 
 

Future perspectives

Dr Fulvio Pinelli and nurse Noemí Cortés have both successfully adopted PICC utilisation into their everyday practice, Pinelli with oncology patients receiving chemotherapy and Cortés with patients in the ICU. Both providers have observed significant benefits in improving both short-term and long-term patient care across various patient types and clinical situations. As a result, Pinelli and Cortés have become strong champions of PICC adoption and advocate for greater clinically appropriate PICC use within their hospitals and their respective spheres of influence. Nurse Cortés’ experience also demonstrates the opportunity for nurses to catalyse optimal VAD management. Both Pinelli and Cortés wanted to share their experience with PICCs in the hopes that other institutions can apply these learnings to their organisations and ultimately benefit more patients in the future. 
 

References

1 Helm RE et al. Accepted but unacceptable: Peripheral IV catheter failure. J Infus Nurs 2015;38(3):189–203.
2 Gorski L et al (eds). Infusion Nursing Standards of Practice. Vascular access device (VAD) selection and placement. J Infus Nurs 2016;39(1S):S51.
3 Bard Access Systems 2016. Instructions for Use: PowerPICC® Catheter.
4 Scoppettuolo G. Clinical problems associated with the use of peripheral venous approaches: Infections. In Sandrucci S, Mussa B (eds) Peripherally Inserted Central Venous Catheters. Verlag Italia: Springer;2014:95–6. 
5 Pittiruti M et al. The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study. J Vasc Access 2012;13(3):357–65. Note: 99.1% accuracy claim based on a post-market study of 114 adult patients within this study receiving a Sherlock 3CG PICC. 
6 Tomaszewski KJ et al. Time and resources of peripherally inserted central catheter insertion procedures: a comparison between blind insertion/chest X-ray and a real time tip navigation and confirmation system. Clinicoecon Outcomes Res 2017;2017(9):115–25.

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