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Original Research: Neonatal Peripherally Inserted Central Catheter Practices and Providers

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Donna Dowling, PhD, RN ❍ Section Editor

Original Research

Neonatal Peripherally Inserted Central


Catheter Practices and Providers
Results From the Neonatal PICC1 Survey
Elizabeth Sharpe, DNP, APRN, NNP-BC, VA-BC; Latoya Kuhn, MPH; David Ratz, MS; Sarah L. Krein, PhD;
Vineet Chopra, MD, MSc

ABSTRACT
Background: Neonatal intensive care units (NICUs) commonly utilize peripherally inserted central catheters (PICCs) to
provide nutrition and long-term medications to premature and full-term infants. However, little is known about PICC
practices in these settings.
Purpose: To assess PICC practices, policies, and providers in NICUs.
Methods: The Neonatal PICC1 Survey was conducted through the use of the electronic mailing list of a national neona-
tal professional organization’s electronic membership community. Questions addressed PICC-related policies, monitor-
ing, practices, and providers. Descriptive statistics were used to assess results.
Results: Of the 156 respondents accessing the survey, 115 (73.7%) indicated that they placed PICCs as part of their
daily occupation. Of these, 110 responded to at least one question (70.5%) and were included in the study. Reported use
of evidence-based practices by NICU providers varied. For example, routine use of maximum sterile barriers was reported
by 90.4% of respondents; however, the use of chlorhexidine gluconate for skin disinfection was reported only by 49.4%
of respondents. A majority of respondents indicated that trained PICC nurses were largely responsible for routine PICC
dressing changes (61.0%). Normal saline was reported as the most frequently used flushing solution (46.3%). The most
common PICC-related complications in neonates were catheter migration and occlusion.
Implications for Practice: Variable practices, including the use of chlorhexidine-based solutions for skin disinfection and
inconsistent flushing, exist. There is a need for development of consistent monitoring to improve patient outcomes.
Implications for Research: Future research should include exploration of specific PICC practices, associated conditions,
and outcomes.
Key Words: catheter migration, central venous catheter, flushing, neonate, NICU, peripherally inserted central catheter,
PICC, team

BACKGROUND AND SIGNIFICANCE neonatal providers performing this function.3 More


Neonatal intensive care units (NICUs) routinely uti- needs to be learned about PICC practices and those
lize peripherally inserted central catheters (PICCs) to inserting and caring for PICCs in neonates. A better
provide nutrition and long-term medications to pre- understanding of their background and challenges
mature and full-term infants. While there has been can identify key areas for quality improvement and
much growth in understanding PICC practices and for optimizing outcomes for this special
outcomes in adults, less has been learned in pediatric population.
and neonatal populations.1,2 This leaves knowledge
gaps regarding practice for those who are the small- Literature Review
est and most vulnerable. Trained vascular access There is ongoing interest surrounding the domain of
clinicians are most responsible for PICC insertion in neonatal PICCs. Given challenges of performing
the adult population, yet little is known about clinical trials in neonates, surveys provide invaluable
information about the state of practice. A number of
Author Affiliations: The School of Nursing, University of Alabama at
surveys have resulted from interest in this specialized
Birmingham (Dr Sharpe); The Division of General Medicine, University area of neonatal vascular access.4-6 An early national
of Michigan Health System, Ann Arbor (Drs Krein and Chopra); and survey of nurses focused on common maintenance
Center for Clinical Management Research and Patient Safety
Enhancement Program, VA Ann Arbor Healthcare System, Ann Arbor, practices and catheter-related sepsis criteria found
Michigan (Ms Kuhn, Mr Ratz, and Drs Krein and Chopra). that the use of barrier precautions varied consider-
Elizabeth Sharpe is a speaker for Argon Medical Devices and Salveo ably and povidone–iodine was the most common
Healthcare, has consulted for C. R. Bard, and is on the Advisory Board
for IV Watch. No conflicts of interest are declared for all coauthors.
agent used for skin preparation.4 Similarly, a survey
Correspondence: Elizabeth Sharpe, DNP, APRN, NNP-BC, VA-BC,
of neonatologists in Japan examined acceptable
University of Alabama at Birmingham School of Nursing, NB406, 1720 catheter tip locations for PICC use, complications,
2nd Ave South, Birmingham, AL 35294 (elsharpe@uab.edu). and informed consent, and reported that acceptable
Copyright © 2017 by The National Association of Neonatal Nurses catheter tip locations varied greatly, pericardial effu-
DOI: 10.1097/ANC.0000000000000376 sion was rare, and most did not obtain informed

