Subsequent steps of the occlusion toolkit require two areas of four-month evaluation. In step four, you will need to conduct a four month audit of flushing and tip migration. In step six, you will need to conduct a line necessity audit. To facilitate this process, we recommend that your team conduct both audits during the same four month window and save the line necessity documentation for use at a later time. 
Occlusion Step 4 Validation - Flushing Validation
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. 
Occlusion Step 4 Validation - Tip Migration Validation
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. 
Occlusion Step 6 Validation - Line Necessity
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. 

Review and address provider factors

Element
Key Institutional Partners
  • Tip confirmation
    • Ensure that tip location confirmation is completed and documented in the medical record
    • Incorporate appropriate catheter tip location into institutional guidelines or policies
      • Confirmation of the catheter tip position in the appropriate position following placement is associated with lower risk of occlusion
      • Catheter tips should be in the lower 1/3rd Superior Vena Cava (SVC), Cavo Atrial Junction (CAJ) or in the Right Atrium position
      • Use of ECG-guided technologies or fluoroscopy is preferred over the use of X-Ray or landmark techniques to position PICC tips appropriately
Hospital Leadership, Providers, IR, Vascular Access Team, QI Department
Resources/Tools
CLOT Tool  (CLOT - Catheter flush, Lumens, Optimal access, Tip)
Pocket card for occlusion risk based on CLOT
Articles/References
​Smith S, et al. Patterns and predicators of peripherally inserted central catheter occlusion:  The 3P-O Study. Journal of Vascular and Interventional Radiology 2017
  • Patient, Provider and Device Factors Associated with Catheter Occlusion
  • Provider-
    • Increased risk: left arm access, administration of cefepime/piperacillin-tazobactam/vancomycin, PICC use in the ICU setting, transfusion of PRBC (packed red blood cells)
    • Decreased risk: right arm access, verification of appropriate tip positioning, SASH method (flush with NS and lock with heparin) (SASH - Saline, Administer medication, Saline, Heparin)
Chopra V, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of Internal Medicine 2015
  • Criteria for the use of PICCs was developed, adopting the RAND/UCLA Appropriateness Method. After a review of 665 scenarios, 43% of PICCs were flagged as inappropriate. Applying these criteria as a guide can help decrease the likelihood of an inappropriate catheter, improve care, and inform quality improvement efforts
Lum P. A new formula-based measurement guide for optimal positioning of central venous catheters. Journal of the Association for Vascular Access 2004
  • The “tailored fit” formula to individual patient height is a reliable tool to predict CVC length. Appropriate catheter length can greatly reduce the guesswork and possibility of complications related to tip malposition
Orme RM, et al. Fatal cardiac tamponade as a result of a peripherally inserted central venous catheter: a case report and review of the literature. British Journal of Anaesthesia 2007
  • Details the proper tip location (Zone A, B & C)
Validation Survey
Occlusion Step 4 Validation - Tip Confirmation Validation
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.

Review PICC care and maintenance policies to ensure that the following flushing techniques are included in your facility's policy

