The many benefits of a
multi-professional PICC
team in terms of safety
and cost-effectiveness
Kathy Kokotis RN BS MBA
Disclosure
The speaker’s presentation today is on behalf of Becton
Dickinson. Any discussion regarding Becton Dickinson
products during the presentation today is limited to
information that is consistent with Becton Dickinson
labeling. Please consult Becton Dickinson product
labels and inserts for any indications, contraindications,
hazards, warnings, cautions and instructions for use.
This systematic review failed to locate relevant
published RCTs to support or refute the assertion
that vascular access specialist teams are superior
to the generalist model.
Carr PJ, Higgins NS, Cooke ML, Mihala G, Rickard CM
Vascular access specialist teams for
device insertion and prevention of
failure (Review) March 2018
Cost Benefit:
Shifting PICC to Bedside Placement
High Tech Suite
Placement
Bedside
Cost Benefit:
Shifting PICC to Bedside Placement
High
tech
suite
Wait
times
Suite
hours
Cost
Transport
ICU
Cost Benefit:
Shifting PICC to Bedside Placement
High tech suite
Cost USD $1,210
Bedside
Cost USD $390
Cost Benefit:
Shifting PICC to Bedside Placement
Meyer B: (Sept/Oct 2010) JIN 33(5) 292-303 Picture rights purchased (5/2019)
Cost Benefit
Shifting PICC to bedside placement
Complication/Outcomes
4 months
MD/IR/Anesthesia (N=48)
High tech suite placement
RN/Bedside (N=91)
Oncology/OPAT Nurses
Non dedicated team (3 RN)
Insertion Success
100%
93.1%
Infection
14.58%
4.4%
Dislodgement
8.33%
2.2%
Time to place
40.125 minutes
62.49 min. (oncology suite)
18 min. ICU (no transfer)
Raigmore Hospital 577 beds UK
Prospective single center cohort analysis (2012-2013)
Average patient had 6.168 cannulas
Placement in radiology cost 42% - 295% (tariff suite) higher than RN
Cost Benefit
Shifting PICC to bedside placement
Walker G. (2013) BJN 22(19) S20-S26
₤956.96
Theatre
Efficiencies stated by Robinson (Brigham)
Advantage dedicated team
94%
• Insertion success bedside with ultrasound
• 78% overall drop in use of IR
24%
• Reduced placement costs with ultrasound
80%
• Reduced wait time with ultrasound
• 7 to 10 day wait time
Potential Safety Benefit:
PICC Teams and Vascular Access Service
Oswaldo Cruz PICC Team
Reduction Cather-related complications
Surgeon-led PICC team (Brigham)
•
Single center retrospective review (2000-2013)
•
Based on refusing to place 30.9% PICC lines ordered
•
PICC lines disapproved for: ICU, positive blood cultures, fever in last
24 hours, renal failure, coagulopathy, short-term antibiotics,
antibiotics can be switched to PO, existing IV routes (PIV, CVL), TPN
not approved
•
Based on BSI rate of PICC 5.9% and thrombotic complications 2.5%
Supplies
Avoided ($491)
• $5.4 M USD
Bloodstream infections
Avoided ($11,971)
• $7.77 M USD
Thrombotic
complications avoided
($7,594)
• $2.25 M USD
Reducing costs and complications (NHS Evidence)
Centralized nurse (3)-led team in radiology
•
University of hospitals Leicester NHS Trust
• Direct
₤25,000
• Indirect
₤730,000
• Revenue costs
• Capital costs
₤225,000
₤110,000
Reducing costs and complications (NHS Evidence)
Centralized nurse (3)-led team in radiology
•
University of hospitals Leicester NHS Trust
–
Save 4 day LOS and fewer repeat cannulations
–
Lower patient infections, pneumothorax or
arterial punctures
–
Time saving labor multiple PIV
–
Standardization of procedure (packs)
Reducing costs and complications (NHS Evidence)
Centralized nurse (3)-led team in radiology
•
University of hospitals Leicester NHS Trust
35
da
ys
₤245 day
₤8575
Pa
tien
t
Reduced LOS Orthopedic
Osteomyelitis outpatient
Why a dedicated team?
There is no solid RCT or
non RCT evidence that a
team decreases
complications but why
do some institutions use
a dedicated team?