Advances in Neonatal Care • Vol. 00, No. 00 • pp. 1-13 1

Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
2 Sharpe et al

consent.6 The most recent national survey of neona- practitioner, items relevant to the context of neona-
tal PICC practices exploring multiple aspects of tal intensive care practice (eg, skin disinfection, neo-
care, including insertion, maintenance, providers, natal techniques). To preserve the integrity of the
training, assessment, and radiographic monitoring, original PICC1 instrument and ensure that compari-
revealed wide variation in numerous practices.5 sons between providers could be made, extensive
Ongoing dialogue in the electronic community of alterations were not possible. However, these were
myNANN frequently addresses and speaks to con- acknowledged within the study team before admin-
cerns regarding PICC use and outcomes. MyNANN istering the Neonatal PICC1 survey.
is the community forum for the National Associa- Participation for the Neonatal PICC1 survey was
tion of Neonatal Nurses (www.nann.org), which solicited through open invitation through the elec-
represents more than 7000 neonatal nurses primar- tronic mailing list of a national neonatal professional
ily in the United States and North America. Mem- organization’s online membership community in June
bers frequently post questions and responses sur- 2015. An electronic link was provided for partici-
rounding PICCs and PICC teams. Although required pants to complete the instrument. Reminders were
for advancing practice, knowledge about how to posted in the same online community at 2 weeks, 4
appropriately insert, care, and manage PICCs in weeks, and 5 weeks. The survey link remained active
neonates is limited. To date, few surveys have exam- for 6 weeks, concluding in July 2015.
ined practices and use of contemporary technolo-
gies, which continue to evolve, when it comes to Statistical Analysis
neonates. None have focused on experience or work Descriptive statistics (percentage, proportion) were
setting of providers that place PICCs in neonates. To used to tabulate the results. Data were assessed and
bridge these gaps, we conducted the neonatal PICC1 summarized according to predefined categories,
survey aiming to better understand these aspects in including demographics, hospital-level characteristics,
this unique population. and provider practices. Respondents were not required
to answer all questions; therefore, the response rate for
What This Study Adds individual questions will vary on the basis of the num-
ber of respondents who answered each question.
• Catheter migration may be more common than infec-
tion as a PICC-related complication. Because some questions allowed for multiple responses
• Systems need to be developed to gather and produce
(eg, provider categorization or preferences), responses
meaningful data related to neonatal PICCs and patient to some questions total more than 100%. All statistical
outcomes. analyses were conducted using Stata 13 MP/SE
• Neonatal providers are using less heparin for flushing (StataCorp, College Station, Texas).
for increased patient safety.
Ethical and Regulatory Oversight
Because the PICC1 survey-based study sought to
METHODS describe existing practice and did not seek to collect
any individual or unit-specific identifiable informa-
tion, the project received a “Not Regulated” status
Study Setting and Participants by the institution’s institutional review board
The Neonatal PICC1 survey was administered (HUM00088351).
through electronic invitation to neonatal nurses or
nurse practitioners who are members of the RESULTS
National Association of Neonatal Nurses. Respon-
dents who opened the invitation were eligible to
participate if placing PICCs was part of their daily Demographics
occupation. A total of 156 individuals responded to the survey
invitation. Of these, 115 qualified to participate
Development and Validation of the Survey because they indicated they placed PICCs as part of
The PICC1 survey instrument was originally admin- their daily practice. Of the 115 qualifying to partici-
istered to adult vascular access specialists through pate, 110 responded to at least 1 question (response
the Association for Vascular Access and the Infusion rate: 70.5%) and were included in the study. Respon-
Nursing Society.7 To gain insight into the neonatal dents represented North American territories, includ-
setting, the survey instrument was modified to incor- ing 30 territories from continental United States and
porate information, evidence, and questions that Canada. Experience level among respondents was
pertained to neonatal providers and practices. Mod- variable: approximately 50% reported inserting
ifications for neonates included substitution of PICCs for 10 years or more, 34% reported that they
neonatal-specific terms (eg, the NICU or unit instead had placed 100 to 500 PICCs while 22% reported
of facility) and, in consultation with a neonatal having placed 500 or more PICCs (Table 1).

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Neonatal Peripherally Inserted Central Catheter Practices and Providers 3

TABLE 1. General Characteristics and Perceived Relationships of Respondents


Which of the following best describes you? N (%) N = 76
Vascular access nurse (or specially trained PICC nurse) 30 (39.5%)
Mid-level provider (eg, physician assistant or advance practice nurse) 40 (52.6%)
Other 6 (7.9%)
How many vascular nurses are on your team? N (%) N = 110
<10 59 (53.6%)

≥10 35 (31.8%)
Unknown/not applicable 16 (14.5%)
How many PICCs have you placed in your career? N (%) N = 76
<500 59 (77.6%)

≥500 17 (22.4%)
How many years have you been inserting PICCs? N (%) N = 76
≤10 y 38 (50%)

