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afruitloop
Why are so many PICC's placed?

I would like to open a discussion on the topic of why are so many PICC's placed now days?  Please let's not get negative and bash each other, keeping our replies civil, open and friendly!

I ask this question coming from a perspective of a former member of a PICC team in a university setting, boasting a 99% success rate.  Yes, as member of this team, I too wanted to place as many PICC's as I possibly could as my focus was just that, I worked on a PICC team and our goal was to increase our PICC numbers.  I now work for Teleflex medical and I have learned much about vother aspects of ascular access, moreso that simply placing PICC's.  With this new found knowledge, I am beginning to question why we are promoting so many PICC's?  I understand from the literature that PICC's and unprotected (non-antimocrobial) CVC's in an ICU or acute care setting have equal rates of infection. (Maki and Safdar,Chest 2005;128;489-495)

 I also understand that a PICC is more expensive, no matter who you get your PICC's from.  I acknowledge that the risk for a complicaiton (pneumo, etc) is a possibility with a CVC, but hopefully as soon as we can get physicians on board with using ultrasound, that should be less of a problem.

Please tell me your thought process and help me understand what your thoughts are.  I know the MD's are becoming reisistant on CVC insertion, that may be one reason.  What are some others?  I thank you for you input in advance.  (I see this trend all across the United States and I ask myself, how did this happen and is this a good thing? Be nice and don't holler at me for asking this!  LOL)

mary ann ferrannini
I can certainly tell you

I can certainly tell you the trend I have seen in the hospital setting and in our community.I have been placing PICCS since 1989 and also work as a home infusion nurse. I will not hollar at you,by the way. Our goal on our IV team has never been to place as many PICCs as we can. We rather take the approach that we will advocate for whatever vascular access device that will meet the patients needs taking into account a multitude of factors,including but not limited to,diagnosis,current therapies ordered,patient preference, duration of therapy,risk for complications (especially infection and thrombosis). If the patient will go home with a VAD we also take into account another host of factors.

 

The major reasons we have observed are:

1. A decreased infection rate. Our rate is still dramatically lower than percutaneously placed chest CVCs.

2. The relative ease of insertion,also increased with the use of bedside US.

3. Nursing can perform the procedure,reducing workload on MDs.Also can be performed as the bedside

4. The availability of better PICC products. This would include increased better catheter materials,and well constructed products.

4. The way in which the patients IV therapy needs are met does not always have the most capable professional performing the task.A lot of this is for financial reasons. In other words,nurses are attempting venipuncture and are unable to get access,so they call and get a PICC order. Since we do not provide 24 hour coverage it is usually prudent to place the PICC.Again.we evaluate,but this is always a problem,not enough of us.

5. Early PICC access also prevents further problems related to the care. For example: reduces delays in treatment,promotes venous preservation, prevents infiltrations and extravasations (to a great degree I should say),can be easily used in the home care setting,improves patients satisfaction with the care as well as reducing needlesticks,

6. Virtually eliminates some of the serious insertion related complications such as pneumothorax.

7. Improvements in health care an availability of pharmaceuticals has increased the need to deliver those therapies. We live in a culture that demands excellent health care and accountability.

8.Provides a stable access,for an intermediate period of time,with the emphasis on intermediate. A great majority of patients fit into this category. Also does not require a surgical procedure to place it and all of those associated costs. Even though some catheters may be comparable in price,the MD still charges more to insert it.

 

I know I could go on and on but I need to get some rest going to be 111 degrees in Sacramento today.

 

 

 

 

 

 

 

 

karrenberg
I can tell you re: the

I can tell you re: the population in the small community hospital where I work.  Many, many chronic, diabetic, pvd, wound care, etc. patients.  Many repeat episodes of vanco or cubicin for recurrent MRSA, osteo, cellulitis, etc. People who are chronic eventually lose peripheral access.   They come into the hospital asking for the PICC team because they know otherwise it's gonna be multiple sticks every time.  It's not an issue of CVC vs. PICC.   many times it's an issue of 'what is the best way to get meds into a patient over the fairly long term, and cause the patient the least harm.'  Also I'm from Miami, recently moved to New Mexico.  Amazingly enough, in Florida, Miami was the last city to really get on board with PICCs.  The whole thing with PICCs is the docs catch on sometimes, region by region.  So PICC use has increased because, PICCs are relatively new (compared to CVCs)  and as docs become familiar and comfortable, they are more inclined to order them.  Here in my little town of Las Cruces, both hospitals have PICC programs.  But our small 140 bed hospital places 4x as many as the other 400 bed hospital.  We are very skilled and the docs trust us.  Are PICC's over used?  I hear stories about ICU's that throw a triple lumen PICC into every patient as a matter of course.  Maybe in a trauma center that would be indicated, but it sounds a little like overkill to me.  I think when used judiciously PICCs are a tremendous asset for the patient. 

