Reduce short term PICC use (e.g., PICC < 5 days) for peripherally compatible therapies
Use the WISE Tool to understand drivers of short-term PICC use
Assess staff knowledge and competency in placing peripheral IV catheters. Lack of skills in placing peripheral IV devices is a key driver of PICC use.
Consider developing a method to identify patients who may have difficult intravenous access.
Consider supervised peripheral IV insertion to ensure staff competency in placing these devices in appropriate sites with appropriate strategies
Consider incorporating vein visualization technology (infra-red viewers) for patients with difficult or poor intravenous access. Visualization technology has been shown to improve success rates, decrease unsuccessful insertion attempts, improve satisfaction and avoid PICC placement
Consider training staff in use of ultrasound technology to obtain access with short or long peripheral intravenous catheters in patients who have difficult venous access
Consider developing a difficult IV Access team to manage patients who are either known to have difficulties with obtaining venous access or where attempts to place peripheral intravenous devices have failed after 2 or more attempts by experienced providers.
Invest in alternatives to PICCs (especially if venous access <14 days is anticipated) including devices such as ultrasound guided peripheral intravenous catheters (USGPIV) and midlines.
Understand and analyze peripheral IV failure rates and identify opportunities to reduce failure rates, maximize dwell times and reduce complications
Consider creating specialized IV teams for difficult IV access to help gain access in patients with poor peripheral veins
Assess rates of accidental catheter dislodgement. If accidental catheter dislodgement is identified as a potential reason for PICC use less than 5 days, the following strategies are recommended:
Assess catheter securement practices
Careful consideration for patients with confusion or acute delirium
Resources & Tools:
HMS site reports (hard copy distributed at collaborative wide meetings and live reports available daily via the HMS data entry system)
Tool that guides data collection/analysis regarding where the PICC was located, indication, who ordered the PICC, and events leading to PICC insertion/removal determine key drivers of short term PICC use.
Chopra V, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of Internal Medicine 2015
Literature reports that venipuncture skills are one of the hardest for novice nurses to master. The DIVA tool is created to help identify patients that will result in difficult IV access. 80% of nurses agree DIVA is a good indicator of IV access difficulty.
A dedicated difficult venous access team in the emergency department reduced the amount of time between physician orders to administration of medication. A dedicated DVA technician is recommended as they are a “concrete solution to threats of patient safety, as well as ED crowding, and [have] the potential to affect both patient- and department-level care.”
Vein visualization as an important tool for patients with decreased vein visibility:
Difficult intravenous pathway increased first attempt success at cannulation by using ultrasound guided peripheral IV insertion by a trained team to access patients with veins that were difficult to visualize and/or palpate.
Dislodgement rates with intravenous catheters are estimated at 1.8-24% events per year. The consequences accidental dislodgement are treatment interruptions, financial costs due to catheter replacement, and patient dissatisfaction. The most common contributing factor of dislodgement is confused patients and catheter tape or securement is loose.