>10 y 38 (50%)
Do you currently have VA-BC or CRNI vascular access qualifications? N (%) N = 76
Yes 2 (2.6%)
No 74 (97.4%)
Are you the vascular access lead nurse for your facility or organization? N (%) N = 76
Yes 18 (23.7%)
No 58 (76.3%)
How would you rank the overall support (eg, staffing, financial, and political) your vascular N = 104
access service receives from hospital leadership? N (%)
Very good or excellent 50 (48.1%)
Fair or good 48 (46.2%)
Poor 6 (5.8%)
How would you describe your relationship with physicians in your unit when it comes to N = 104
communicating recommendations or management of PICCs? N (%)
Very good 71 (68.3%)
Good 28 (26.9%)
Fair 5 (4.8%)
How would you describe your relationship with bedside nurses in your unit when it comes to N = 104
communicating recommendations or management of PICCs? N (%)
Very good 67 (64.4%)
Fair or good 36 (34.6%)
Poor 1 (1.0%)
Abbreviations: CRNI, certified registered nurse in infusion; PICC, peripherally inserted central catheter; VA-BC, vascular access-board
certified; y, years.

PICC Inserter Characteristics of specially trained PICC nurses in individual units


Providers inserting PICCs included vascular access varied, the majority reported that there were fewer
nurses (53.6%), neonatal hospitalists, neonatal than 10 such nurses (53.6%) in their unit. The
nurse practitioners or physician’s assistants (63.6%), majority of respondents described themselves as
and interventional radiologists (14.5%). In addition, advanced practice nurses (52.6%) or specially
some respondents specifically identified as neonatal trained NICU PICC nurses (39.5%). Nearly a quar-
nurse practitioners (14.5%). While the total number ter (23.7%) of respondents identified as being the

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Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
4 Sharpe et al

vascular access lead nurse (eg, PICC team leader) for Maintenance and Management of PICC
their unit. Only 2 respondents (2.6%) reported Complications
holding current vascular access certification by the Dressing changes were reported as being under the
Vascular Access Certification Corporation (eg, purview of specially trained NICU PICC nurses by
Vascular Access–Board Certified, VA-BC) or Infu- 61.0% of respondents. Similarly, 67.1% stated that
sion Nurses Society (eg, certified registered nurse in they did not use securement devices (eg, Statlock
infusion) (Table 1). [Bard Medical, Covington, GA], Grip-Lok [Zefon
International, Inc., Ocala, FL]). The most commonly
Hospital/Facility Characteristics reported needleless connector used was a neutral
Respondents reported working in not-for-profit hospi- valve connector (32.5%) or positive displacement
tals (59.2%), academic medical centers (32.9%), and connector (30.0%). Frequency of needleless connec-
for-profit hospitals (7.9%). The majority of respon- tor change varied, but was most commonly reported
dents (59%) reported working in facilities that had at as being exchanged either every 72 hours (27.5%) or
least 250 hospital beds and fewer than 40 NICU beds every 24 hours (23.8%) (Table 3).
(58.7%). Facility characteristics varied among those The majority of PICC inserters (85.4%) reported
surveyed: 105 (95.5%) reported having hospitalists in that bedside nurses were primarily responsible for
their facility and 58 and 56 (52.7% and 50.9%) adherence to a flushing protocol. Most (48.8%)
reported an affiliation with a medical school or nurs- described targeted flushing practices (flushing
ing school, respectively. Most reported that their facili- lumens that were not being actively used or only
ties tracked both numbers of PICCs placed (82.7%) used for blood draws) with a slow flushing tech-
and catheter dwell times (88.2%). The electronic med- nique. The most commonly reported volume of flush
ical record system was most often utilized to perform was no more than 2 to 3 mL (92.7%). Normal saline
these functions (47.8%), followed by user-maintained was most often used as the flushing solution (46.3%).
documents (42.4%). The majority of respondents esti- The reported interval between flushing ranged from
mated the number of PICCs placed monthly in their every 8 hours to once every 24 hours, with no single
units as fewer than 25 (79.8%) (Table 2). interval being most prevalent (Table 3; Figure 1).
When catheter occlusion was suspected, the
PICC Indications and Insertion Practices majority (59.5%) reported the use of tissue plasmin-
The 2 most commonly reported indications for neo- ogen activator. Although responses were low,
nates to receive PICCs were total parenteral nutri- respondents were more inclined to remove the device
tion and difficult peripheral venous access. During and consider replacement at a new site when cathe-
insertion, 90.4% of respondents reported the use of ter migration more than 2 cm was encountered
all 5 maximum sterile barrier precautions including (8.9%). A third of respondents (32.9%) indicated
sterile gloves, gown, cap, mask, and full body drapes. that they would discontinue the PICC for any sign of
A total of 83.3% of PICC inserters reported rou- phlebitis; 27.8% reported that they would also pro-
tinely receiving assistance from a vascular access vide supportive measures such as warm compresses
nurse when placing the PICC. Only 41 (49.4%) and analgesics (Table 4).
respondents stated that they used chlorhexidine- With respect to complications, respondents indi-
containing solutions for skin disinfection prior to cated that catheter migration was the most com-
PICC insertion. Similarly, only 2 respondents (2.4%) monly encountered PICC complication (47.2%),
stated that they used ultrasound to locate a suitable followed by catheter occlusion (13.9%), coiling/
vein for PICC insertion. Most (82.9%) reported rou- kinking after insertion (12.5%), phlebitis (9.7%),
tinely trimming PICCs to length prior to insertion and central line–associated bloodstream infection
with more than half (52.9%) utilizing a specialized (CLABSI) (9.7%) (Table 4; Figure 2).
trimming device for this purpose (Table 3).
Neonatal PICC Inserter Views Regarding
PICC Policies and Monitoring Schema PICC Use
The majority of those surveyed reported that written With respect to the appropriateness of PICC place-
policies for PICC insertion (89.4%) and PICC care ment, the majority of those surveyed (92.1%) stated
and maintenance (97.1%) existed in their units. that less than 5% of PICCs placed in neonates were,
Most respondents (81.3%) also reported having a in their opinion, inappropriate or avoidable (Table 4).
written process for daily review of PICC necessity. Nearly half of all respondents (48.1%) described
Of those with written processes, this included a mul- support from hospital leadership as very good or
tidisciplinary review (53.8%) or a physician-driven excellent; however, a small number reported this as
review (50.8%). Only 17.7% reported that vascular poor (5.8%). Relationships between physicians and
access nurses were empowered to discontinue PICCs bedside nurses when communicating recommenda-
that were not in use without physician authorization tions regarding PICCs were most often described as
(Table 2). being very good (68.3% and 64.4%, respectively).