lynncrni
One other factor driving the

One other factor driving the increase in PICCs is the decreasing professional payments to physicians for placing CVCs. The emphasis on cost containment makes it easy to equate the operational cost of PIV insertions  to the cost of PICC insertion. About 7 to 8 PIVs = 1 PICC. So keeping as much of that DRG or capitated fee is critical to finanacial success of the organization. 

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

sjf12rn
If you were the patient,
If you were the patient, would you prefer a PICC or a cvc placed by a resident into your  chest? I would take the PICC placed by an experienced IV nurse. Also, do you have evidence to support your statement that PICCs and untreated CVCs have the same infection rate? Thank you for opening up the discussion.

Looking for

afruitloop
Yes, the reference that I

Yes, the reference that I spoke of that describes PICC and untreated CVC's in acute / critical care setting having equal rates of infection was actually listed but here it is for you.....Safdar and Maki, Chest  2005;128;489-495.

BTW, I would want the best line for me or mine.... I have opinions on what that would be, but my goal is to understand why it is occurring in your hospitals. Thanks for contributing to the conversation! 

Cheryl Kelley RN BSN, VA-BC

Chris Cavanaugh
Here is another article for

Here is another article for your reference:

Turcotte S, Dubé S, Beauchamp G.

Abstract
Peripherally inserted central venous catheters are not superior to central venous catheters in the acute care of surgical patients on the ward.
World J Surg. 2006 Aug;30(8):1605-19. Review.
PMID: 16865322 [PubMed - indexed for MEDLINE]

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

sjf12rn
I know for a fact that the

I know for a fact that the infection rate of our PICCs within the hospital is extremelly low and that is why PICCs are becoming the device of choice in  our ICU. Also, we do not use untreated CVCs in our hospital. Most patients receive PICCs because it is a more comfortable procedure for them at the bedside and the most experienced and capable people are performing the procedure. Residents and interns at our hospital are not always the most capable and are not the most experienced and they make more than multiple attempts at placement and many times are unsuccessful and end up ordering a PICC (even when they are using ultrasound for the CVC placement). I just know for myself or my family, I would not want anyone placing a CVC into the groin or the chest. I would always opt for a PICC. Sometimes, patients are not PICC candidates for a number of reasons and we always evaluate the patient and suggest the best option to meet their needs. It just seems as though technology is advancing and PICCs are becoming the device of choice. It is becoming harder and harder to get MDs and our IR department to even place an implanted port when we suggest it for pts due to their fear of infection and it being a long-term, tunneled device that is not as easily removed as a PICC. I just think PICCs are the wave of the future and the NOW. I don't see that changing any time soon, at least where I am.

Looking for

Karen Day
Karen Day's picture
I too come from a hospital

I too come from a hospital where picc usage has increased tremendously and for various reasons.  We began our bedside picc team 3 years ago and since then have increased our picc usage by approximately 40 - 50%.  Here are several reasons why I think this has occurred.

When we first began, our skills were should I say lacking - many MD's didn't trust us and preferred to get a CVC placed because it was done by a fellow MD.  After 3 years, I can honestly say that we are very well trusted and called the "experts".  Doctors will even consult us to discuss line options in a patient because they realize that we take our jobs seriously and we are in this for the patients, not to see how many picc lines we can place.  They respect our opinions and advice and I must say, they usually follow it.  If we suggest that a patient is not a picc candidate, we tell them why and offer them some options to think about for that particular patient.  Placing a picc line is safer in some patients than placing say a CVC or a port - especially if they are anticoagulated.  since it is a peripherally placed line, bleeding can be easily controlled if it is encountered.  I have to say, that we review labs on every patient we place a line.  If a patient has a prolonged PT/INR, we are cautious when placing the line, but we are still able to perform this for them - some physicians will refuse placing a port or other CVC when a patient has prolonged PT/INR or low platelets. 

