Download When PICC Lines are Not Clinically Indicated: Considerations for

When PICC Lines are Not Clinically
Indicated: Considerations for
Successful Peripheral Venous Access
Page 1 of 11
© 2014 Christie Medical Holdings, Inc.
When PICC Lines are Not Clinically Indicated:
Considerations for Successful Peripheral
Venous Access
Written by Jessica Knowlton, MS CRA
Introduction
Much of the time, the decision of which
vascular access device (VAD) to place in a
particular patient is an easy one. The woman in
labor and delivery without any co-morbidities or
significant medical history will likely receive a short
peripheral catheter (SPC, figure 1) for delivery of
fluids. The elderly cancer patient undergoing
chemotherapy and parenteral nutrition needs a
central venous access device (CVAD, figure 2)
because of the caustic nature of the drugs being
delivered. Yet there is a spectrum of patients who
fall somewhere between the need for a SPC and
Knowing that CVADs such as peripherally
inserted central catheters (PICCs) are only needed
for certain populations and have a much higher
price point compared to SPCs, it is important for
healthcare providers and facilities to empower
Figure 2 Different Types of Central Catheters [25]
themselves to increase their success rates for SPC
placement. One study found that 24% of PICCs
placed were due to failed venous access with SPCs.
[1]
If a PICC line is being placed solely because
peripheral intravenous access has failed, this more
invasive procedure can be avoided using the right
tools.
Figure 1 Short Peripheral Catheters [24]
CVAD making the choice of device unclear.
Medications, patient co-morbidities, and patient
history, including tolerance for VADs, all become
part of the risk assessment for infusion therapy
devices.
In addition to patient specific
considerations, healthcare facilities, which are
subject to ever decreasing revenue streams, must
weigh the cost of the device against the prescribed
treatment regimen, adding another layer of
complexity to an already difficult decision.
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During the last decade, the number of
devices put onto the market to assist healthcare
workers in placement of SPCs has and continues to
grow. Ultrasound, transilluminators, and nearinfrared (NIR) devices represent the most widely
available devices that clinicians use to assist in
vascular access. This paper will review the NIRbased vascular access assistive devices in context
with the devices being used and the age population
being served.
© 2014 Christie Medical Holdings, Inc.
Types of Vascular Access Devices
When
considering
vascular
access
procedures for their patients, health care providers
have at their disposal a wide array of catheter
options. The most commonly placed vascular
catheter is the short peripheral catheter (SPC,
A.K.A. peripheral IV [PIV], peripheral venous
catheter [PVC], peripheral intravenous catheter
[PIC or PIVC], etc.). Investigators estimate that
between 70% and 90% [2] of hospitalized patients
require SPCs during their stay which equates to
approximately 15 – 20% of all patient days in acute
care hospitals. [3]
SPCs are placed, much as their name
implies, into the peripheral anatomy. Most of the
time for adults this means the top of the hand, the
side of the wrist, or the forearm. For neonates and
infants, in addition to the hand and forearm, the
saphenous vein in the leg or the temporal or frontal
veins in the head are often accessed. [4] The
location of SPC placement limits the types of fluids
or medications that can be delivered through them,
because the devices are placed into vascular areas
that can be easily damaged by harsh fluids or
medications. For instance, parenteral nutrition,
infusates with a pH less than 5 or greater than 9,
and infusates with high osmolality (>600
mOsm/L) can damage the lining of peripheral
blood vessels. [5] This may cause chemical phlebitis,
an inflammation of the lining of vessels caused by
delivery of harsh fluids [4] and can lead to
extravasations or infiltrations into the surrounding
tissue.
Extravasations/infiltrations can be
devastating for the patient or their family and result
in litigation expenses for the hospital facility. One
of the ways to avoid this complication is the use of
longer catheters that terminate in the large vessels
of the chest: central catheters.
Central Vascular Access Devices (CVAD,
A.K.A. central venous catheters [CVC]) come in a
number of different forms, but their main function
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is to provide a place for harsh infusates to be
diluted prior to entering the rest of the circulatory
system. This means that these devices terminate in
a large, central vessel such as the superior vena cava
(figure 3.) or right atrium. [4]
Figure 3: Termination Points for CVADs © ShutterStock
There are three main categories of central
venous access devices: non-tunneled catheters,
tunneled central catheters, and implanted ports.
The peripherally inserted central catheter (PICC,
figure 4) is a variation on the non-tunneled central
catheter. It is similar because the terminal end of a
line rests in the superior vena cava, much like the
other CVADs, but it differs from a typical CVAD
in that the vein of interest is accessed much further
Figure 4 Single, Double and Triple Lumen PICC Lines [26]
down the arm (i.e., more ‘peripherally’) towards the
antecubital area. PICCs are placed under a sterile
field just like other CVAD devices. The health
care provider feeds the catheter into either the
basilic or cephalic veins at a point above the
antecubital area. Ultrasound is used to verify
location of the vein and also to verify that the
© 2014 Christie Medical Holdings, Inc.
catheter has been fed correctly into the vessel.