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Neonatal Peripherally Inserted Central Catheter Practices and Providers 5

TABLE 2. Facility Characteristics


Which of the following best describes your primary work location? N (%) N = 76
Academic medical center 25 (32.9%)
For-profit community-based hospital 6 (7.9%)
Not-for-profit community-based hospital 45 (59.2%)
Number of hospital beds in your primary work location N (%) N = 78
<250 32 (41.0%)

≥250 46 (59.0%)
Number of neonatal intensive care unit beds in your primary work location N (%) N = 109
<40 64 (58.7%)

≥40 45 (41.3%)
Does your facility have hospitalists? N (%) N = 110
Yes 105 (95.5%)
No 3 (2.7%)
Unknown/not applicable 2 (1.8%)
Is your facility affiliated with a medical school? N (%) N = 110
Yes 58 (52.7%)
No 51 (46.4%)
Unknown/not applicable 1 (0.9%)
Is your facility affiliated with a nursing school? N (%) N = 110
Yes 56 (50.9%)
No 49 (44.5%)
Unknown/not applicable 5 (4.5%)
Does your facility track the number of PICCs placed each month? N (%) N = 110
Yes 91 (82.7%)
No 10 (9.1%)
Unknown 9 (8.2%)
How many PICCs do you think your unit inserts each month? N (%) N = 104
<25 83 (79.8%)
25-49 18 (17.3%)
50-100 1 (1.0%)
>100 2 (1.9%)
Does your facility track the duration or dwell time of PICCs (number of days)? N (%) N = 110
Yes 97 (88.2%)
No 7 (6.4%)
Unknown 6 (5.4%)
How does your unit track the duration of PICCs? N (%) N = 92
Through the electronic medical record system 44 (47.8%)
Manually through user-maintained documents (eg, excel spreadsheets) 39 (42.4%)
Through a module outside the electronic medical record system (eg, billing data) 2 (2.2%)
Unknown/other 7 (7.6%)
(continues)

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6 Sharpe et al

TABLE 2. Facility Characteristics, Continued


Does your unit have a written policy regarding standard PICC insertion practices? N (%) N = 104
Yes 93 (89.4%)
No 9 (8.7%)
Unknown 2 (1.9%)
Does your unit have a written policy regarding standard PICC care and maintenance? N (%) N = 104
Yes 101 (97.1%)
No 3 (2.9%)
Does your unit have a written medical or nursing process to review the necessity of N = 80
PICCs on a daily basis? N (%)
Yes 65 (81.3%)
No 12 (15.0%)
Unknown 3 (3.8%)
Which of the following best describes this written medical or nursing process (select all N = 65
that apply)? N (%)
Daily multidisciplinary review 35 (53.8%)
Daily physician review 33 (50.8%)
Daily bedside nurse review 21 (32.3%)
Daily vascular access nursing review 9 (13.8%)
Automated electronic systems to review 6 (9.2%)
Daily infectious diseases or infection preventionist review 4 (6.2%)
Daily pharmacist review 3 (4.6%)
Other 1 (1.5%)
Are vascular access nurses empowered to remove PICCs that are idle or clinically N = 79
unnecessary without physician authorization? N (%)
Yes 14 (17.7%)
No 65 (82.3%)
Abbreviation: PICC, peripherally inserted central catheter.

