Evaluation of an electrocardiographbased PICC tip verification system Gemma Oliver and Matt Jones
Performing a chest x-ray after insertion of a peripherally inserted central catheter (PICC) is recognised as the gold standard for checking that the tip of the catheter is correctly positioned in the lower third of the superior vena cava at the right atrial junction; however, numerous problems are associated with this practice. A recent technological advancement has been developed that utilises changes in a patient’s electrocardiograph (ECG) recorded from the tip of the PICC as a more reliable method. This evaluation discusses how a vascular access team in a large acute NHS Trust safely and successfully incorporated the use of ECG guidance technology for verification of PICC tip placement into their practice. Key words: Peripherally inserted central catheter ■ Electrocardiographguidance technology ■ Tip placement ■ Accurate verification method
T
he East Kent Hospitals University NHS Foundation Trust’s vascular access team has been established for about three years, and places approximately 1600 peripherally inserted central catheters (PICCs) each year. It is a multi-professional team consisting of four experienced vascular access nurses and anaesthetic consultants. Historically, PICCs were placed by a vascular access team member as a single-handed procedure at the bedside; PICC tip position was checked, postprocedurally, by radiological confirmation.The team all followed the same PICC insertion process, aiming to place the PICC via the basilic vein just above the anti-cubital fossa, and measure the proposed PICC length using a landmark technique. The choice of left or right arm insertion is left to the patient. Once placed, the tip of all central venous catheters, including PICCs, should lie in the lower third of the superior vena cava close to the entrance to the right atrium (Royal College of Nursing (RCN) intravenous (IV) Therapy Forum, 2010; Infusion Nurses Society, 2011). The correct positioning of a PICC is essential to avoid serious complications, such as thrombus, perforations, migrations and arrhythmia (Yap et al, 2006). However, using a landmark technique alone has shown that malpositions of the PICC tip on insertion can occur in as many as 20% of cases (Dionisio et al, 2001). As a result of this high malposition rate, the current recommended practice is to perform a post-procedural chest Gemma Oliver is the Vascular Access and Hospital-at-Home Matron, and Matt Jones is a Consultant Anaesthetist and Vascular Access Lead, East Kent Hospitals University NHS Foundation Trust, Kent Accepted for publication: June 2013
S24
x-ray and confirm the PICC position against anatomical landmarks (Chu et al, 2004; Pittiruti et al, 2008; Sansivero, 2012). However, this procedure is far from ideal because it can add time, cost and radiation exposure implications (Smith et al, 2010); it can also be imprecise and subject to observer variability (Moureau, 2010), as well as then requiring possible PICC repositioning. Local audit data concurred with this evidence. Up to 15% of PICCs inserted within the Trust could require post-procedural adjustment or even reinsertion as a result of being too long, too short, up the jugular vein or inappropriately looped in the venous anatomy (Table 1). There could also be a time delay in between placing the PICC and the post-procedural x-ray being performed, leading to delays in IV treatment. In the past 20 years, there have been successful developments in technology, enabling the central catheter position to be checked using analysis of the patient’s eclectrocardiograph (ECG) rhythms, measured from the tip of the catheter as guidance; this has recently been considered for PICC placement. First described by Hellerstein et al in 1949, changes in the P wave measured from the tip of a central venous catheter can be clearly identified as it passes from the superior vena cava through the cavo-atrial junction and into the right atrium (Figure 1). Using a specialist ECG system, the PICC is attached to lead II of the ECG system via a purpose-built saline adaptor (e.g. Vygocard). A column of saline is then used to transmit the ECG signal to the end of the PICC. The morphology of the P wave, when measured from the catheter tip as it is passes from the superior vena cava through to the right atrium, can be clearly identified (Sansivero, 2012). Using the elevation in the P wave as verification that the central venous catheter is in a correct position has been shown to more frequently result in correct positioning of the catheter tip compared with conventional methods (Pittiruti et al, 2008). In 2011 the first ECG guidance system was introduced to the UK market and given British Standards Institution CE certification (Nautilus®, S.C. Romedex International, Romania).