Also, with many advances in picc lines such as CVP monitoring - these lines can provide the same advantages as a CVC but you are using the smallest catheter possible in order to meet the needs of your patient which is an INS standard.   We have also found that nearly 100% of our home health agencies and LTC facilites are more familiar and comfortable with a PICC line as opposed to a CVC and when patients are discharged to these types of facilities, this is the preferred access.  Most Home Health agencies will not accept any other type of central line except for a picc line.

I must also brag on our infection rates, we have had 0 primary CRBSI related to picc lines in the past 5 - 6 months and a rate of less than 1.5% prior to that - I don't think that could compare to the rates found in CVC lines.  We use a full barrier precautions and don't allow anyone in the room while we perform the procedure.  Often times when a CVC is placed, there is no full barrier drape applied, many people are in the room or in some cases such as trauma or arrest (especially in the ER) the lines are placed "dirty", not to mention that even with the use of ultrasound, rarely is a CVC placed with only 1 stick performed.

Lastly, i must say is the cost.  As Lynn mentioned earlier, insurances are paying less and less for a doctor to place a central line.  By having a nursing bedside picc team at our facility, we allow other necessary procedures to be performed in our Interventional Radiology suites and actually save the hospital approximately $1500 per line placed at bedside as opposed to having it placed in an IR suite.  Since we place approximately 120 lines per month, that is a potential cost savings to our facility of over 2 million dollars annually. 

thanks for the discussion topic, it's a good one.

Karen

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

First let's start with the Maki study cited from 2005 and why it is such a bad study:

You will find this discussion on the limitations of this PICC vs. C VC study in Jamie Bowen Santolucito's paper in the JVAD 2008 for the Suzanne Herbst Award.  She has a thorough discussion on why this study is so out of date compared to 2008.

The PICC lines in the Maki study were placed by an RN using no ultrasound or micro and all were 3, 4 F below the antecubital.  Each patient in this study got over 2 PICC lines each to make a 14-15 day therapy.  Seems excessive but it was a silicone PICC so breakage?  By the way all the radiology PICC lines and there were 1,000 of them were completely excluded from this study group.  Only the RN placed lines were included.

The PICC lines were taken from a control group of two other studies.  The first control group study of PICC's had no chlorhexidiene, full barrier placement and that study looked at using 1% chlorhexidiene on the non control group.  The second control group of PICC's had no biopatch, chlorhexidiene and full barrier placement and that study looked at using Biopatch on the non control group.  Than these results were compared to a coated CVC with shorter dwell times.  Sounds fair.  The PICC lines had no coatings, biopatch, full barrier placement, ultrasound, micro, chlorhexidiene.

The study date was collected in late 1999 and early 2000.  Very up to date for a publication in 2005.  In other words by the time the data was published it was five to six years old.

So do acute care CVC's have a higher / lower rate of infection than a PICC.  I would not base that answer on this study at all. 

I would base that answer on a study with:

Chlorhexidiene

Full barrier

biopatch

Upper arm PICC placement with ultrasound and micro

In other words using the IHI recommendations for CVC insertions

The newest study with a zero infection rate for PICC lines and that study has data for over 2,000 lines placed is by Harnage from Sacramento and she cited a zero rate for 15 months.  You will find Sophies work in RN for May, and in the JVAD.  By the way IHI has picked up the Sutter Roseville Hospital story as well and she is presenting everywhere.  The great thing about Sutter's work they used IHI recommendations for PICC placement including all the high-tech tools.  Awesome job Sutter.  Way to go!!!  sero PICC infections.  It is about the care factor!

 Kathy Kokotis

 

Kathy Kokotis

Bard Access Systems

afruitloop
Kathy, I see you started

Kathy,

I see you started out with a "first" point, but never made it to a second point.  And in your point, to totally missed my point!   

The goal of my posting was to gather an understanding of the current practice by the nurses who presently place PICC's (and who are contributing to the decision of what line is being placed) as to why they are doing.  I appreciate all of the responses that I have received.  The trend has changed and I hope to understand it better.

Also, to note, the object of the post was not to critique the CHEST article, as you did. The title of the thread was "Why are so many PICC's being placed?"

