​Step 1

Review Occlusion Data to Identify Areas for Improvement
Element
Key Institutional Partners
  • Perform an audit to understand current drivers and patterns of occlusion at your facility
    • Use the CLOT tool to perform your audit to determine where occlusions are occurring (CLOT - Catheter flush, Lumens, Optimal access, Tip)
      • Remember, catheter occlusion can occur because of:
        • Mechanical problems with the catheter (kinking, pinch off)
        • Problems with the catheter caps
        • Formation of a fibrin sheath/tail within the catheter or around the tip of the catheter
        • Intraluminal thrombosis
        • Crystallization of mineral deposits (calcium, lipid, or dye) within the catheter causing physical obstruction
        • Mural or venous thrombosis around the catheter exit site
      • Strategies aimed to improve occlusion have to consider all of these possibilities
QI Team, Vascular Access Team
  • Identify which units or types of units (i.e. ICU vs non-ICU) have the highest rates of PICC-related catheter occlusion
    • Subsequent interventions in this toolkit should be focused on these patient care areas 
QI Team, Vascular Access Team
Resources/Tools
CLOT Tool (CLOT - Catheter flush, Lumens, Optimal access, Tip)
Audit form to help guide review of occlusion cases at your facility
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
    • Patient: advanced age, elevated BMI, severe liver disease, diabetes, hemoglobin <10, ICU status
    • 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)
    • Device Factors (strongest predictors of occlusion)- higher gauge, double lumen, triple lumen, catheter tip malposition at any point during dwell
Validation Survey
Occlusion Step 1 Validation - Review Occlusion Data
  • 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. 

​Step 2

Review and Address Device Factors
Element
Key Institutional Partners
  • Use the catheter with the least number of lumens 
    • Use MAGIC or another validated decision tool to determine appropriate device lumens
Hospital Leadership, Providers, IR, Vascular Access Team, IT
  • Evaluate who is determining appropriateness/number of lumens 
    • Consider if another clinician type should be involved (i.e. Vascular Access Teams)
    • Ensure those identified as most appropriate to determine appropriateness/number of lumens are educated on appropriate device choice/insertion
Hospital Leadership, HMS PICC Team, QI Department
  • Default PICC order sets to single lumen use unless reasons for multi-lumen catheters exist
Hospital Leadership, Providers, IR, Vascular Access Team, IT
  • Create guidelines which specify conditions/indications in which multi-lumen PICCs are appropriate to guide use at your hospital
    • Example:  Use the Michigan Less Lumens – Less Risk criteria when selecting a multi-lumen catheter
Providers, IR, Vascular Access Team
Resources/Tools
Assessment/Decision Tools Tools to Assist with Determining Potential Vesicants: Example Inpatient PICC Order Set Criteria 
PICC Tier 1 Resources and Tools
Articles/References
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
Xiong Z, et al. Interventions to reduce unnecessary central venous catheter use to prevent central line-associated blood stream infections in adults:  A systematic review. Infection Control & Hospital Epidemiology 2018
  • Interventions aimed at improving CVC appropriateness, assessment, and prompt device removal significantly reduce CLABSI rates. Analysis of secondary outcomes showed a decrease in catheter occlusion
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
    • Device Factors (strongest predictors of occlusion)- higher gauge, double lumen, triple lumen, catheter tip malposition at any point during dwell
Lam PW, et al. Impact of defaulting to single-lumen peripherally inserted central catheters on patient outcomes:  An interrupted time series study. Clinical Infectious Diseases 2018
  • Defaulting non-ICU PICC orders to single-lumen devices resulted in a sustained decrease in PICC-associated complications, particularly occlusion
Swaminathan L, et al. Improving PICC use and outcomes in hospitalized patients:  An interrupted time series study using MAGIC criteria. BMJ Quality & Safety 2018
  • A multi-modal intervention based on MAGIC resulted in a modest decrease in inappropriate PICC use
Bozaan D, et al. Less lumens-less risk:  A pilot intervention to increase the use of single-lumen peripherally inserted central catheters. Journal of Hospital Medicine 2019
  • An intervention involving setting PICC default orders to single-lumen devices, establishing criteria of when multi-lumen PICCs are appropriate, and provider, nursing, and pharmacy education resulted in significant decrease in inappropriate PICC use, as well as an overall increase in single lumen PICC use
Validation Survey
Occlusion Step 2 Validation - Device Factors
  • 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 use of valves/connectors
Element
Key Institutional Partners
  • Often, occlusion has to do with connectors, not the catheter itself
Hospital Leadership, Providers, IR, Vascular Access Team
  • Neutral connectors have the least displacement and may be the best choice
Hospital Leadership, Providers, IR, Vascular Access Team
  • Certain connectors are anti-reflux and can lower risk of occlusion
Hospital Leadership, Providers, IR, Vascular Access Team
Articles/References
​Hitchcock J, et al. Preventing intraluminal occlusion in peripherally inserted central catheters. British Journal of Nursing 2016
  • Results suggested the introduction of the bi-directional needle-less connector had a positive impact on the persistent withdrawal occlusion and occlusion rates in PICCs
Validation Survey
Occlusion Step 2 Validation - Review Use of Valves/Connectors
  • 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. 