Confirmation of tip location for this and all
CVADs
is
done
using
fluoroscopy,
echocardiogram, or radiograph imaging (figure 5). [6]
more susceptible to vascular access failure. This
patient population may require specialized access
equipment to accommodate their needs. [9] Part of
the physiological changes that occur in this patient
population that is widely known is their
predisposition to metabolic syndrome or diabetes.
Diabetes, while being its own co-morbidity that has
implications for vascular access, also carries with it
a higher risk of renal insufficiency and renal disease
compared with persons without diabetes. [7]
the superior vena cava [29]
Patient Considerations
Patients with cancer have likely had
extended sessions of vascular access and are
receiving several different types of medications.
The vascular infusate with the most extreme
chemical characteristics in terms of pH or
osmolality coupled with duration of infusion (i.e.
dwell time) will dictate vascular access device
needs. [10]
In addition to the infusates being delivered
and dwell time, specific patient-related information
needs to be taken into account when selecting an
appropriate vascular access device. Co-morbidities,
either present or historical, have a profound impact
on device selection.
Aside from patients with significant comorbidities, there are those that fall into a difficult
venous access patient category for other reasons.
Different patient characteristics like age, presence
of visibly-identifiable vessels, edema, prematurity or
history of prematurity [11], skin color, body mass
Figure 5 Radiograph of a central line terminating in
One of the co-morbidities that has a
significant effect on catheter selection and
placement is renal insufficiency and/or chronic
kidney disease (CKD). These patients may present
with other significant co-morbidities that
necessitate vascular access; yet, due to the fragility
of their veins, it is important to preserve
vasculature for near and long term access. [7] CKD
patients commonly have arteriovenous fistulas
(AVF) placed for hemodialysis purposes which
have been shown to decrease mortality and
morbidity in these patients. However, AVFs have
high failure rates that are associated with certain
types of vascular access procedures (figure 6). [8]
Obese patients’ anatomy and physiology
changes as their weight increases making them
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Figure 6 Sclerosed AVF Secondary to PICC Placement [28]
index [12] all contribute to increased difficult venous
access status. Patients who are known to be or
who have had difficult venous access are a large
concern because of the stress they and their
healthcare provider have prior to the procedure [12]
and the pain they experience on a routine basis.
Pain from vascular access can lead to healthcare
© 2014 Christie Medical Holdings, Inc.
avoidance and can affect their physiological
responses. [13]
Cost Considerations
The economic atmosphere in healthcare
facilities is in constant flux, now so more than ever.
Reimbursement from the Center for Medicaid and
Medicare Services and other payers is decreasing at
inpatient facilities for standardized services.
Additionally, reimbursements for hospital acquired
conditions have been completely eliminated as
quality of care efforts have been moved to the
forefront of healthcare facility assessments.
Forty years ago, the majority of
reimbursement centered on a per diem rate paid by
insurers. This was daily fee or rate that was billed
by the hospitals and paid by the insurers, at that
time in the U.S., Blue Cross and Blue Shield,
Medicare, and Medicaid. Under this system there
was no incentive for hospitals to focus on valuebased care as they were paid for what they billed.
As costs started to rise, the insurance companies
began to implement efforts to control these costs
by introducing the diagnosis-related group (DRG)
system. [14]
National averages for the cost to place a
PICC line by a registered nurse are approximately
$700 [15] between labor and material; the cost for an
SPC is about 30 times less at $23 [16]. This number
increases dramatically if the facility is using
physician’s assistants or interventional radiologists
to place PICC lines. Considering the large cost
difference between SPCs and PICCs, it makes
sense for facilities to institute practices that would
make placement of SPCs more successful when a
physician or nurse decides that this the appropriate
course of treatment.
VeinViewer Impact on PICC Placement Rates
About 10 years ago, the first NIR-based
vascular access assistive devices came onto the
market. VeinViewer (Christie Medical Holdings,
Inc., Memphis, TN), developed by scientists at the
University of Tennessee Health Science Center,
was the first NIR-based direct projection vein
finding system on the market and is, to date, the
market leader (figure 7).
Under the current DRG system, hospital
facilities are reimbursed a flat rate for a patient’s
care instead of a daily rate for the care. This has
shifted the responsibility for cost reduction to the
healthcare facility as no matter what sort of
treatments the patient had at the facility, the same
amount of money was reimbursed.