DISCUSSION In addition, we found that catheter migration was


reported as the most common PICC-related
This study is the latest to examine neonatal PICC complication—trumping infectious causes, occlu-
practices in the United States and the first to view the sion, and other mechanical issues. This finding is
environment of care by exploring policies and pro- important as it suggests enhanced focus on training
viders’ perceptions surrounding organizational sup- and securement for neonates and infants is impor-
port. We found that certain evidence-based practices tant. Catheter migration internally or externally can
have gained traction. For instance, the use of maxi- create treacherous conditions imperiling the small
mal sterile barriers when inserting PICCs in neonates baby. That mechanical complications have come to
as a CLABSI-preventive strategy appears common. the forefront in this study suggests that with effec-
Similarly, the use of normal saline rather than hepa- tively implemented infection preventive strategies in
rin to maintain PICCs is common. However, we also place, other complications are receiving greater cog-
found that some evidence-recommended practices nizance. Noteworthy is that most did not utilize a
are lacking. For instance, the use of chlorhexidine securement device. This could be due to the non-
for skin antisepsis was reported as low despite evi- availability of an engineered stabilization device spe-
dence of benefit. Similarly, there was little use of cific for each PICC, and the challenge of achieving
ultrasound despite recommendations for its use as a adequate contact area on the small baby’s limited
standard of care in adult and pediatric populations.8 and fragile skin surface. Alternatively, catheter
These data suggest improvement in practices that migration may have been previously overlooked or
might be important in enhancing patient safety. underrecognized as a complication.9 Evaluation

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Neonatal Peripherally Inserted Central Catheter Practices and Providers 7

TABLE 3. Reported Practices of Respondents


Routinely uses all five sterile barriers when placing a PICC (sterile gloves, gown, cap, mask, and N = 83
full-body drapes), N (%)
Yes 75 (90.4%)
No 8 (9.6%)
Do other vascular access nurses routinely assist you when you insert a PICC? N (%) N = 84
Yes 70 (83.3%)
No 14 (16.7%)
Which of the following products do you routinely use to disinfect the patients skin prior to PICC N = 83
insertion? N (%)
Chlorhexidine gluconate with or without alcohol 41 (49.4%)
Other 42 (50.6%)
Do you use ultrasound to find a suitable vein prior to PICC insertion? N (%) N = 83
Yes 2 (2.4%)
No 81 (97.6%)
Do you routinely trim the PICC to length? N (%) N = 82
Yes 68 (82.9%)
No 14 (17.1%)
What instrument do you use to trim the PICC? N (%) N = 68
Specialized trimming tool 36 (52.9%)
Scissors 32 (47.1%)
Who is primarily responsible for administering and adhering to a flushing protocol at your N = 82
facility? N (%)
Bedside nurses 70 (85.4%)
Vascular access nurses (or specially trained PICC nurses) 4 (4.9%)
Other 8 (9.8%)
Which of the following best describes your recommended PICC flushing protocol? N (%) N = 82
Nontargeted flushing (flush all lumens daily, irrespective of use) 9 (11.0%)
Targeted flushing (flush lumens based on use or nonuse) 40 (48.8%)
Other 33 (40.2%)
Which of the following best describes your flushing technique? N (%) N = 82
Slow flushes 40 (48.8%)
Pulsatile (stop and go) flushing 32 (39%)
Rapid push flushes 1 (1.2%)
Other
How many mL’s do you typically use when you flush each lumen of a PICC? N (%) N = 82
No more than 2-3 mL 76 (92.7%)
More than 3 but less than 5 mL 4 (4.9%)
At least 5-10 mL 1 (1.2%)
More than 10 mL 1 (1.2%)
(continues)

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8 Sharpe et al

TABLE 3. Reported Practices of Respondents, Continued


Which of the following best describes the frequency at which you recommend flushes of the N = 82
PICC? N (%)
Before and after each use of the PICC 18 (22.0%)
Daily 2 (2.4%)
Every 12 h 11 (13.4%)
Every 8 h 16 (19.5%)
Other/unknown 35 (42.7%)
Which of the following agents are most often used for flushing PICCs at your facility? N (%) N = 82
Normal-saline only 38 (46.3%)
Heparin only 16 (19.5%)
Both heparin and normal saline flushes (based on device or patient characteristics) 23 (28.0%)
Other 5 (6.1%)
Who is most responsible for performing dressing changes for PICCs? N (%) N = 82
Vascular access nurses (or specially trained PICC nurse) 50 (61.0%)
Bedside nurses 11 (13.4%)
Other 21 (25.6%)
Does your facility use a securement device to prevent PICC migration? N (%) N = 82
Yes 27 (32.9%)
No 55 (67.1%)
Which of the following securement devices does your facility use? N (%) N = 80
Neutral valve connectors 26 (32.5%)
Positive displacement connectors 24 (30.0%)
Negative displacement connectors 11 (13.8%)
Split septum connectors 8 (10.0%)
Other 11 (13.8%)
How often are needleless connectors typically changed in your unit? N (%) N = 80
Every 24 h 19 (23.8%)
Every 48 h 2 (2.5%)
Every 7 d 8 (10.0%)
Every 72 h 22 (27.5%)
Every 96 h 13 (16.2%)
Other 16 (20.0%)
Abbreviations: d, days; h, hours; PICC, peripherally inserted central catheter.