Element
Key Institutional Partners
  • SASH technique (SASH - Saline, Administer medication, Saline, Heparin)
    • Use of 10cc IV NS flush, administration of drug, 10 cc IV NS flush followed by 2-5cc heparin lock is associated with lower risk of occlusion
      • Note: Use the heparin lock only if indicated or per manufacturer guidelines for PICC devices in use at your facility. If a heparin lock is not indicated, use the SAS (saline, medication administration, saline) method
    • If giving more than one drug, 10cc IV NS flush, administer drug 1, 10cc IV NS flush, administer drug 2… followed by 10cc IV NS flush and 2-5cc heparin lock
      • Note: Use the heparin lock only if indicated or per manufacturer guidelines for PICC devices in use at your facility. If a heparin lock is not indicated, use the SAS (saline, medication administration, saline) method
Providers, IR, Vascular Team, Hospital Leadership, QI Department
  • Flushing catheters before and after each use and daily, if not in use, is associated with lower risk of occlusion than other flushing modalities
    • Each lumen of the PICC should be flushed with a minimum of 10 cc NS daily if not being used
Providers, IR, Vascular Team, Hospital Leadership, QI Department
  • Ensure the following staff are educated in flushing practices and implement a method to evaluate competency:
    • Nursing Staff
    • Any other staff/clinicians responsible for the care and maintenance and/or drawing blood from PICC lines
Providers, IR, Vascular Team, Hospital Leadership, QI Department
  • Develop criteria for who can draw blood from PICC lines at your facility which may include nurses and/or other clinicians
    • Provide education to core group of staff on correct process for drawing blood from PICC lines and implement method to establish competency
​Providers, IR, Vascular Team, Hospital Leadership, QI Department
Resources/Tools
CLOT Tool (CLOT - Catheter flush, Lumens, Optimal access, Tip)
SASH Method handout (SASH - Saline, Administer medication, Saline, Heparin) 
SAS Method handout (SAS - Saline, Administer medication,Saline) 
Care and Maintenance Handout for Nurse
Articles/References
​​Goossens, GA. Flushing and locking of venous catheters:  Available evidence and evidence deficit. Nursing Research and Practice 2015
  • A review of intravenous catheter flushing and locking describing techniques, sufficient volumes, and necessity. High risk associated with common flushing agents requires investigation of alternatives
Occlusion Management Guideline for Central Venous Access Devices (CVADs). Vascular Access:  Journal of the Canadian Vascular Access Association 2013 (Free)
Smith S, et al. Patterns and predicators of peripherally inserted central catheter occlusion:  The 3P-O Study. Journal of Vascular and Interventional Radiology 2017
  • Patient, Provider and Device Factors Associated with Catheter Occlusion
  • Provider-
    • Increased risk: left arm access, administration of cefepime/piperacillin-tazobactam/vancomycin, PICC use in the ICU setting, transfusion of PRBC (packed red blood cells)
    • Decreased risk: right arm access, verification of appropriate tip positioning, SASH method (flush with NS and lock with heparin) (SASH - Saline, Administer Medication, Saline, Heparin)
Validation Survey
Occlusion Step 4 Validation - Care and Maintenance Policy Review and Staff Education
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
Perform audit to determine staff compliance/practice with flushing idle catheter
Element
Key Institutional Partners
  • Each lumen of the PICC should be flushed with 10 cc NS daily if not being used
QI department, HMS PICC Team, Nursing Leadership
  • If PICC is idle >24 hours, query physician to PICC necessity
QI department, HMS PICC Team, Nursing Leadership
  • If PICC is idle >48 hours, query physician regarding PICC removal
QI department, HMS PICC Team, Nursing Leadership
  • Daily lab draws are not an indication for PICC use
QI department, HMS PICC Team, Nursing Leadership
Resources/Tools
​The validation process for flushing catheters requires a four-month audit. Later in the process, you will also have to conduct a four-month audit of line necessity. The audit forms for both steps are included below. We recommend that your team conduct both audits during the same four month window and save the line necessity documentation for use at a later time. 
Articles/References
​Occlusion Management Guideline for Central Venous Access Devices (CVADs). Vascular Access:  Journal of the Canadian Vascular Access Association 2013 (Free)
​Goossens, GA. Flushing and locking of venous catheters:  Available evidence and evidence deficit. Nursing Research and Practice 2015
  • A review of intravenous catheter flushing and locking describing techniques, sufficient volumes, and necessity. High risk associated with common flushing agents requires investigation of alternatives
Pittiruti M, et al. Evidence-based criteria for the choice and the  clinical use of the most appropriate lock solutions for central venouscatheters (excluding dialysis catheters):  a GAVeCeLTconsensus. Journal of Vascular Access 2016
  • The prevention of occlusion is based on the proper flushing and locking technique with normal saline
Validation Survey
​​Occlusion Step 4 Validation - Flushing Audit and Review
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
Implement organizational procedure to check catheter tip position following CT if you see a pattern of occlusion developing after radiographic studies
Element
Key Institutional Partners
  • Once PICC has been placed and verified, occlusion may represent movement of the catheter tip
Providers, IR, Vascular Team, Hospital Leadership
  • Movement of the catheter tip especially occurs after CT scans with power injection through catheter
Providers, IR, Vascular Team, Hospital Leadership
Resources/Tools
​PICC Occlusion and Tip Migration Audit Form 
Articles/References
​Lee J, et al. Displacement of a power-injectable PICC following computed tomography pulmonary angiogram. Radiology Case Report 2017
  • Case report and literature review related to PICC displacement or migration after contrast injection for radiologic study recommending review of catheter tip position following CT
Morden P, et al. The role of saline flush injection rate in displacement of CT-injectable peripherally inserted central catheter tip during power injection of contrast material. American Journal of Roentgenology 2014
  • Laboratory testing indicates PICC tip migration following contrast media injection for CT is likely often unrecognized and underreported. Higher rates of saline flush administration associated with contrast injection may be the primary cause of catheter tip displacement
Lambeth L, et al. Peripherally inserted central catheter tip malposition caused by power contrast medium injection. Journal of Vascular and Interventional Radiology 2012
  • Report of patients who experienced PICC catheter movement following injection of contrast for radiologic studies
Validation Survey
Occlusion Step 4 Validation - Tip Migration and Catheter Occlusion Review
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
Avoid transfusing blood through PICCs when possible
Element
Key Institutional Partners
  • Transfusion of blood products is associated with greater risk of occlusion in PICCs
Providers, IR, Vascular Team, Hospital Leadership
  • Consider using peripheral lines for transfusion of blood products if feasible
Providers, IR, Vascular Team, Hospital Leadership
Resources/Tools
CLOT Tool (CLOT - Catheter flush, Lumens, Optimal access, Tip)​​
Pocket card for occlusion risk based on CLOT
Articles/References
Smith S, et al. Patterns and predicators of peripherally inserted central catheter occlusion:  The 3P-O Study. Journal of Vascular and Interventional Radiology 2017
  • Patient, Provider and Device Factors Associated with Catheter Occlusion
  • Provider:
    • Increased risk: left arm access, administration of cefepime/piperacillin-tazobactam/vancomycin, PICC use in the ICU setting, transfusion of PRBC (packed red blood cells)
    • Decreased risk: right arm access, verification of appropriate tip positioning, SASH method (flush with NS and lock with heparin) (SASH - Saline, Administer medication, Saline, Heparin)
Validation Survey
Occlusion Step 4 Validation - Final Provider Factors Validation
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.