PICC (Peripherally Inserted Central Catheter)
Increasing patient comfort and reducing medical complications
Tristan Porter had an ear infection he just couldn't shake. It started in October, when he was just 3 months old. His pediatrician tried several different oral antibiotics, but the stubborn infection kept coming back, all through the winter months.
By May it was time for stronger action. His pediatrician admitted Tristan to the hospital for testing to determine the exact bacteria and for intravenous (IV) medicine to fight it. Tristan would need IV antibiotics for three weeks, but fortunately he didn't need to stay in the hospital the whole time. He could get a PICC line, which would allow his parents to give the medication safely at home.
What Is a PICC?
PICC stands for "peripherally inserted central catheter." A slender, flexible tube is inserted into a vein in the upper arm and threaded to a large vein near the heart. This catheter can stay in place for weeks or even months, so it can be used for long-term intravenous treatment. With a PICC, Tristan could have weeks of IV antibiotics without needing repeated needle sticks.
It sounds good, but Jill Porter says that when she learned her baby would get a PICC, "I freaked out! I had one when I was pregnant and it was a bad experience." She was greatly relieved when the process went very smoothly.
"Looking at the data helped us improve our practice so we can really make a difference for children." Darcy Doellman, RN, PICC resource nurse team leader |
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Researching Best Practice
Cincinnati Children's Hospital Medical Center is a national model for PICC-line placement. Three factors account for the unique success of our PICC program: unusual collaboration across disciplines, meticulous data collection and research to document best clinical practice.
The result is better outcomes for kids who need PICC lines.
When the PICC program began, explains Darcy Doellman, RN, team leader for the PICC resource nurses, specially trained nurses inserted the PICC at the patient's bedside — which is still standard practice at most hospitals. But if the nurse had trouble finding a suitable vein, or the catheter did not thread into place correctly, there were delays and potential risk while the patient waited for a radiologist to be available to assist.
Not satisfied with the results we were having, radiologist Neil Johnson, MD, and the PICC nurses began to imagine a better way.
They moved the procedure to the Interventional Radiology suite. There, immediately after the catheter is inserted, a picture is taken using a fluoroscope, which produces a moving X-ray image. A radiologist then checks the catheter's position. If it has not been advanced far enough, or has been pushed a bit too far, the nurses can adjust its position with certainty under fluoroscopy. If necessary, an ultrasound-guided insertion can be performed for even greater accuracy.
As a result of this collaboration between nurses and radiologists, the PICC team has achieved an outstanding 97 percent success rate getting PICCs into the best possible position in a large central vein.
The Right Spot Makes a Difference
When this approach was first implemented, it was widely believed that the precise placement of the PICC in a large central vein was not essential for long-term IV treatment. Most doctors believed that IV medicines could be given as safely if the catheter was placed into a mid-size vein. But as they had greater success placing the PICCs into a central vein, the PICC nurses noticed that catheter tips placed in a central position seemed to last longer, with fewer complications.
To confirm their observation, they conducted a retrospective study and analyzed data from 1,266 PICCs. This was the largest study ever done of PICCs in children. Their research proved that those in a non-central position were eight times more likely to have a complication.
"Looking at the data helped us improve our practice so we can really make a difference for children," says Doellman.
Reducing the Need for Sedation
The PICC team also pioneered a family-friendly approach that reduces children's anxiety and discomfort so there's less need for sedation during the procedure.
A child life specialist meets with the child and parents in advance to explain what to expect. During the procedure, the specialist distracts the child by talking, reading a story, playing music or showing a video. As a result, the team sedates only 6 percent of its patients, a rate dramatically lower than other children's hospitals.
This approach was very comforting for Jill, who feared that Tristan would squirm and need to be sedated.
Because Tristan was so young, he was wrapped in a soft papoose to keep him warm and secure during the procedure. "I really appreciated this because then I could be his comfort and not have to hold him down," Jill says. With his mother and father holding his hand, Tristan watched baby Mozart movies while the nurse found the tiny vein in the baby's arm. "They did a really good job," Jill recalls. "As soon as the stick was done, he lay still. He did really well."
Sharing Their Knowledge
The PICC team has published its findings about catheter tip placement and distraction techniques to share their knowledge across the profession. Last year, Doellman received the Suzanne LaVere Herbst Award for Excellence in Vascular Access Practice, presented by the National Association of Vascular Access Networks. She was honored for "making a substantial contribution to vascular access practice by improving patient outcomes" and "contributing to the science of vascular access."
Several times a year, she offers classes on PICC line insertion. Physicians and nurses from as far away as California and London, England, have attended, and she is now planning a more comprehensive apprentice program for clinicians wishing to shadow the PICC team for several days.
Meanwhile the team is continuing its research to find new and better techniques and products to improve the comfort, safety and effectiveness of PICC line placement.
"There are always new things we can study to improve care," Doellman says. "To me 'change the outcome' means identifying ways to provide the safest and most reliable PICC so that we can meet the patient's needs today and in the future."
