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anna liang
bedside PICC insertion: malposition rates without tip locator device.
would like to know your PICC program's tip malposition rate. did a pubmed search and found one cited 2.1% & the other 85.8%. 
From 2.1 to 85.8%?? Quite a

From 2.1 to 85.8%?? Quite a range--how is "malposition" defined?

Can't find my records at the moment,but my re-Xray rate after initial placement was around 12% in 2005,10% first part of 2006 and 7% later in 2006. Decrease was mainly due to being more dilligent about checking the jugular before the first Xray.

Those of your using a tip

Those of your using a tip locating device... have you seen a decrease in malpositions? I have always check the jugular for the first x-ray and seemed to have done OK with only having a few malpositions.




anna liang
Thank you. your data is very
Thank you. your data is very helpful.
for the 85.8% one, malposition was defined as the tip not in the distal third SVC. personally, I don't understand how practical that definition was. for example, for a new born, even a 0.5 cm difference in length can make the tip out of the range of the distal third SVC. (interestingly, that article didn't define IVC malposition as specific as SVC).
when I place picc in the newborn population, the target tip location is mid SVC. (the risk of tip migrate to RA, leads to cardiac perforation)
Would you mind giving me the
Would you mind giving me the references for the articles you found? TY.
anna liang
Kristin Walker
I agree with one of the
I agree with one of the other comments that was previously submitted!  Since I've started evaluating the jugular vein, my malposition rates have dropped incredibly--almost zero in the jugular!  Thanks to the teachings of Scott Gilbert at Queens on Oahu!  Thanks Scott!

Kristin Walker RN, BSN, OCN Maui Memorial Medical Center IV dept.




Gina Ward
What do you all refer to as

What do you all refer to as checking the juglar prior to getting the first xray?  Are you using your ultrasound probe?  I dont seem to have luck with that.

Or are you referring to the Sherlock system?

Gina Ward R.N., VA-BC

holly hess
Gina, I think what most are


I think what most are referring to is the use of the ultrasound probe to check the IJ. A little practice and you will easily be able to see the PICC. We catch this at the time of insertion and reposition before the first x-ray. Occasionally we might miss it, and I have had a couple go to the contralateral IJ which I don't routinely check because it is so rare. On this site under downloads is a poster I did for last year's conference showing what it looks like in the IJ.


..I can tell when the line
..I can tell when the line went jugular by the way it performs...slow to draw frequently more air in the line...harder to flush...I reposition while still in a sterile field...and once the stiffener has been removed, a slow advancement fixes the behaves like it should....years of picc placements
Halle Utter
We have never used a tip

We have never used a tip locating device, and our malposition rate is very low.  We are a contract PICC team that places lines in multiple facilities, hospitals, LTACs, and SNFs.  We check the jugular with the U/S probe, and I agree that most nurses who have placed a lot of PICCs KNOW when they are going up instead of down.  You can just feel it, and the catheter acts differently.  I know some people swear by them, but I see it as just an additional cost and much more trouble than it's worth.  I cannot see the need. 

Halle Utter

Hallene E Utter, RN, BSN Intravenous Care, INC

Timothy Royer B...
For those who just the

For those who just the jugular.  Are you checking both?

Had a patient yesterday that I put a single lumen PICC without the use of a tip locating system in the left basilic upper arm vein.  Everything went very well.  Slid right in, good blood return, and checked the left jugular and no PICC seen.  Figured this was one of the easiest PICCs I had for the last week!  Nice PICC to end the day.

Chest X-ray done - see figure "X-ray 1".  Contralateral and up the internal jugular.  The only thing I could have thought of at this point is why didn't I use a TLS Stylet in this patient.

Patient was doing fine.  Pulled the PICC back inserted a TLS stylet and watched the catheter drop into the SVC as PICC was reinserted.

Repeat Chest X-ray was done - see Figure "X-ray 2".  Near the caval atrial junction.

Additional time spent of my time - 1 hour (from time 1st sent to radiology to time resent to radiology).  Plus additional supplies.  Patient delay of care.

The Tip Locating Systems are only going to get better.

If you are not using a TLS, think about checking both jugulars and hope you are not curled back, contralateral, or looped.

Karen Day
Karen Day's picture
I agree Haley, I place picc

I agree Haley, I place picc lines both full time at my facility (about 100 per month) and as a contract picc inserter as well, my malpositions are less than 2%.   I never use a TLS, tried the Navigator a few times and hated it.  Tried the Sherlock and hated it too, I thread my catheter in a slow steady motion and let my "fingers" talk to me during insertion.  I can feel when the catheter turns wrong or coils on me.  Upon completion of insertion, I feel the jugular vein and if the picc is up the IJ, you can feel it when you flush.  Also after everything is done, I can auscultate with a stethoscope, granted my sterile field is gone by then, but usually have very few malpositions.  If one did occur this late in the game, I usually sit the patient up as high as they can tolerate and flush the line, it usually falls right down into the SVC.