Literature search In order to plan the proposed implementation of the UK ECG system, a literature review was undertaken to evaluate existing knowledge in relation to the topic. A literature search strategy was considered on how to identify appropriate pertinent research and evidence. The search engines considered appropriate for obtaining evidence relevant to this study included CINAHL, MEDLINE, EMBASE, British nursing index, Cochrane Collaboration and Google Scholar. The key words that were used were echocardiogram (ECG and EKG), peripherally inserted central line (and PICC), central line and chest x-ray. It
© 2013 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
picc verification became evident that there is not a significant amount of literature surrounding the areas being studied. In light of this, and for the purpose of completeness, an incremental approach was also applied and the reference lists from articles obtained via the search engines were reviewed and any missing key literature obtained. The evidence was reviewed and deliberated with regards to the accuracy, efficiency, cost and safety of the procedures.
Table 1. Peripherally inserted central catheter placement within East Kent Hospitals University NHS Foundation Trust from May to October 2011 Total number of PICCs placed with follow-up chest radiograph
597
Placement satisfactory
509 (85%)
Placement unsatisfactory
88 (15%)
– too short
13
– too long
45
Two literature review aims
– looped up the jugular vein
17
The first aim was to review the evidence regarding postprocedural chest x-rays and their efficiency in establishing correct PICC tip position. Current evidence suggests that chest x-rays are at present the recognised method of confirmation of PICC placement (Pittruiti et al, 2008; RCN IV Therapy Forum, 2010; Sansivero, 2012). However, the literature review revealed several criticisms of this procedure. Three main themes were identified: ■■ There can be a time delay between placing the PICC and starting IV treatment while the patient waits for the confirmation x-ray and for it to be reported ■■ Some PICCs will require post-procedural adjustments, resulting in further interventions and x-rays. In some cases this may result in the PICC having to be replaced and a potential delay in commencing IV therapy (Tian et al, 2009) ■■ The accuracy of post-procedure chest x-rays seems questionable, and interpretation is often operator-dependent; for example, Michelle et al (2004) identified that up to 40% of chest x-ray readings following PICC insertion were discrepant. The second aim was to establish the evidence surrounding ECG-guided PICC (and central venous catheter) placement.
– looped in the subclavian/innominate vein
13
PICCs=peripherally inserted central catheters
Figure 1. Changes in P wave measured by electrocardiograph at the tip of the peripherally inserted central catheter can clearly show placement in the right atrium. Original image from Dr Mauro Pittiruti, used courtesy of Vygon UK
© 2013 MA Healthcare Ltd
This search conversely found that all three of the criticisms of post-procedural chest x-rays were cited as advantages of the ECG-guided PICC system, in that:
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
S25
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
There is also little evidence regarding the actual procedure and how complicated it is to perform or build into existing practice.
Pilot
Figure 2. Electrocardiograph-guided placement of a peripherally inserted central catheter ■■ There
is no time delay in starting treatment as the system gives an instant result ■■ There is no post-procedural PICC adjustment required as the system works with live placement results, giving 100% accuracy (Pittiruti et al, 2008, 2012) ■■ The studies performed so far state that it is easy to read and not open to variable interpretation. However, criticisms of the ECG-based approach have also been reported in the literature—for example, that the system is not suitable for everyone (e.g. patients in atrial fibrillation or with pacemakers; Pittiruti et al, 2008), that expensive equipment is required (Tian et al, 2009) and that it requires clinician education (Moureau, 2010). The current UK policy and local policies were also reviewed at this stage in relation to best practice for PICC position confirmation. The major pertinent policies, for example the RCN’s standards for infusion therapy (RCN IV Therapy Forum, 2010) and the Infusion Nurses Society (2011) guidelines, all advocate the use of chest x-ray post-procedure. However, both policies were written before the ECG-guided system was launched in the UK. The evidence behind ECG-guided PICC placement so far appears consistently positive with regard to confirmation of the PICC tip within the cavo-atrial junction. There is strong evidence to support ECG-guided PICC placement from a procedural perspective. However, there are some significant gaps in the evidence; importantly, there are no UK-based studies and there is only one nurse-led study (Moureau, 2010). Corresponding PICC position on X-ray
Surface
Surface ECG
Practical challenges The team places PICCs as a completely single-handed procedure at the bedside, so it was necessary to understand during the pilot whether the system could be incorporated into existing clinical practice. The team found that the following challenges needed to be considered and overcome with the implementation of the ECG system.
