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Guidance sytems: Best Practice or a luxury?

I place PICCs at 2 different facilities.  I use a guidance system at one place and have timely digital X-ray at the other.  Which is best practice or is it a wash?  I prefer the guidance system but have not been able to convince my other facility to even look at one.  Is this in the realm of opinion or is there science?

Chris Cavanaugh
Cost/Benefit analysis

I think you need to do a cost/benefit analyis for your population to determine the need.  Right now, the technology that is available is flawed, and does not give accurate enough response to replace an x-ray, referring to the Sherlock and Navigator.  There are other types of tip location systems just coming to market that are EKG based and other types of systems that are currently in development that may be able to replace x-ray and be more accruate with less complications such as interference from monitors, bedrails, pumps, and the need for frequent recalibration.  Of course, some of these systems may be very costly to a PICC team, especially when they are first available.

I think you need to monitor how many malpositions you have as a percentage of all your PICCs placed.  This will be different for each inserter, and patient population.  Then decide if the cost of the tip location system is worth it.  If your wire costs $30, and you malposition 1 in 10 PICCs (a high number), it is costing you $300 to avoid the additional x-ray for that one malpoisition.  You need to decide if it is worth it to you.

There are techniques that can be used to determine a jugular malposition using ultrasound and other methods at the bedside, before the sterile field is broken.  There was a paper published recently that discussed these.  You can work with a more advanced clinician, or a clinical specialist from the product you use, to learn these techniques. 

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

So you are saying it is not

So you are saying it is not best practice, just an economic decision.

I believe that best practice

I believe that best practice is getting the PICC tip to the right location on the initial insertion. It doesn't matter how fast your x-rays are available because once your sterile field is broken down re-positioning is problematic and requires additional procedures whether you power flush or exchange. Using the economics helps teams justify getting a positioning system to improve their mal-position rate. It is true that while the current tip locating systems show the direction of the catheter, exact tip placement is not possible. However, the upcoming systems that use ECG will give us that.

Very well put Chris. Also

Very well put Chris. Also with the digital x-ray system where the image is available on the xray unit results are practically immediate and a line can be repositioned without having to remove the plate, etc.

Timothy L. Creamer
Tip Location Systems

Tip Location Systems allow the inserting clinician to reposition a catheter within the original sterile field, preventing possible risk of contamination and improving  the timely release of PICC's for use. Compliance with IHI head to toe maximum barrier draping guidelines prevents the temptation to impair the sterile field by placing the ultrasound probe on the neck to rule out ipsilateral IJ involvement. According to Trerotola et al (2007) the malposition rate was 10% not including tips in the RA. Only 36% of the malpositioned catheters were ipsilateral IJ, 64% of the malpositions would not have been prevented by scanning the ipsilateral neck. Does the risk of catheter and/or site contamination resulting in a prolonged LOS outweigh the comparable low cost of a special stylet? Preventing delays for ICU patients requiring vasoactive gtts will avoid potential extravasations. The appropriate line at the appropriate time for the appropriate therapy and with the appropriate technology; in my opinion it only improves patient outcomes.

Timothy L. Creamer RN, CRNI

Clinical Specialist, Bard Access Systems

Florida Division


ECG guided tip location is current "best practice" and I do not feel that way simply because I am associated with an ECG guided technique. ECG guidance is more accurate than surface landmarks (100% vs. 53%). To use x-ray as the "gold standard" is also fallacious since 20% of the time, x-ray is inaccurate when compared to an even better "gold standard", echocardiography (see,%20ACCURATE%20CENTRAL%20VENOUS%20PORT-A%20CATH%20PLACEMENT.pdf). Any x-ray, digital or otherwise, involves time and expense (your lost time waiting for it, technician time, radiologist time, computer storage for the digital image, transcription time for the report, and so on), let alone the radiation exposure to the patient, disruption of the sterile field, etc. ECG guidance provides immediate feedback on tip location so no chest x-ray is necessary and may be accomplished for 1/5 or less of the price of an x-ray. It is 100% correlated with echocardiographic tip location (see the same reference). Anything that is more accurate than the current practice, saves time and money and improves efficiency should be considered best practice. The data supporting ECG guidance is extensive (see - and many more references are contained within these references). This is the "science" of tip location - it is not "opinion" (in my opinion).

Heather Nichols
Guidance Systems: Best practice or a luxury?

