Impact on CLABSIs With Bundle Implementation and Staff Education

Peripheral Infusion Therapy in Children Hospitalized in a Reference Hospital in Pediatrics In the Northeast Region of Brazil

Placement of a Peripherally Inserted Central Catheter Line in a Persistent Left Superior Vena Cava: A Review of Positioning and Clinical Implications

Extracolonic Manifestations of Chronic Ulcerative Colitis

Automated precision localization of peripherally inserted central catheter tip through model-agnostic multi-stage networks

ObjectivesMost paediatric oncology patients require intravenous access for investigations and administration of chemotherapy. Traditionally this has been through a Hickman line, but increasingly peripherally inserted central catheter (PICC) lines are...

Peripherally inserted central catheter (PICC) bloodstream infection surveillance rates in medical intensive care, medical-surgical wards, extended care, and outpatients

Bedside placement of peripherally inserted central catheters (PICCs) may result in navigation to undesirable locations, such as the contralateral innominate or jugular vein, instead of the superior vena cava or right atrium. Although some guidance and tip location tools exist, they have inherent limitations because of reliance on physiological measures (eg, chest landmarks, electrocardiogram, etc), instead of anatomical assessment (ie, geometric changes in the vasculature). In this study, an accurate, anatomically based, non-X-ray guidance tool placed on a novel 0.035" conductance guidewire (CGW) is validated for PICC navigation and tip location. The CGW system uses electrical conductance recordings to assess changes in vessel cross-sectional area to guide navigation of the PICC tip. Conductance rises and oscillates when going in the correct direction to the superior vena cava/right atrium, but drops when going in the incorrect direction away from the heart. Bench and invivo studies in six swine were used to confirm the accuracy and repeatability of the PICC placement at various anatomical locations. The PICC tip location was confirmed by direct visualization vs the desired location. CGW PICC guidance was highly accurate and repeatable with virtually no difference between actual and desired catheter tip location. The difference between the CGW PICC location vs the desired target was-0.07± 0.07 cm (6.6% error) on the bench and 0.04± 0.10 cm (5% error) invivo. No complications or adverse events occurred during CGW usage. The CGW provides an anatomically based, reproducible, and clinically significant method for PICC navigation and tip location that can improve accuracy, decrease the wait time prior to therapy delivery, decrease cost,and minimize the need for X-ray. These findings warrant clinical evaluation of this navigation tool for PICC line placement.

Peripherally inserted central catheters (PICCs) are commonly used in NICUs. Although they have many benefits, they also have many potential complications. Confirming catheter tip position is essential to decreasing complications, but the best method to achieve confirmation is unclear. Literature review for studies that address line position confirmation to assist health care providers in evaluating the available research and to identify gaps in the literature. A literature search of four major databases followed by an ancestry approach was performed. Articles reviewed specifically discuss PICC lines and PICC line placement confirmation. Data on confirming PICC placement were lacking. Fluoroscopic placement is ideal, but cannot be done at the bedside and is costly. Supine chest radiograph is the most widely used method and is convenient, but when line tip position is unclear, contrast or ultrasound confirmation can be used. When PICC lines are placed in the saphenous vein, infants may benefit from supine and lateral abdominal radiographs to ensure placement in the inferior vena cava. More studies are needed to generalize findings. PICC line tips should be located in the superior vena cava or inferior vena cava close to the junction with the right atrium (0.5-1 cm outside of the cardiac chambers in premature infants and 1-2 cm outside of the cardiac chambers in larger infants). Arm position is very important when performing radiographs for placement because movement of the arm can cause migration of the catheter. There is also significant inter-observer variability when identifying line tip position.