Maximal P wave The recommendation is that the PICC tip is left in position where the P wave of the ECG is at maximal height. During the pilot it became apparent that there could be a vast discrepancy in individual patients’ P wave height at maximal position; in some patients this was half the height of the QRS complex and in others it was higher than the QRS complex. In order to guarantee that the maximal height of the P wave had been achieved, a process was developed whereby the PICC was inserted until the P wave showed a negative deflection or started to get smaller in size, indicating placement in the right atrium. The PICC was then pulled back until the negative deflection had disappeared and the maximal P wave achieved.
Figure 3. Electrocardiograph (ECG)-guided placement of the peripherally inserted central catheter (PICC) with radiological confirmation
During the pilot it was assessed whether it was possible for the operator to remain sterile and still work the ECG system single-handedly, and the solution to this seemed to be preparation; the parts of the process where the operator may need to touch the unsterile system were reviewed and solutions found. Groundwork can be done before the sterile part of the process commences—for example, attaching the ECG leads to the patient and lead II that attaches to the end of the PICC put in a convenient, easily reachable location.The ECG system can
© 2013 MA Healthcare Ltd
Intravascular
The ECG system as part of a single-handed, sterile procedure
Intravascular ECG taken from end of PICC
S26
The emerging themes in the literature were important to consider when moving forward and planning the proposed implementation of the system. As a result of the apparent gaps in the literature, it was decided that a pilot study should be performed. The pilot was conducted within the Trust on one site by the authors. The ECG verification system was used on 20 consenting patients with PICCs being placed under ECG control (Figure 2); then a post-procedural chest x-ray was performed and PICC position reviewed. The main aims of the implementation pilot were to establish: ■■ Whether the ECG-guided PICC placement system was reliable and correct ■■ Whether ECG-guided placement could be integrated into existing practice, improve efficiency and enhance patient care The team rapidly became confident with the system, and the pilot showed the tip location of all 20 PICCs to be radiologically in the lower third of the superior vena cava/right atrium junction; an example of this is shown in Figure 3.
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
picc verification also be turned on and prepared at this time. Once the sterile PICC placement procedure was underway, the authors examined and tested a method to see if any of the system that needed to be touched could be done through a sterile gauze barrier, such as connecting the unsterile ECG lead II to the saline adapter and using the system’s touchpad.
Initial PICC length The PICC length was found to be particularly important when using the ECG system; if the PICC length is too short it may not reach the point in the superior vena cava where the P wave morphology starts to change, potentially leading to misleading negative results. It is therefore important not to cut the PICC too short.
Time added to procedure Although there is a small increase in the total procedure time associated with using the ECG-guided system, the team felt it only added a few minutes to the overall procedure time. The time taken to order an x-ray, wait for the results, interpret the results and then act on any misplaced central venous catheters was felt to be far greater.
Getting a good trace Time needs to be spent to ensure that a good ECG trace is obtained from the tip of the PICC, and it was found to be important not to rush the insertion and allow the ECG trace time to settle. This is because any operator movement of the PICC seriously affects the quality of the displayed ECG trace. The patient needs to remain relatively still for this part of the procedure to reduce interference. It is also essential to ensure that the PICC is well flushed to ensure that there is a continuous column of saline within the PICC to enable electrical conductivity from the tip to the electrode. The ECG trace from a valved PICC needs to be taken while continuously gently flushing the PICC to ensure the valve is open and that a continuous column of saline is present from the PICC tip to the ECG lead.
Patients with cardiac history
© 2013 MA Healthcare Ltd
It was necessary to establish if each patient had any known cardiac history before PICC insertion. Additional assessment questions needed to be asked to establish if the patient had any cardiac history, particularly of atrial fibrillation or the presence of a pacemaker (as the ECG system is relatively ineffective on this group of patients). Asking this before laying the sterile insertion trolley and opening the ECG lead (saline adapter) prevents the lead being opened unnecessarily and the costs associated with this. Plans can also be made for a post-procedural x-ray. Although there were changes in practice required, the pilot team felt that the system was relatively easy to use and that it could safely be embedded into clinical practice. Funding and purchase were approved for three systems, and the procedure was rolled out to the rest of the vascular access team.