revealing distal displacement of a PICC could also techniques or awareness of current guidelines for
have been an accepted prerequisite to premature dis- best practice recommendations.12
continuation. Thus, accurate data collection demon- With catheter migration, a serious consequence to
strating the full scale of this problem may not be be feared, trimming is critical as its omission enables
available. Consistent definitions and documentation excess external catheter length, which can poten-
of catheter migration and other complications are tially migrate inward with potentially fatal compli-
needed in determining relevant targets for quality cations.13 Trimming practices appeared largely
improvement. As has been demonstrated, data col- unchanged from earlier findings with a small increase
lection and reporting have impacted CLABSI reduc- in the use of specialized trimming devices.5
tion.10,11 More needs to be learned about the nature, In addition, we observed that providers report
timing, and direction of catheter migration to design overall positive perceptions of organizational sup-
strategies such as consistent training in securement port and teamwork from leadership, physicians, and

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Neonatal Peripherally Inserted Central Catheter Practices and Providers 9

that neonatal providers may be unaware of the exis-


FIGURE 1 tence of a flushing protocol. In addition, daily review
of line necessity prompting catheter removal as soon
as no longer needed may obviate the need to lock the
device.
The need for outcomes data related to PICC prac-
tices either exceeds the current functionality of elec-
tronic medical record systems or has not yet been
effectively addressed and incorporated. The conduct
of randomized controlled trials in our population
remains challenging, though they may yield valuable
information regarding optimal complications-
prevention strategies. Practitioners report efforts to
utilize other manual strategies to collect data points
Reported flushing frequency (n = 82).
to construct big data. With less than half of respon-
dents tracking PICC data and duration through the
electronic medical record system, a need to develop
nurses. This is in contrast to adults where studies systems, add functionality to existing systems, or
suggest that these ties are more variable and subop- train users to track these data is needed. The fact
timal.7 Finally, CLABSI-prevention bundles have that some respondents track NICU’s duration and
evolved into distinct written policies for insertion volume of PICCs manually through user-maintained
and care and maintenance. Processes for daily review documents (electronic spreadsheets or databases)
of PICC necessity are now the norm in the NICU, in illustrates the need for consistent approaches to col-
contrast with earlier reports where less than 10% of lecting data in an era driving toward standardization
units conducted this type of monitoring.5,14 Neona- for enhanced patient safety. Our work identifying
tal providers appear to be judicious in considering this gap is a critical first step in addressing this need.
the intended therapy’s duration, and well in com- Providers and infection preventionists will need
mand of appropriate PICC utilization, in contrast to these capabilities and resources to guide the develop-
what has been found with adult populations.3 These ment and monitoring of new evidence-based initia-
data advance the science of PICC practice in this spe- tives to support future quality improvement work.
cial population in new and important ways. There was little use of ultrasound reported in this
Chlorhexidine gluconate adoption for PICC inser- study. However, ultrasound is the standard of care in
tion was lower than in an earlier study (52.9%), adults and pediatric patients, not in neonates. Find-
which was surprising considering the benefits in ings related to limited ultrasound use are consistent
CLABSI reduction and liberalization of the package with previously reported data, though as capabilities
labeling.5 This may be due to the small sample size of newer technology evolve, this may shift.5 Addi-
of this study. In contrast, more recent work demon- tional barriers to NICU adoption of ultrasound,
strates a dramatic increase in use of chlorhexidine such as capital equipment expense, training, height-
gluconate for disinfection (86%) for multiple proce- ened skill required, and maintaining proficiency
dures in the NICU.15 once acquired, also exist. Although there are bene-
The diversity of flushing practices was notewor- fits of ultrasound beyond vessel location, this tech-
thy; however, the majority reporting normal saline nology has yet to be fully embraced by neonatal pro-
as the flushing solution demonstrates a shift from an viders and more research is needed to realize this
earlier survey where neonatal PICCs were seldom possibility.21
locked and heparin amounts varied.5 This may rep- That respondents reported specially trained PICC
resent adoption of emerging findings describing suc- teams assume the responsibility for a critically impor-
cess with solely normal saline in peripheral intrave- tant procedure such as PICC dressing change demon-
nous devices, guiding limiting heparin use.16 A recent strates alignment with recognition of teams effec-
systematic review failed to conclude superiority of tively reducing mistakes to support patient safety.22 A
normal saline or heparin in flushing central venous significant number of respondents indicated that they
catheters in infants and the risk of heparin-induced were specially trained NICU PICC nurses working in
thrombocytopenia bears consideration.17-19 a team. This area targeting vascular access presents a
We were surprised by the wide variation in flush- ripe opportunity for formalization as an entity for
ing frequency intervals considering the availability recognition both within and external to the institu-
of published flushing protocols.20 Lack of consis- tion. NICU-based providers (specially trained nurses,
tency in flushing protocols can be attributed to neo- nurse practitioners, and physicians) dominated PICC
natal PICCs primarily being used for continuous insertion in neonates and seldom ventured beyond
infusion, and with less prevalent need to lock, or this population. Defining which of these core