   Very good response Tim.  When we initially started using a guidance system, we thought to save time and money by not needing multiple CXR's.  We saw several other resons as time went on.  I was able to show a relatively large cost savings over a years time, by using our guidance system.  Not needing multiple CXR's is nice for the facility as well as the patient.  No need for them to "glow" from radiation they do not need. :-) 

   The real cost savings came from not having to open up extra materials to reposition (bad practice and not reccommended) or exchnge a catheter due to the malposition.  With all of the full barrier practice these days, that stuff can add up if it is done properly, and within guidelines.  We also decreased anxiety of the nurse and patient.  The nurses felt more confident that their procedure was going to go well the first time.  Patients do not understand, no matter how much we explain, that malposition is a common problem with PICC insertions.  It makes them nervous to think that the nurse may have "messed up", or not done something right.  A PICC placement is a scarey procedure to most people, especially now that we look like we are doing minor surgery at the bedside with all the full barrier stuff.  Can you place a price on piece of mind?

    We also found ways to decrease manipluation of the catheter therefore decreasing possible damage to the vein.  If you know where its going the first time you feed the catheter in, you can stop when the malposition begins instead of going all the way in, pulling back, and all the way in again.  As we all know, this can happen multiple times before you get it right if ever. 

   These are just a few reasons for a navigational system I have.  Chris said it best with a cost analysis and knowing your malposition rate.  That is a beginning.  Then trial everything out there.  Research it and find out what is on the horizon.  Don't wait on it though.  Choose one now, and keep your eyes open and ears listening for new technology.  It happens everyday, but you definately need a guidance system now. If it is not considered best pactice, it should be.


I agree with Heather that TLS

I agree with Heather that TLS is the best practice not luxury.

Glenda Dennis
ECG PICC tip confirmation

I have been using ECG guidance for PICC tip locatiion for about a year now and find that I am able to be very precise in where I put the tip.  I also use ECG for verifying the tip location for PICC's that have been placed in other facilities or for patient that have been discharged and readmitted with their PICC.  I have saved huge amounts of time that was previously spent waiting for and looking at chest x-rays.  I have saved a lot of money and radiation for patients by not having to have a post PICC chest x-ray. I consider this technique best practice without doubt. 

I think that tip navigation
I think that tip navigation is a luxury. If someone is good at their craft and many are, why add the extra cost? If each team keeps good data and looks at success rates, like number of attempt to access a vein and malposition rates you can determine if you need to refine basic skills or improve assessment. There will always be those patients that will be unsuccessful with or without the tip navigation.
            Some PICC nurses will never be good I know of nurses that are 68% successful with ultrasound and the tip navigation, and others that are 94% successful without added cost. Adding cost to placement only helps one part of the process and it’s not the patient the hospital or the inserter. As a group of professionals we all need to take inventory of our own skills.
            Once ECG tip location is approved by the FDA and recommended as the “gold standard” like using ultrasound and there is no need for the CXR then it will be best practice. As of now we need an x-ray and inserters need to be realistic about their skills some will never be 90% or better with or without tip navigation or ECG guidance.
Rodney Allen
tip navigation

I respectfully disagree with you Constance.  Without a navigation system you will have a 10% malposition rate no matter how good you are.  This is according to a study done at MD Anderson in Houston with hundreds of PICCs placed by many different nurses.  I have done it both ways for years and have a 99% success rate.  Have been using a navigation system the last 3 years (hated it at first but learned how to use it with practice),  and have saved my patients many X-rays, time, and risk of infection with having to reposition malpositions.  Since posting this last year, I am convinced that it should be best practice.


I also disagree with you.  Since we have the Sherlock system, our malposition rate has been2-3 percent, and some of those are knowing that the tip is in the wrong position put the patient does not have any other access and we will send him to interventional radiology to see if they can repostion it.  We love our Sherlock and are eagerly awaiting the EKG update!!


To Rodney Allen, Would you

To Rodney Allen,

Would you mind sharing your statisics from MD.Anderson to us? I'm trying to convince my manger to let us keep our TLS. Our PICC team has our numbers to show the management. But it was not convincing enough.

Thank you in advance.

Just Curious

Please know I am not being disrespectiful, why is your hospital trying to move away from TLS, and why wasnt you data enough to convince them that is worth the extra cost? Didnt your malposition rates decrease when you went to it or did  they stay the same?......just curious. Once ECG is avalible and there is no need for the CXR dont you think they will decide that the added cost is well worth it?

Andrea what would you recommend for the person/team that has a  3-4% malposition rate without TLS. Isnt it important to keep costs down when and if you can? Once ECG is the gold standard like ultrasound there wont be a debate. Does anyone place PICCs without an ultrasound anymore?

TLS is best practice

I agree with the comments below that using a "synchronous" guidance system is best practice for all the reasons stated and ecg alone isn't enough imo.  I can't tell you how many times I have seen a catheter heading toward a malposition and been able to make a small adjustment within the original sterile field to get it to go the right way.  ecg is great for the final tip position but "synchronous" TLS is well worth the money on the trip down.

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