 

Cheryl Kelley RN BSN, VA-BC

karrenberg
In the article by Turcotte,

In the article by Turcotte, which was published in 2006, he states "data were extracted from 48 papers published between 1979 and 2004."  That's not exactly up to date information.  He also  cclaims that 40% or more of PICCs need to be removed before completion of therapy.  With these articles, they always compare rates of thrombi, and infections.  What about another problem with  CVL, i.e. pneumothorax? I've place literally thousands of PICCs in my career, haven't dropped a lung yet. How many docs can say that about CVL placement?

Halle Utter
I think there are lots of

I think there are lots of reasons for more PICC lines.  One reason is patient comfort - especially patients with limited venous access possibilities.  If a patient has ever had a PICC before, they will request it if there is a need for any type of ongoing IV therapy because they know it's (usually) a one stick procedure and will also save them sticks for any labs needed.  The general public is becoming more knowledgeable about types of IV access, and patients and/or families will request a PICC where they might not request a CVC.

Secondly, there is preservation of the vasculature of the upper extremities.  As the specialty of IV therapy and infusion has grown, we are more aware of the different properties of the drugs we infuse, ie pH and osmolality, and the consequences of administering these drugs peripherally.  It has become the standard of practice to make decisions regarding access type based on what is going to be infused,  and not following the SOP puts one at risk legally if there is an infiltration or throbophlebitis.  

Thirdly, what are you basing your statement that "PICCs are more expensive" on? More expensive than a CVC? Multiple PIVs? Many patients that have a CVC end up with a PICC so the CVC can be removed.  A patient can go to the floor with a PICC.  Many hospitals prefer not to have a subclavian or jugular on the floor units, but are not concerned about a PICC.  Time and money are saved when drugs are administered on time and labs are drawn on time.  Hospital stays are shorter when reliable venous access is maintained.  

I think there are other reasons we see more PICCs than we used to, but overall in many cases it is the most comfortable cost effective choice when a patient needs ongoing IV access and/or the administration of medications that fall outside of the pH and osmolality parameters for peripheral administration.  I sure don't believe it should be about how many PICCs we can place, but about what is best for the patient.  A PICC isn't always the best choice, but it frequently is.

Halle Utter, RN, BSN

Intravenous Care, INC 

Hallene E Utter, RN, BSN Intravenous Care, INC

Heather Nichols
Wow! This is such a great

Wow! This is such a great discussion, I had to chime in.

I have heard a lot about PICC's and CVC's (and by the way, a PICC is a CVC), but no one has yet mentioned "other" types of VAD's. Our team here at U of L is a lot like Karen Days team in her earlier thread. We are a Vascular Access Consult Team, not the PICC team. We get an order for a PICC, and we go do a full assessment on the patient, and work with the doctor to make a combined, collaborative, decision about what type of access is needed to properly continue whatever IV treatment that particular patient needs. We have a consult form we fill out and leave on the chart. Most the time, even grudgingly, the doc's respect, and agree with us. Not always though. We work with residents and attendings, and it is constant educating due to the monthly turn over. We, however, do more than just PICC's and triple lumens. We work fairly well with our IR dept. They place tunneled catheters (even tunneled PICC's) of all kinds, ports, quads, And even occasionally help us to finish a PICC we are unable to get to the SVC. Of course it is definately more expensive for the patient to go to IR, but sometimes it cannot be helped. Like all have already agreed upon, a PICC is not always the best choice.

I do believe PICC's are being used thoughtlessly now days, but even though they are, a lot of patients still fall through the cracks because nurses and doc's do not know enough about vascular access. We need more Vascular Access Consult teams,and educators, and less "PICC stick and run" teams. The more professional, educated, and dedicated we become, the more the doctors and other disciplines will respect and value our opinions and decisions. There is nothing I hate more in nursing than to hear a nurse say, "because the doctor ordered it" like that nurse has no brain to evaluate the patient he or she is taking care of. What is the pH and osmolarity of that drug? What is it being used to treat and how long? Is it really needed? And finally, what type of vascular access device would be best for MY patient I am supposed to be advocating for? These are not hard questions, they just take a little more of our precious time to answer and possibly a little backbone and a lot of critical thinking skills to disagree with the doc and change his or her mind.

That is my opinion, and one other thing, if your doc's are not using proper sterile technique, full barrier precautions, and ultrasound, to place their central lines, make them. Show them why if you have to sit on them to make them listen. Bring them supportive evidence based material until they want to do what you say to just get you off their backs. It is always nice when you get one or two to understand and support you. It helped us to make it easier for them. We put together a central line insertion kit for them so that they did not have to wait for supplies. They also had no reason not to use what we asked them to use because it was right in front of them. These may be short term lines, but that is no excuse (except in a code of course) not to do it right. FIGHT for you patients!