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Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
10 Sharpe et al

TABLE 4. Reported Approach to Complications and Views Regarding PICC Practice


Most commonly encountered PICC-related complication N = 72
Catheter migration 34 (47.2%)
Catheter occlusion 10 (13.9%)
Coiling or kinking after insertion 9 (12.5%)
Phlebitis over insertion site 7 (9.7%)
Central line–associated bloodstream infection 7 (9.7%)
DVT 4 (5.6%)
Catheter fracture or embolization 1 (1.4%)
What is your preferred approach to treating catheter occlusion? N (%) N = 79
Use a tissue plasminogen activator product 47 (59.5%)
Other 32 (40.5%)
What is your preferred approach to treating a PICC that has migrated out <2 cm? N (%) N = 79
Obtain a chest x-ray film to verify tip position 72 (91.1%)
Remove device and consider replacement at a new site 3 (3.8%)
Perform a complete catheter exchange over a guide-wire if possible 2 (2.5%)
Advance device back into vein 1 (1.3%)
Other 1 (1.3%)
What is your preferred approach to treating a PICC that has migrated out >2 cm? N (%) N = 79
Obtain a chest x-ray film to verify tip position 63 (79.7%)
Remove device and consider replacement at a new site 7 (8.9%)
Perform a catheter exchange over a guide wire if possible 5 (6.3%)
Advance device back into vein after cleaning with alcohol or chlorhexidine 1 (1.3%)
Other 3 (3.8%)
What is your preferred approach when you suspect a patient has PICC-associated phlebitis? N (%) N = 79
Supportive measures 22 (27.8%)
Discuss physician 28 (35.4%)
Discuss nurse 1 (1.3%)
Remove PICC 26 (32.9%)
Other 2 (2.5%)
What is your preferred approach when you suspect a patient has a PICC-related DVT? N (%) N = 79
Notify all caregivers (eg, physician, bedside nurse, resident, or student) 13 (16.5%)
Notify bedside nurse and physician-in-charge 45 (57.0%)
Other 21 (26.6%)
Reports suggest that PICCs are unnecessarily removed when a patient develops a fever. In N = 76
your experience, what percentage of PICCs may have been removed in this manner? N (%)
<10% 10 (13.2%)

≥10% 66 (86.8%)
Reports suggest that PICCs are sometimes placed for inappropriate reasons and could be N = 76
avoided. In your experience, what percentage of PICCs are inappropriate or could have been
avoided? N (%)
<5% 70 (92.1%)
5%-9% 6 (7.9%)
Abbreviations: DVT, deep vein thrombosis; PICC, peripherally inserted central catheter.

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Neonatal Peripherally Inserted Central Catheter Practices and Providers 11

FIGURE 2

Most commonly reported PICC-related complications (n = 72). DVT indicates


deep vein thrombosis; PICC, peripherally inserted central catheter.