Step 3

Review and address patient factors
Element
Key Institutional Partners
  • Consider MAGIC to help inform decision of catheter choice in the ICU 
    • ICU patients have greater rates of catheter occlusion than non-ICU patients
Hospital Leadership, Providers, IR, Vascular Access Team
  • Train insertion staff to assess for risk of occlusion based on patient factors and ensure appropriate provider and device factors are taken into account prior to PICC insertion 
    • Consider placing PICCs on the right side to reduce risk of occlusion if technically feasible, as PICCs placed in the left arm have a higher risk of occlusion
Hospital Leadership, Providers, IR, Vascular Access Team
​Resources/Tools
CLOT Tool (CLOT - Catheter flush, Lumens, Optimal access, Tip)
Pocket card for occlusion risk based on CLOT (CLOT - Catheter flush, Lumens, Optimal access, Tip)
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
    • Patient- advanced age, elevated BMI, severe liver disease, diabetes, hemoglobin <10, ICU status
Validation Survey
Occlusion Step 3 Validation - Insertion Staff Education Regarding Patient Risk Factors.
  • 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.
Patient education regarding care and maintenance of PICC line
Element
Key Institutional Partners
  • Educate patients regarding precautions they need to take while the PICC line is in place including no lifting heavy weights, no contact sports, avoid lifting the arm above your head, and monitoring the catheter length on the skin
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Educate patients on PICC care
  • Evaluate when patients are being educated and ensure that education occurs at a minimum prior to/upon PICC insertion and upon discharge if the patient is being discharged with a PICC
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
Resources/Tools
Validation Survey
Occlusion Step 3 Validation - Patient 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.

Step 4

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.

​Step 5

Early Identification and Treatment of Occlusion
Element
Key Institutional Partners
  • Early assessment and intervention key to successful restoration
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership, QI Department
  • Catheter salvage is preferred method – more timely, reduces therapy interruption, reduced trauma, reduced risk of complications, and decreased costs
Providers, IR, Vascular Access Team, Hospital Leadership/Nursing Leadership, QI Department
  • Treatment type varies depending on the type of catheter occlusion – mechanical, chemical, or thrombotic
Providers, IR, Vascular Access Team, Hospital Leadership/Nursing Leadership, QI Department
​Resources/Tools
Articles/References
​Occlusion Management Guideline for Central Venous Access Devices (CVADs). Vascular Access:  Journal of the Canadian Vascular Access Association 2013
​Pittiruti M, et al. Evidence-based criteria for the choice and the  clinical use of the most appropriate lock solutions for central venous catheters (excluding dialysis catheters):  a GAVeCeLT consensus. 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 5 Validation - Early Identification of Catheter Occlusion and Treatment
  • 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.

​Step 6

Line Necessity/Removal 
Element
Key Institutional Partners
  • Daily audits of lines to determine clinical necessity of the device
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership, QI Department
  • Rounds should be multi-disciplinary, including physician and nursing leadership at the unit-level whenever possible
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership, QI Department
  • If a line has not been used for >24 hours - query physician regarding PICC necessity
    • De-escalate devices to peripheral whenever possible
    • Daily labs are not an indication for a central venous catheter or a PICC unless the frequency of lab draws is >3 times per da
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership, QI Department
  • If a line has not been used >48 hours, it should be considered idle – query physician regarding PICC removal
​Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership, QI Department
  • PICCs or CVCs that are placed in the ICU setting should be reviewed prior to patient transitioning out of the ICU
    • If not necessary, remove and secure peripheral access
    • If necessary, determine and document date or conditions of removal and ensure process for removal is in place
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership, QI Department
​Resources/Tools
Articles/References
​ ​Xiong Z, et al. Interventions to reduce unnecessary central venous catheter use to prevent central line-associated blood stream infections in adults:  A systematic review. Infection Control & Hospital Epidemiology 2018
  • Interventions aimed at improving CVC appropriateness, assessment, and prompt device removal significantly reduce CLABSI rates. Analysis of secondary outcomes showed a decrease in catheter occlusion
McDonald EG, & Lee, TC. Venous catheter use in medical inpatients through regular physician audits using an online tool. JAMA Internal Medicine 2015
  • Use of an online audit tool by Physicians focused on re-evaluating CVC appropriateness resulted in a 46.6% reduction in use of CVCs 
Aufricht G, et al. Analysis of central venous catheter utilization at a quaternary care hospital. Baylor University Medical Center Proceedings 2019
  • Audit and feedback regarding appropriateness of central lines resulted in a decrease of 65% of central venous catheters that were not clinically indicated
Lederle FA, et al. The idle intravenous catheter. Annals of  Internal Medicine 1992 
  • Twenty percent of all patient-days of IV catheter use were idle. Efforts should focus on reducing unnecessary use
Parenti CM, et al. Reduction of unnecessary intravenous catheter use. Internal medicine house staff participate in a successful quality improvement project. Archives of Internal Medicine 1994 
  • Idle IV catheter episodes decreased significantly after a house staff-led intervention. House staff proved critical to successful quality improvement and should be further included to improve patient care and enhance education of quality improvement processes
Validation Survey
Occlusion Step 6 Validation - Line Necessity and Removal
  • 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.

Step 7 (only if Catheter Occlusion Rates Remain High)

Consider auditing catheter tip location if occlusion rates remain high
Element
Key Institutional Partners
  • Perform X-Rays to examine catheter tip
Providers, IR, Quality Department
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
Early prevention of occlusion via tPA prophylaxis
Element
Key Institutional Partners
  • If occlusion rates do not decrease with the steps above, early and aggressive prophylaxis of occlusion with tPA products is recommended
    • Catheter with sluggish, slow or poor flow -> tPA prophylaxis
    • Catheter lumen not aspirating but flushing well -> tPA prophylaxis
    • If tPA is used as a prophylaxis measure, contact the coordinating center
Providers, Quality Department, Administration
  • Because tPA is expensive, it may be best to target prophylaxis of occlusion in patients at high risk of this event (ICU, TPN or chemotherapy patients) – use the CLOT tool to determine where events are occurring to consider this possibility (CLOT - Catheter flush, Lumens, Optimal access, Tip)
Providers, Quality Department, Administration
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