Heather 

 

KATHLEENT.MOHN
kathy mohn-las vegas--I

kathy mohn-las vegas--I would be willing to bet that after 1 October 2008, PICCs are

going to become even more demanded  than they are now.  Hospital organizations will

be painfully aware that with IV Team placement and management, they will save a bundle on PICCs because with the precise placement that we are able to provide, the

infection and complication rate is less. That will equate to more profitability and financial

stamina than in those facilities that do not place central lines with maximum sterile barrier precautions or with the additional technologies today available for site selection,

line stabilization, and prolonged decreasing of skin micro-flora around the exit site.

In this community many physicians will not even place a triple lumen CVC on the

patient-they call the PICC Team!!! Even the residents once they have placed their

required number of triple lumens punt to the IV Team.  And the infection rates

support this decision.  I am also happy to report that a few physicians are beginning

finally to place central lines via ultrasound- and they are showing the residents how to use ultrasound as well--Thank Goodness!!!

kathy mohn-las vegas

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Cheryl sorry to go after the chest article but it is a sore subject with me as it really bashes the PICC line with inaccurate information and looks nursing practice look bad.

So back to the question why are PICC line usages increasing:

First and formost economics of scale.  The MD is now paid by CMS $108-$120 to place an acute care line with the risk of pneumothorax, hemothorax, arterial puncture and liability especially if not using ultrasound

Secondly time - MD's do not want to come in on weekends, off hours or have even time during the day to necessarily do lines.  If a PICC team is there is is easier to refer the case

Third - The PICC is a device that does not need to be removed as it is a long term indicated device

fourth - The PICC line materials have changed allowing for faster fluids, multiple lumens, power injection, CVP monitoring and the RN tools have changed for accurracy in placement

Fifth - PICC teams tend to have better care and maintance than hospitals withou teams although no guarantee there

Sixth - cost of a PICC with everything including RN labor (Naylor) is cited at $305 at the bedside the cost of an acute care catheter with full barrier and coating averages around $120 is a guess and the RN assist is $60 and the x-ray is $35 and the non counted hour of MD time is $120 so the total is $335 so the cost is really equal except that the hospital is not always employing the doctor.  In the case of a hospitalist the hospital does employ the MD so why use MD time if a PICC could be done.

I think I have run out.  The key here is the PICC market is not as widespread as one may think.  I enjoyed the Miami post as the author stated they just started using PICC lines and that is true.  There are more hospitals in the united states not using PICC lines than there are using PICC lines believe it or not.  PICC lines are regional in acceptance and one can have a hospital that is 1,000 beds doing 200 lines and anther that does 10,000 lines.  Care differ.  Teachnig hospitals overall tend to use less PICC lines as there are more residents to practice on central lines.  Not sure I like the idea of practice.  Reminds me of a pneumothorax.

Better answer I hope but I hate that Maki study as it is full of so many false statements and because it is in Chest it is believed by MD's and gives PICC lines a bad name

Kathy

Kathy Kokotis

Bard Access Systems

pafrn
Thank you Cheryl for an

Thank you Cheryl for an interesting topic!  I have read many interesting replys to this question and for me, I am going to keep it very simple.  I have been placing PICC lines for the past 10 years and would say the following are the reasons I see:

1.  MD's no longer want to place CVC's which is probably due to re-imbursement issues, the possibility of complications and infection and the bottom line is that it is easier for them to order a PICC line than to be bothered in placing a CVC themselves.

2.  Many of the patients we have placed PICC lines in truly have horrible access and are in need of a line but not to the extent that a CVC needs to be placed by an MD which we know will not last as long as a PICC line.  For these patients the PICC line is less risky and serves the purpose for vascular access quite well.

3.  Many patients are being admitted to the hospital who have had PICC lines in the past and are asking their Doctor for one when they are admitted.

My feeling is that there is a place for both types of central lines and over the years we have worked very hard to make sure that even though a PICC line was ordered that we acted as a patient advocate to make sure that the correct type of line was placed in the end....and I would say for the most part, the PICC line ended up being the central line of choice over the CVC.

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