Introduced in China in the late 1990s, Peripherally Inserted Central Catheters (PICCs) have undergone rapid development and are widely used to deliver chemotherapy for cancer treatment and to establish adult postoperative parenteral nutrition pathways (Zhong, 2007). The technologies and methods related to PICC insertion have also developed rapidly. The United States Infusion Nurses Society and Oncology Nurses Society have published a number of clinical nursing practice guidelines for vascular access devices (Alexander, 2011; Camp-Sorrell, 2011), which present the best practice evidence for multiple steps of the PICC insertion process, such as the selection and preparation of the puncture site and catheter insertion. Such guidelines aim to standardize the procedures, effectively utilize limited health resources, and protect the patients’ interests. The current PICC insertion procedure in our hospital was developed from experience-based standards and processes are mechanically executed. To address this practice problem, we conducted a project to explore how to effectively implement the best practice of PICC insertion in our hospital. Our hospital is a tertiary cancer care center, affiliated with Fudan University with approximately 400 PICC insertion cases per month. The vascular access care outpatient clinic is led by PICCs specialty nurses and currently staffed with 1 chief nurse, 5 full-time PICC insertion nurses, and 11 full-time point-of-care nurses. This clinic is also equipped with three vascular ultrasound systems. The PICO (Population, Intervention, Comparison, Outcome) question that guided the project was as follows: In patients receiving a PICC line insertion (P) how does use of best practice affect insertion procedures, (I) how does it compare to experience-based insertion procedures, (C) how does it affect patient outcomes and nursing outcomes (O)? Between October and December 2012, the following databases were systematically reviewed: The Joanna Briggs Institute Library (1998–2012), EMbase, Elsevier (1990 to present), Web of Knowledge, Ovid, China National Knowledge Infrastructure (CNKI, 1990–2011) and the Chinese Wanfang database. A Web-based review of relevant guideline websites and professional websites, including the National Guideline Clearinghouse (NGC) and the Registered Nurses' Association of Ontario (RNAO), were also conducted. Five PICCs insertion-related guidelines that were currently in use in the United States, the United Kingdom, and Canada (Alexander, 2011; Camp-Sorrell, 2011; O'Grady et al., 2011; Pratt et al., 2007; Registered Nurses' Association of Ontario, 2008) were obtained. The key terms used in this project included peripherally inserted central catheters or PICCs and best practice or ultraso* or modified Seldinger technique or insertion or chlorhexidine or maximum sterile barrier or catheter tip location and position or complications. Fudan University Evidence-based Nursing Center is one of the cooperation centers of Joanna Briggs Institute (JBI) so the JBI evidence grading system version 2010 in Chinese was used for appraisal (Yan Hu, 2012). When determining appropriate catheter length, a PICC insertion nurse should use a measuring tape to measure from the point of venipuncture, over the course of the selected venous pathway, across the shoulder to the right side of the sternal notch, and down to the third intercostal space (Level III; Camp-Sorrell, 2011; Claasz & Chorley, 2007). Two percent of chlorhexidine gluconate ethanol solution is recommended to disinfect the skin at the catheterization site (Level I; Camp-Sorrell, 2011; Registered Nurses’ Association of Ontario, 2008). During the PICC insertion process, a maximum sterile barrier should be established. The operators should wear masks, hats, sterile powder-free gloves, a sterile gown and spread large, sterile sheets; the patients should wear masks and hats, and their entire body should be covered with sterile sheets (Level I; Alexander, 2011; O'Grady et al., 2011; Pratt et al., 2007). Vascular ultrasound guidance combined with the modified Seldinger technique should be used to insert the PICC catheter into the upper arm, especially the right upper arm, which lead to improved puncture and catheterization success rates and reduced complications related to mechanical damages (Level I; Li, Yan, & Zhang, 2013; Zhang et al., 2011). The optimal position for the catheter tip is from the lower third of the superior vena cava to cavoatrial junction; however, the catheter tip should not enter the right atrium (Level I; Infusion Nurses Society, 2006; National Association for Vascular Access Networks, 1998). Markers for determining the optimal position of the PICC tip on chest X-ray films include the carina of the trachea, the right main bronchus angle, and the upper right edge of the heart shadow, and position 4 cm or two thoracic vertebrae below the carina of trachea are considered appropriate (Level III; Baskin, Jimenez, Cahill, Jawad, & Towbin, 2008; Liu, Zhao, & Wang, 2011; Mahlon & Yoon, 2007). When the PICC have been inserted to the predicted length, an ultrasound probe can be used to detect the jugular vein on the catheterization side to exclude the possibility that the catheter tip entered the jugular vein and to facilitate timely adjustment (Level II; Bullock-Corkhill, 2010; Schweickert et al., 2009). Vascular ultrasound system is recommended to distinguish arteries, veins and nerves or nerve bundles to prevent the accidental perforation of arteries or nerves (Level II; Jin, 2005). The steps of the PICC insertion procedure in our hospital were formed based on the nurses’ experiences. This situation was not conducive to establishing and implementing a best practice. In order to ensure the safety of patients and improve the quality of care, we needed to use the current, best scientific evidence that was available to guide our PICC insertion practices. Before applying the body of evidence to our practice, we formed the project team. The team was led by the nurse researcher, directed by the head nurse of the clinic and supported by the director of hospital nursing service department. The seven-member team ultimately included PICCs insertion nurses, the head nurse, the director of the nursing department, a diagnostic radiologist and an interventional radiologist. The process utilized for integrating the evidence into practice included five steps. A situational assessment and analysis was conducted prior to the clinical implementation of the evidence: (a) an assessment of hospital resources and facilities, current rules or processes, the staff workload, the use of related materials; (b) interviews were conducted with the head nurses and PICC insertion nurses related to attitudes toward the existing PICC insertion process, the practical difficulties expected for evidence implementation, and director's support for and attention to the process; (c) an assessment of the feasibility and complexity of the planned implementation of best evidence for PICC insertion in hospitals, with or without an increase in the workload of the PICC insertion nurses and the nurses’ acceptance of the practices. Based on the assessment of evidence from the literature and our existing procedure, supports or barriers were identified and analyzed, and strategies of maximum resources utilization and evidence-based implementation were developed. For example, the mark, which used to detect the PICC tip position in our hospital, was the count of the rib on X-ray images. It was quite different from the best evidence synthesized at the beginning of the project. Therefore, the recommended detection of the PICC tip position was one of the revised items in PICCs insertion procedure. Additional evidence-based changes were: The implementation of 2% chlorhexidine for disinfectants and a maximum sterile barrier for patients; the