Advantages (CVAS) stated by Alexandrou
Nurse Led Central Venous Access Service
Experience placer with ultrasound
Physician (MD)
No ultrasound utilized
Respiratory Care
Practitioners (RCP)
Ultrasound utilized IJ
Complications
IJ only
N=181
All CVC
N=538
IJ only
N-292
All CVC
N=327
Mechanical Rate
11.04%
7.10%
2.05%
2.14%
Pulsatile blood flow
5
12
4
4
Pneumothorax
6
1
Malpositioned catheter
15
21
2
2
Ramirez C: JAVA 15(4) 207-211
Single center prospective 27 month study (250) beds
MD did not utilize ultrasound guidance RCP did for IJ
All femoral and majority subclavian placed by MD
Successful: Training
•
Evidence based consensus
task-force (WoCoVA)
•
Didactic
•
Practicum
•
Testing process
•
Proctorship.
•Moureau N, Lamperti M, Kelly LJ (2013) Evidence-based consensus on the insertion of central venous access devices: definition of minimal requirements for training. BJA 110:347-356
•https://commons.wikimedia.org/wiki/File:Magic_wand.svgThis image is considered public domain simply because thewitches and warlocksat Commons wished it so. It'sMagic!
No Magic number for
Experienced placer
Tsotsolis N. Annals of Translational Medicine (2015) 3(3):40
Experienced placer
Tsotsolis N. Annals of Translational Medicine (2015) 3(3):40
Picture purchased April 2019
> 50 Catheterizations
Potential higher mechanical
complication rate
Minimum Operator Requirements:
CICC insertion (JCI)
5
supervised
Chest
insertion
5
supervised
Femoral
insertion
10 total
supervised
insertions
minimal
Obtain a qualified second operator after 3 unsuccessful sticks (unless emergent)
The Joint Commission. Preventing Central Line–Associated Bloodstream Infections: Useful Tools, An International
Competency: Placement
Author / Year
Number of
Procedure
Comments
Guideline
American Society of
Echocardiography
and the Society of
Cardiovascular
Anesthesiologists
(2011)
10 under
supervision
Ultrasound guided
CICC
A portion in
simulation lab
Lack of scientific literature to specifically delineate the number of procedure
Learning Curve:
Ultrasound Guidance Proficiency
•
Single institution prospective observational study
•
Emergency room 33 placers (non-physician)
–
1077 PIV access attempt in 796 patients
• 4 USG PIVs
• First attempt
70%
Success rate
• 15 to 26 USG PIVs
• First attempt
> 88%
Success rate
Learning Curve:
Sliding lung excludes pneumothorax
•
Single institution prospective observational study in
health volunteers
•
(57) 4
th
year medical students
• 4.5 correct attempts
Identify sliding
lung on 6
th
attempt
Cost training RN to place a PICC
Didactic
Observations
Practicum
Proctored
placements
PICC, Stick, and Run
Dedicated labor
Creating an
assessment
process
Vascular Access ServicePVAS
Peripheral vascular access service Vascular access RN USG PIV Midlines Extended dwell CVAS
Central venous access service
Intensivist, fellow, resident nurse
Non tunneled CVC PICC
VAST
Vascular access tunneled catheter service
Surgeons/IR
Tunneled CVC Ports
Martillo M: (October 8, 2019) AJIC 47(10
)
Triage to the appropriate
VAS team based on:
•
VAD medication
•
Time
Slide Taken from Mauro Pittiruti (AVA 2018)
Patients are on irritant & vesicant drugs
which needs VAD assessment
Patients are Complicated and Need VAD Assessment
Far from the tracheostomy1 Upper arm low bacterial colonization2 Helmets for NIV2 Replacement for emergent Femorals1 Orthopedic devices1 Wound Infection neck or chest2
Patients are
Complicated and
Need VAD
Assessment and
skilled insertion
with ultrasound
Jugular catheter
skepticalscalpel@hotmail.comPatient Coagulation Considerations and damaging the vein or artery
Procedures with Low Risk of
Bleeding, Easily Detected and
Controllable (Category 1)
Applicable Vascular Procedures
Dialysis access intervention
Central line removal
PICC line placement
Procedures with Moderate Risk
of Bleeding (Category 2)
Applicable Vascular Procedures
Tunneled central venous catheter
Subcutaneous port procedure
Patel et al. Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous Image-guided Interventions. JVIR 2012. 23:727-736