The implications of this flat-rate payment
system are that hospital facilities must focus their
attention on delivering courses of treatments that
maintain or improve quality of care, all while
driving down the cost for those treatments. In
terms of the vascular access devices that are used to
deliver healthcare, the costs can multiply very
quickly.
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Figure 7 Counterclockwise from Upper Left: VeinViewer Flex,
VeinViewer VisionXTND, VeinViewer Vision2 [27]
The basic science behind VeinViewer is
quite simple. Invisible, NIR light is directed from
the device onto the surface of the skin at a
wavelength of 850nm. The light penetrates the
skin up to a depth of 15mm and hemoglobin will
absorb this light. Other tissues such as skin cells,
© 2014 Christie Medical Holdings, Inc.
adipose tissue, and connective tissue will reflect the
light. Any light that has been reflected is detected
by VeinViewer and is almost instantaneously
turned into an image that is projected back onto
the skin providing users with visual confirmation of
vessel location (figure 8).
Without
VeinViewer
With
VeinViewer
Figure 8 Image of arm with and without VeinViewer imaging
© Christie Medical Holdings, Inc.
Peer-reviewed research has shown that
VeinViewer technology helps clinicians improve
first-attempt stick rates by over 60% in pediatric
populations, [17], [18] improve first-attempt stick rates
in difficult venous access patients, [19] improve
overall procedure time, [18] and improve patient
perception of care. [20] In fact, VeinViewer has the
most peer-reviewed literature of any NIR-based
vascular access device on the market and new
research continues in expanding scopes of practice.
Mercy Hospital, Oklahoma City Study
In 2012, at the Association for Vascular
Access annual conference in San Antonio, Texas
members of the neonatal intensive care unit
(NICU) at Mercy Hospital in Oklahoma City
presented data on how VeinViewer helped them
reduce the number of PICC lines being placed in
their patient population. [21] Prior to beginning their
study, nursing staff noticed an uptick in IV stick
attempts when placing a peripheral IV. After a
certain number of failed attempts, these neonates
would receive a PICC line for routine venous
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access. As a result, PICC usage increased in their
unit along with supply costs.
During an in-service by Christie in their
emergency department, the NICU staff saw
VeinViewer being demonstrated and wondered if
the device could help them to reduce the number
of medically unnecessary PICC lines being used.
Christie agreed to partner with the staff and
support their efforts to improve patient care.
Baseline data was collected without
VeinViewer to understand where the NICU was in
terms of IV attempts per patient and the number of
PICCs that were being placed when it was not a
clinical necessity. After collecting data on 192
patients, the unit found that the average patient was
receiving 5.27 stick attempts prior to success with
six of those patients receiving double-digit (≥10)
sticks. The highest number of sticks prior to
success was 17. The resulting rate of PICCs placed
when they were not initially clinically indicated was
1:13. VeinViewer was then added to their current
standard procedures and data was collected for 100
patients. Using the device, the average number of
attempts prior to success dropped to 3.1.
Additionally, the number of double-digit stick
attempts decreased to just one patient who received
11 stick attempts before success.
Most
importantly, the rate of medically unnecessary
PICC lines dropped to 1:25, an improvement of
more than 30% (table 1). Though these are interim
results, the team anticipates that the final results
will trend similarly by publication time.
Mercy Oklahoma City Study Interim Results
Metric
# Attempts
per patient
Double-digit
attempts
Medically
Unnecessary
PICCs
Standard
Using
VeinViewer
Improvement
5.27
3.1
>40%
6
1
>80%
1:13
1:25
>30%
Table 1: Interim Results of the Mercy Hospital PICC Reduction Study [21]
© 2014 Christie Medical Holdings, Inc.
St. Elizabeth Healthcare Study
During the same time that the Mercy
Hospital study was being conducted, another study
on reducing medically unnecessary PICCs using
VeinViewer technology was being conducted
unbeknownst to Christie staff.
Instead of
addressing the needs of NICU patients, this study
sought to improve the care of patients whose
vasculature needed preservation due to kidneyrelated co-morbidities.
Patti Wilcox and her team of nurses sought
to understand if VeinViewer could help in their
vein preservation program. As has been discussed
previously, nephrology patients’ vasculature is
end stage renal disease, or, and most importantly, at
any time in their life are at a higher risk for AVF
failure (figure 6). [8] Therefore, vein preservation in
this population is extremely important.
For their study, the St. Elizabeth team
began by collecting data on the number of PICC
lines being placed per month prior to instituting
VeinViewer technology during 2012. At their
facility, physician’s assistants and, occasionally,
physicians themselves, place PICC lines. After
tracking the 2012 monthly rates, the team instituted
the use of VeinViewer by their nursing staff during
2013. Purchased specifically to be used when
placing short peripheral catheters, the nurses were
instructed to use the device as much as possible
Figure 9 Adapted from St. Elizabeth Study Poster with Permission
fragile compared to the normal population.