Before trialing the Sherlock

Before trialing the Sherlock at our hospital from Jan 10th - Feb 9th of this year, I did a "retro" of our PICC malposition rate.  Our pre-Sherlock malposition rate was between 12-15%, with malposition defined as a PICC tip position 1) at or above the proximal SVC (including Azygous, Innominate, Subclavian, IJ, double-backed down an alternate arm vein or any coiling in these areas) or 2) contralateral (or "cross-overs".)  Prior to our trial, we routinely checked the IJ with US and usually caught those; however the malpositions I wanted to capture were the "cross-overs", where you have absolutely no way to tell other than with a tip location device.  As well, we all know how different our patient's anatomies are and despite consistent measuring techniques, we can still be "very short", depending on the path their vein(s) take.

Our trial consisted of 70 PICC insertions using the Sherlock and am happy to say we not only captured some of the obvious ones (IJ, coilings) but also 10 "cross-overs". 

I continue to track our malposition rate post-Sherlock Trial and can boast that we currently run < 1%.  As well, it is RARE that we aren't at least mid-SVC and get our "wet reads" back indicating "distal SVC" or "Cavo-atrial junction" more and more. 

I was VERY skeptical prior to using the Sherlock, as I'm all about the numbers and proof.  As well, I'm not a "salesman", but someone who's always looking for ways to improve process / productivity and decrease "rework".  For us (as one colleague said at AVA last year), "not using Sherlock is like not using Ultrasound".   We agree 100% and no longer dread the "last PICC of the day!!!"

Joann Rinella


  We place about 150 piccs


We place about 150 piccs per month and our malpostion rate (anything outside of mid, low or svc/ra junction) averages about 25%.  

We're very much looking forward to lowering that with a tip locating device. 

Does anyone have any data on your cost savings after going to one of these systems? 

Does anyone "selectively" use the device on certain patient populations?  This is something our management is suggesting we do to save costs. 




Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA


Timothy Royer B...
This is a rough estimate. I

This is a rough estimate.

I will attach a general formula where you just enter the numbers.

# of PICCs Placed per year1300Cost$50.00Labor (Nsg + RT + MD)
Avg % Malpositioned27.3%$35.00add'l x-ray 
# of Malpositioned355$125.00(supply cost to replace PICC)
Cost to reposition$125.00To Replace$210.00 
Cost per year for Malpositions$44,362.50To Reposition$125.00 
Initial Investment for Sherlock$1,000.00for two 
Special Sherlock Stylets / per$20.00 
Stylets per year$26,000.00 $18,362.50Cost savings    

Timothy Royer B...
Excel spread sheet did not
Excel spread sheet did not transfer to forum very well.  Will attach as file.
Hi Tim, Could you define

Hi Tim,

Could you define your malposition rate?  What exactly did you consider malpositions?

How did you calculate your cost to reposition?  Can you give me an example of a repositioning?

Have you calculated your malposition rate using tip locating system? 

Thanks for your time.

Darilyn Cole, CRNI

Mercy General Hospital

Sacrmento, CA

Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA


Timothy Royer B...
Could you define your

Could you define your malposition rate?  PICC Tip not in the lower 1/3 SVC near the caval atrial junction / PICC Placements

What exactly did you consider malpositions?  Anything not in the lower 1/3 of the SVC near the caval atrial junction.

How did you calculate your cost to reposition?  Hourly cost of PICC nurse + supply costs + Rad Tech time + radiologist time.  I think that was it.

Can you give me an example of a repositioning?  Having to pull back or advance catheter or do an complete exchange.  Power flushing.

Have you calculated your malposition rate using tip locating system?  On those patients that we use the TLS (some of my staff are still novices with the use) - about 1% to 3%.  That is down from 27%.


holly hess
navigator and malposition rates

Could anyone using the Navigator tip location system please report their data in reduction of malposition rates when using the system, particularly in peds and especially in neonates, for anyone using the new neonatal locator.



malpositioned PICCs


All I have to say is I LOVE  my Site Rite 6 with built in Sherlock!

Took me a little while to trust the Sherlock, but after 4 years of using it we maybe have had one or two malpostioned PICCs(and this was after finding out the nurses on the shift before dropped it!)  Even our rads will ask us "what did your Sherlock tell you ?".

I can't imagine ever going back to the days of "checking the neck" with the ultrasound machine, or ever relying on a stethascope to confirm that my PICC was down. I'm not even interested in the new technology of using the EKG. What would you do for a patient not in normal sinus rhythym? Use the Sherlock right ?  :)

have a great day!           Cherylanne Perry RN,CRNI  Clinical Coordinator IV Therapy   St. Joseph Hospital Nashu NH

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