personnel comprise a team will be important in pro- Considering the short term of activation, this survey
ducing meaningful outcomes-related data. Dedicated yielded robust state representation (30 states) com-
teams providing advanced knowledge have been rec- pared with a previous national survey administered
ognized as key in preventing complications, have over a longer period (43 states; raw unpublished
been demonstrated to be beneficial in the NICU, and data, Sharpe, 2013).
are recommended to enhance patient safety in health-
care.8,23,24 Respondents reported variable amounts of Strengths
experience and this is interpreted as an advantage in The Neonatal PICC1 survey assessed the practices
developing the succession plan for a team. Although and perceptions of neonatal nurses who place PICCs,
few providers reported holding certification in vascu- and is the first to be successfully conducted entirely
lar access, this finding was not unexpected consider- within an electronic community framework of neona-
ing most NICU nurses who pursue certification tal providers in the United States. This study provides
choose a recommended comprehensive credential valuable insight into the current state of PICC prac-
such as neonatal intensive care nursing or critical care tices in neonates and demonstrates the power of utiliz-
nursing certification.25 ing current electronic technology to capture a dynamic
snapshot. This study is also among the first to identify
Limitations catheter migration as the most common PICC-related
The target population was members of a national complication in neonates, suggesting that there is a
organization who elected to participate in an elec- need for improved strategies for catheter securement
tronic mailing list online community. Although the and consistent training. Another key finding was that
overwhelming majority of the membership joins the data collection for PICC duration is being accom-
electronic community, this subset resulted in a plished through multiple modalities. This highlights
smaller than desired sample size. It is difficult to the need for either more user-friendly functionality in
quantify the subset population of members whose existing systems or the development of new systems.
duties and interests comprise or include PICC inser- The heterogeneity of providers’ backgrounds can pro-
tion. While the results may not be fully representa- vide a strong foundation for future collaborative care.
tive of the overall membership, those who were Positive perceptions of organizational support are
motivated to participate represented their own prac- encouraging moving forward in the current complex
tices and opinions. Voluntary self-selection may landscape of healthcare as leadership support is asso-
have elevated expression of certain practices accord- ciated with patient safety climates with decreased risk
ing to participants’ biases. The length of the survey of hospital-acquired harm.26
may have contributed to premature terminal fatigue The results highlighted key differences in the
as completion required stamina and commitment approach to vascular access between the neonatal
without interruption. Movement to exit the survey and adult populations. The use of both ultrasound
was noted particularly at a question about fever, and chlorhexidine gluconate is universally accepted
which is uncommon in neonates. The electronic in the adult population. Neonatal providers deemed
method of administration may have eliminated par- PICC utilization overwhelmingly appropriate for
ticipants who may have preferred to complete the patient needs in contrast to adult providers (92.1%
survey in more traditional paper-based format. vs 36.4%). Neonatal providers came from more

Advances in Neonatal Care • Vol. 00, No. 00

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12 Sharpe et al

Summary of Recommendations for Practice and Research


What We Know • A collaborative team approach to infusion therapy has been recognized as inte-
gral to successful delivery of care.
• Provision of vascular access for neonates has traditionally been performed by
dedicated NICU-based providers from various backgrounds, including neonatolo-
gists, nurse practitioners, and specially trained nurses.
• Diversity in practice has been the norm for neonatal PICCs.
What needs to be studied • More needs to be learned about how best to prepare, support, and elevate
NICU-based PICC teams to produce positive outcomes and prevent PICC-related
complications.
• There is a need for refinement of best practices for flushing, related to the use of
normal saline or heparin, as no one solution or interval has yet been identified as
optimal in neonates.
• There is an identified need for comprehensive systems to capture and produce
outcomes-based data.
What we can do today • Formalize implementation, training, and ongoing support of collaborative inter-
professional NICU-based PICC teams.
• Develop systems to monitor patient outcomes data related to PICC teams in the
NICU.
• Collaboratively develop and implement comprehensive evidence-based bundles
directed at minimizing PICC-related complications: catheter migration, occlusion,
phlebitis, and central line–associated bloodstream infection in neonates.

heterogeneous backgrounds than adult providers. community. Our survey results provide foundational
There were higher reports of using only heparin insight about contemporary PICC practices and pro-
flushes in the more-at-risk neonatal population viders’ perspectives in our national neonatal com-
(19.5% vs 2.1%, adults).7 munity. Essential to progress is the need for effective
data management platforms to identify and guide
CONCLUSIONS the next generation of strategies for improvement.
There is a compelling need to generate evidence that
The Neonatal PICC1 survey provides important demonstrates the superiority of a unified workforce
information that reiterates diversity in practice but in implementing best practices. With the dearth of
also new areas for practice improvement, such as evidence in this population, our results can inform
team formalization, refinement of flushing proce- the development of future research on which to build
dures, minimizing the risk for catheter migration, a community of best practice for our tiny patients.
and accurate data reporting. While the primary
focus of the original PICC1 survey was not directed Acknowledgments
at capturing neonatal data, neonatal-specific modi- This project was funded by an Investigator Initiated
fications achieved unique data. Future iterations of Research Grant from the Blue Cross Blue Shield of Mich-
this instrument have the potential to capture more igan Foundation (Grant Number 2140.II, principal
meaningful neonatal practice and outcomes infor- investigator: Dr Chopra). The funding source played no
mation not only in the United States but globally. role in study design, data acquisition, analysis, or deci-
The decision to utilize a PICC is not without risk.1 sion to report these data. Dr Chopra is supported by a
The continued variability in PICC practices suggests career development award from the Agency of Health-
a need for: care Research and Quality. This work was also sup-
ported by the Department of Veterans Affairs, Health
• Development of systems or additional func- Services Research and Development Service, and
tionality for systems to monitor PICCs and National Center for Patient Safety. Dr. Krein is supported
associated complications with outcomes data by a VA Health Services Research and Development
reporting capability. Research Career Scientist Award (RCS 11-222). The
• Formalization in definition, education, training, views expressed in this article are those of the authors
and functions of specially trained PICC teams. and do not necessarily reflect the position or policy of the
• Collaborative approaches to preventing cathe- Department of Veterans Affairs or the US government.
ter migration and other complications includ-
ing administrative institutional support. References
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