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Startup PICC Program

We have an insertion only PICC practice at our small hospital - 25-30 PICCs/month.  Have a new dept. manager who is interested in developing PICC program.  I'll be heading things up. 

Aside from tracking QA issues (BSI, thrombus, other complications and tracking them with individual inserters), what are the elements of a good PICC program?

Give me some input on where to start.  Thanks.

Michael Mc

If you only focus on

If you only focus on pre-insertion assessment and the insertion procedure, you are addressing only the smallest portion of that catheters life. Your team should be the experts in all infusion practices, serve as educators, resource people, consultants, on all issues with use of that catheter for all infusion. This is the huge missing piece when a hospital chooses to have a team that only focuses on catheter insertion. There is also a trend identified at recent infection prevention conferences where hospitals are finding that patients with very difficult peripheral venous access can not be stuck by the staff nurses. These patients are referred for many unnecessary PICC insertions. More PICCS equals more CRBSI as reported by these facilities. One has documented this and gotten approval for 2 more FTEs on their infusion team, while another reported that this trend made them stop using PICCs totally. Of course this last approach did not make sense to me but that was their choice. This means your team should be the backup group for all patients with difficult venous access to avoid these unnecessary PICCs. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Would suggest calling

Would suggest calling yourselves...something like....Vascular Access Service (you do much more than just PICC's  if you follow Lynn's direction!)

We are the Vascular Access Department

 but are, fortunately, involved in much more than that and in line with what Lynn is suggesting.  We're an IV team and a PICC team (have been placing PICCs since 1992).  Have 4-5 IV RNs on day shift, 1-2 PICC RNs day shift, and 2 PICC RNs into the evening.  We provide peripheral access and consulting for most areas of our 500 bed academic Level I trauma facility, and are back up and resource to the outpatient clinics.  We teach med students, with the assistance of the College of Medicine, about vascular access.  We are part of a core team of MDs that developed a curriculum for central line insertion training in our sim lab.  We're involved in policy making, quality projects and audits, infection prevention committees and case reviews, product evaluation.  We're IV Therapy resource for home health and other facilities in the region.  We are skilled at determining tip location and confer with radiology when we have questions or differences of opinion.

I think the core element of all that we do is patient safety and advocacy.  It sounds like you're on the right path because you mention QA issues.  If you keep patient safety and advocacy in mind at all times, here is what I would suggest, to whatever degree you can, based on our experience (I realize you are a small facility, but you could do this in bite size steps) :

1.  Involve yourself in important committees:  Infection Prevention, Nursing Pharmacy (re: infusion issues), Policy, and of course Quality.   Infusion Therapy and Vascular Access is our profession and specialty; many professionals that you think WOULD have access to best practice information, don't.  You must be the foundation of this information for your facility. 

2.  Keep yourself and your colleagues well educated and up to date.  Attend INS and AVA conferences, provide presentations at your facility.  Make sure you have access to important reference texts and journals.  Provide regular presentations, inservices, newsletters to the PICC team as well as general nursing staff.  Provide inservices and presentations to providers.

3.  Promote Early Vascular Access in policy and in practice.  Talk to MDs and write patient notes about your recommendations for vascular access for those patients.  You may feel like a pest sometimes, but after a year or two - they'll get it and appreciate you.  Your recommendations might range from nurse placed PICC to hypodermoclysis to IR placed alternative PICC placement or implanted port to peripheral access.  Learn the technique and best practice guidelines for U/S guided peripheral IV insertion.

4.  Learn to determine tip location from someone who teaches to vascular access specialists.  Radiologists and other MDs usually don't have significant training re: vascular anatomy of the thorax as pertains to line placement - it's a little crazy some of the readings we've seen.  We've caught 2 arterial placements that rads read as venous.  We frequently find they read azygous as "looped in the SVC".  Currently, we're pretty sure that because they know we want our PICC tips in the caval atrial junction, they are calling everything CAJ unless it is grossly malpositioned (that's another story I won't go into right now - we're working on this).  If you learn tip location, I guarantee that you will be helping patients and eventually the patient's providers will come to depend on your expertise.

This may seem like a lot, but the benefits to our patients are great.

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Wow.  Thanks for the

Wow.  Thanks for the direction, and giving me something to aim for.  'bite size steps' and patience will have to become my mantra.

Michael Mc

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