use of vascular ultrasound technology; the identification of artery, vein, nerve and the catheter migration into the jugular vein using vascular ultrasound. The vascular access management software was improved by adding information about the catheter tip location, the one-puncture success rate, the tube insertion success rate, and the incidence of complications during catheterization, such as primary catheter malposition. The preliminary investigation conducted before the evidence-based changes were implemented revealed that although the nurses had received the Shanghai Institute of Nursing PICC insertion competency certificate, their training had mainly focused on technical operations; the nurses lacked theoretical training, and their basic knowledge of evidence-based nursing was relatively weak. Before the evidence was implemented, PICC insertion nurses and managers who participated in this project were educated on the updated evidence related to PICCs, new PICC insertion process and relevant documentation requirements. A video demonstrating the new PICC insertion process was produced for training PICC insertion nurses. As a result, full preparation for the transition to the new, evidence-based PICC insertion practice was provided. After receiving permission from the hospital's institutional ethics review board, the PICC insertion checklist and newly revised PICC insertion process was implemented in clinical practice. Core team members were available to answer questions, address issues that arose during the implementation, and provide timely feedback and solutions. It was vital to build in structures and processes to ensure continued and appropriate use of the interventions. A PICC insertion checklist was developed to monitor the quality of PICC insertions conducted by the nurses. This documentation form included the patient ID number and patient identity verification and recorded all the steps according to the PICC insertion process and each item could be marked as “conform” or “did not conform.” The checklist was spot-checked and completed by the chief nurse on the unit. Meanwhile, case study meetings were organized to discuss prevention and treatment measures for common complications that arose during the catheterization processes. After the completion of the clinical implementation, the managers and all PICC insertion nurses met for a discussion and summary to determine areas for further improvement. The data for 867 patients who underwent PICC insertion in the vascular access care outpatient clinic was collected in July and August 2013 before the evidence-based practices were implemented. The period from October 2013 to February 2014 was the implementation phase for evidence-based PICC procedures. The data with 742 patients were recorded and then compared with those before the implementation of the evidence-based protocol. With the provision of additional education, the average knowledge score of nursing staff increased from 110.7 to 118.3 out of a possible total score of 120 on a PICC line insertion knowledge test designed by the team. As part of the education program, all five PICC insertion nurses were trained about PICC insertion updated knowledge about upper arm catheterization under ultrasound guidance combined with the modified-Seldinger technique. The implementation of this evidence-based intervention improved the quality of care in the vascular access outpatient care clinic, as reflected in the following patient outcome indicators: The percentage of patients who chose the upper arm instead of traditional forearm catheterization increased from 98.96% (858/867) before the implementation of evidence-based practices to 99.87% (741/742) after the implementation. The result of Fisher exact probability method showed the difference to be significant (p < .05). The PICC insertion nurses’ updated knowledge related to selection of the catheterization arm also improved patient outcomes. The results of the chi-square test indicated that the percentage of patients (81.4%, 604/742) whose PICC catheter tip reached the optimum position was significantly higher than that (75.78%, 657/867) before the changes (p < .05). Finally, implementing improvements in the methods for measuring the PICC catheter insertion in vitro improved the patient outcome of accurate targeting of the PICC catheter tip in the lower 1/3 of the superior vena cava or cavoatrial junction, and not into the right atrium. Before the changes were implemented, the nurses adjusted the catheter in 19.39% (32/165) cases with the PICC catheter tip positioned too deep. The percentage increased to 47.37% (45/95) cases after the evidence-based practice change. This finding was statistically significant (p < .001). The results showed that the ability of nurses to detect the PICC tip position on X-ray image significantly improved when the catheter tip was positioned too deep. One difficulty in the implementation of evidence-based practices is the normalization of such practices. In addition to training, an effective way to continuously strengthen practices is to integrate them into the daily work of nursing. In this study, we revised the PICC insertion procedures and conducted training to integrate evidence-based practices into the operational procedures. The operational procedures could change the behaviors of the nurses and ultimately enable them to achieve mastery of evidence in their daily work while normalizing the new practices. Continuous strengthening of the evidence and monitoring of implementation measures are key factors in normalizing best practices (Aitken et al., 2011). The primary role of monitoring is to ensure the effective implementation of the evidence-based measures, and the normalization of the changes. In addition, continuous monitoring could reveal whether the current measures required modification or whether new measures needed to be added. The implementation of evidence-based innovations in this project was monitored by the chief nurse using the PICC insertion checklist. During the group discussion on evidence implementation that was part of this project, the nurse researcher and PICC insertion nurses found that some barriers influenced the adherence to evidence-based PICC procedure, such as the inconsistencies between what “they knew” and what “they do.” The key to overcoming this barrier and reduce these inconsistencies was to allow the learned knowledge to be effectively applied in clinical practice. The evidence informs the practitioners about what to do, but the specific procedures still need to be further refined and developed by researchers and practitioners according to specific clinical scenarios, including details pertaining to time, frequency, objects, methods, approaches, recording, and feedback. It is important to progress from experience-based practice to evidence-based practice, and use scientific evidence to guide our practices, to ensure the safety of our patients and improve quality of our care. During the best practices implementation process, it was essential to take full advantage of the functional roles played by researchers, care managers and PICC insertion nurses; apply effective strategies consistent with the clinical context; and make efforts to apply the evidence to daily work to ensure effective implementation. The outcomes of the implementation project were reported to the nurses in the clinic, the IV-team members, and the nursing quality supervisors in our hospital. The implementation protocol was introduced across the hospitals affiliated with Fudan University. Project results were disseminated through oral presentations at four regional and international doctoral student forums and oncology nursing conference. The best evidence on PICCs insertion developed in this project will be published on the website of Fudan University Evidence-based Nursing Center.