Because of this, the amount of vascular access and
the types of catheters used for vascular access has
to be greatly considered. Many patients with
chronic kidney disease receive dialysis treatments
through an arteriovenous fistula (AVF). Peerreviewed research has shown that patients who
receive PICC lines prior to AVF surgery, prior to
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and especially when second or third attempts were
being made. No other changes to their catheter
placement procedures were made.
During the
first 9 months of data collection in 2013 the
investigator found that the number of PICCs
placed from patients coming through their
department had decreased by 261 versus the same
timeframe in 2012 (figure 9). This data was
© 2014 Christie Medical Holdings, Inc.
presented at the 2014 annual convention of the
Infusion Nurses Society in Phoenix, Arizona.
Combined with nationwide averages for cost of
materials and cost of personnel time estimated at
$700 per line [15], the facility saved approximately
$180,000 during this 9 month time period. More
complete data which continues the trend of
unnecessary PICC reduction is scheduled to be
presented at the annual convention of the
Association for Vascular Access in September
2014.
INS
Recommends
Technology
Vein
Visualization
In 2011, the Infusion Nurses Society (INS)
published a revision to their Infusion Nursing
Standards of Practice. [22] At this time, INS only
recommended consideration of vein visualization
technology because there was scant published
literature about these products and their efficacy in
the field of vascular access. Since then, mounting
literature by investigators on VeinViewer products
has provided key opinion leaders and experts at
INS with the evidence needed to draft the first-ever
statement that, for short peripheral catheters,
health care providers should “[i]ncorporate vein
visualization technology as a routine strategy for
patients with difficult or poor venous access” as a
standard practice for improving patient safety. [23]
The position statement authors continue that
“visualization technology can improve success
rates, decrease unsuccessful insertion attempt, and
improve patient satisfaction.”
This position
statement echoes what researchers and clinicians
are experiencing every day with this technology:
VeinViewer is not a nice-to-have medical device for
large hospital systems. VeinViewer technology is a
must-have device that will improve placement of
short peripheral catheters for small, community
hospitals as well as large, multi-hospital health care
systems.
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Conclusion
The procedures that patients undergo are,
most often, clinically indicated by the patient’s
disease process or co-morbidities. Therefore, the
risk of the procedures balances with the benefit.
However, there are occasions when more invasive
procedures are the result of failed less invasive
procedures. Occurrences such as these begin to tip
this balance towards treatments that are not
commensurate with the patient’s medical history or
experience and may expose them to unnecessary
complications.
Placement of PICC lines that are not
clinically indicated for a patient exposes the patient
to increased risk of adverse events such as
thrombosis, pneumothorax, CLABSIs. Patients
undergoing dialysis currently or those who might
be on track to have dialysis treatments later in life
can experience significant complications when
PICC lines are placed indiscriminately. Vein
preservation programs around the country are
looking for ways to combat these complications
and improve their patient outcomes.
Additionally, hospital administrators, under
the burden of reduced reimbursement for bundled
procedures, are investigating ways of reducing costs
all while improving patient satisfaction scores and
increasing healthcare efficiencies. Few products on
the market claim to benefit patient outcomes,
satisfaction scores, and a hospital’s bottom-line and
have the evidence to back up those claims.
Both sponsored and independent research
has shown that VeinViewer can decrease the
number of PICC lines that are not clinically
indicated in pediatric and adult populations. At an
average cost of $700 per PICC line [15], facilities can
save $7,000 if just 10 short peripheral catheters are
successfully placed and PICC lines that are not
clinically indicated for that patient are avoided.
© 2014 Christie Medical Holdings, Inc.
This cost savings, coupled with the INS
position statement on short peripheral catheters,
and the supporting peer-reviewed literature
provides a strong foundation of evidence that
VeinViewer is no longer just a luxury device for
hospitals that have extra budget for capital
expenses. It proves that VeinViewer is a must-have
device for facilities that want to improve patient
care all while reducing healthcare costs.
About the author: Jessica Knowlton is the Associate Clinical Research Specialist for Christie Medical Holdings, Inc.,
manufacturer of the VeinViewer line of vascular imaging devices and accessories. Her pre-Christie background is in
molecular biology focusing on fields of orthopaedics, DNA repair, and vaccine preclinical development. She holds an
advanced degree in Clinical Research Administration and has conducted research trials in the fields of vascular access
and ophthalmology.
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© 2014 Christie Medical Holdings, Inc.
Bibliography and Noted Images
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© 2014 Christie Medical Holdings, Inc.
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© 2014 Christie Medical Holdings, Inc.