Long-term catheters are often necessary for outpatient care after an allogeneic hematopoietic stem cell transplantation (HSCT), However, there is paucity of data on the use of peripherally inserted central catheter (PICC) in post-HSCT setting. We prospectively evaluated the systematic use of PICC in 37 consecutive patients returning home after HSCT. In 6 out of 37 patients, the PICC was exclusively used for weekly blood controls. In 31 patients, the PICC line was used at home for hydration (18), antibiotics (3), intravenous human Ig (7), transfusions (10), extracorporeal photopheresis (3), chemotherapy (2), artificial nutrition (1), and/or palliative care (1). PICC complications were reported in ten patients (27%), causing eight PICC removals. At the end of the study, 35 patients had their PICC removed. PICCs were used with a median duration of 67days. Reasons for removal were that PICC was not considered to be useful any longer (16), suspicion of infection (inflammation without documentation) (5) or infection (2), patient's wish (4), death (4), accidental withdrawal (2), puncture site bleeding (1), and catheter change due to extracorporeal photopheresis (1). Three venous thromboses were reported (8%), requesting one PICC removal because of associated infection. In other cases, an antithrombotic treatment was initiated. Although the number of patients included in the study was small, our results suggest that PICC is a safe long-term venous access for home care after HSCT.

Persistent left superior vena cava (PLSVC) is an anatomic variant that is relatively uncommon in the general population. Lead extraction through PLSVC is extremely rare. Due to unusual anatomy, the procedure carries challenges that require special considerations and careful planning. The authors report a case of lead extraction through a PLSVC with occluded right superior vena cava and highlight the challenges and outcomes of the procedure.

Background Placement of central venous port catheters (CVPS) and peripherally inserted central catheters (PICC) is an integral component of state-of-the-art patient care. In the era of increasing cost awareness, it is desirable to have more information to comprehensively assess both procedures. Purpose To perform a retrospective analysis of interventional radiologic implantation of CVPS and PICC lines in a large patient population including a cost analysis of both methods as well as an investigation the learning curve in terms of the interventions' durations. Material and Methods All CVPS and PICC line related interventions performed in an interventional radiology department during a three-year period from January 2011 to December 2013 were examined. Documented patient data included sex, venous access site, and indication for CVPS or PICC placement. A cost analysis including intervention times was performed based on the prorated costs of equipment use, staff costs, and expenditures for disposables. The decrease in intervention duration in the course of time conformed to the learning curve. Results In total, 2987 interventions were performed by 16 radiologists: 1777 CVPS and 791 PICC lines. An average implantation took 22.5 ± 0.6 min (CVPS) and 10.1 ± 0.9 min (PICC lines). For CVPS, this average time was achieved by seven radiologists newly learning the procedures after performing 20 CVPS implantations. Total costs per implantation were €242 (CVPS) and €201 (PICC lines). Conclusion Interventional radiologic implantations of CVPS and PICC lines are well-established procedures, easy to learn by residents, and can be implanted at low costs.

BackgroundAlthough the use of a peripherally inserted central catheter (PICC) has many advantages for the treatment of neonates, catheter malposition may result in serious complications that could be life-threatening. We report the case of a 10-day-old neonate with cardiac tamponade secondary to a PICC line who was successfully treated by pericardiocentesis.Case presentationAn Iranian (Asian) preterm male neonate was born by Cesarean section with a birth weight of 1190 g and a first-minute Apgar score of 7. Based on an increased respiratory distress syndrome (RDS) score from 4 to 7, resuscitation measures and intubation were performed at the neonatal intensive care unit (NICU). On day 3 after birth, a PICC line was inserted for parenteral therapy. A chest X-ray confirmed that the tip of the PICC line was in the appropriate position. Mechanical ventilation was discontinued 72 h post-NICU admission because of the improved respiratory condition. On the day 10 post-NICU admission, he suddenly developed hypotonia, apnea, hypoxia, hypotension, and bradycardia. Resuscitation and ventilation support were immediately started, and inotropic drugs were also given. Emergency echocardiography showed a severe pericardial effusion with tamponade. The PICC line was removed, and urgent pericardiocentesis was carried out. The respiratory situation gradually improved, the O2 saturation increased to 95%, and vital signs remained stable.ConclusionsDramatic improvement of the neonate's clinical responses after pericardial drainage and PICC removal were suggestive of PICC displacement, pericardial perforation, and cardiac tamponade.

The establishment of reliable central venous access is essential in the management of patients with major complications, including pneumothorax and hemopneumothorax. Although peripherally inserted central catheters (PICCs) offer advantages over traditional central venous approaches, PICC lines are associated with a number of insertion and maintenance problems, including clotting and catheter fracture. These complications often result in catheter removal before completion of prescribed therapy. We conducted a retrospective descriptive study in a convenience sample of 322 consecutively placed PICC lines. Study variables included size of catheter, tip placement, infused solutions, patient diagnosis, and unit of line placement. The rationale for line discontinuance as well as for complication rates is described. Complication rates for infection and central venous thrombosis were less than 1%. Phlebitis occurred in 9.7% of patients, and catheter fracture occurred in 9.7% of patients. Two distinct clusters of phlebitis, early and late development, were observed. Early phlebitis is attributable to the mechanics of insertion, and late phlebitis is attributable to chemical and patient-specific causes. Catheter fractures were primarily related to tearing of the catheter during insertion or traction on the catheter-hub junction (51.6%). The majority of published data about PICC lines is in the area of chemotherapy or antibiotic infusion. Our study supports the use of PICC lines in patients receiving a variety of solutions, primarily parenteral nutrition. With an experienced, team approach to catheter placement and maintenance, PICC lines provide reliable, cost-effective venous access and reduce many of the complications of central venous access in a variety of clinical settings.

Persistent left superior vena cava is rare and asymptomatic and is usually discovered incidentally during or after insertion of a central venous catheter. There is uncertainty as to whether or not the catheter should be removed after its malposition resulting in persistent left superior vena cava. We reported an unusual case of a breast cancer patient with a persistent left superior vena cava detected after a peripherally inserted central catheter insertion. The patient had undergone a modified radical mastectomy and needed to insert a peripherally inserted central catheter for chemotherapy. After the peripherally inserted central catheter insertion, the chest X-ray and computed tomography showed that the catheter was located in the persistent left superior vena cava. After an assessment of the persistent left superior vena cava and the catheter tip position, the peripherally inserted central catheter remained in the persistent left superior vena cava for further therapy. To ensure the integrity of the catheter, special follow-ups and tip position observations were carried out. The peripherally inserted central catheter was safe until the end of chemotherapy with no complications. Although the peripherally inserted central catheter tip was located in persistent left superior vena cava, given that the persistent left superior vena cava coexisted with a right superior vena cava with the similar lumen, the peripherally inserted central catheter could be used normally under strict attention.