Rolling out the system In order to embed the procedure into practice it was important to consider the wider implications of this change in practice. The rest of the vascular access team needed to be trained on
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
the ECG system. All members were given individual training by the matron and consultant until they were confident with the new process.They were well supported and encouraged to seek back-up if they had any concerns with individual patients. The vascular access nurses needed to feel confident in this process as they have the individual responsibility for signing off any PICCs they place as correctly sited and fit for use. It was also necessary to educate the rest of the staff in the hospital as to why a post-procedural x-ray was no longer required. The ward staff predominantly seemed happy with the process if the vascular access team were able to take responsibility for confirming PICC position. They were interested in the procedure and there was little resistance to the rolling out of this technology. The Trust’s PICC insertion paperwork was adjusted to reflect the change in practice; the guidelines were also reviewed and rewritten to incorporate the new process, and appropriate competencies developed. The team has now successfully placed over 2000 PICCs under sole ECG guidance, and our findings and data are in line with the growing body of international evidence that supports the use of ECG guidance as an accurate verification method for PICC tip position.
Benefits Since introducing the system there have been numerous benefits found, including: ■■ A release of clinical time—it is no longer necessary to revisit patients to adjust the PICC position, as the ECG system gives real-time, accurate confirmation that the PICC tip is in the correct position at the cavo-atrial junction ■■ The system allows for prompt initiation of infusion therapy and immediate release of the PICC for use. Not needing to wait for x-rays before commencing IV treatment or relying on others to check x-rays has significantly improved patient flow and increased patient satisfaction with the process ■■ There is a significant cost reduction associated with no longer performing chest x-rays. Based on the Trust’s estimated cost of £35 per x-ray and cost of additional equipment being £12 per procedure, this was found to be a saving of £23 per procedure. The initial outlay for three ECG systems meant that there was a saving of approximately £15 500 in the first year. The use of this system in the following years equates to a saving of approximately £38 000 each year for the Trust. This does not take into consideration the cost of any repeat x-rays required if the PICC position is incorrect, or indeed the cost of staff time associated with organising and analysing the repeat radiograph ■■ Elimination of x-ray exposure to patient and clinician—this also opens up the procedure for patients for whom x-rays are
Key points n Correct placement of peripherally inserted central catheters (PICCs) is essential to avoid potential complications n Current practice recommends radiological confirmation of PICC position (chest x-ray); however, there can be problems associated with this practice n An electrocardiograph-guidance system can be safely and costeffectively incorporated into existing PICC placement practice n Immediate confirmation of PICC tip position allows for immediate commencement of intravenous therapy, thus improving patient care
S27
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
not recommended, such as pregnant women.
Keys to success
Summary
The authors identified that there were several keys to implementing this technology successfully: ■■ The full literature review that was performed before introducing the system enabled the team to assess fully the strengths and limitations of the process; this then enabled the implementation to be carefully planned ■■ During the pilot, time was taken to consider how to build the ECG guidance into practice, aiming for minimal disruption to the existing process. This was carefully considered so that the system was seen to enhance practice and improve patient flow ■■ Although there is a learning curve associated with the procedure, all the PICCs in the Trust are placed by a dedicated team so only a core of five staff had to be trained. Once the matron and consultant were trained and confident, the training was then disseminated to the rest of the team members. They were all given individual training and support until they were confident in their practice ■■ The team comprises senior nurses, but is led by a consultant anaesthetist, who is enthusiastic about supporting the senior nurses in developing new skills. This level of clinical leadership has enabled the team to feel supported, and having access to senior clinical guidance and support when necessary has enabled themrapidly to develop confidence in the system and procedure.
As well as concurring with current research, our experience as a UK team performing bedside PICC insertion single-handedly adds a significant extra dimension to the current available evidence.The team continues successfully to place PICCs under sole ECG guidance and finds the addition of the system a positive enhancement of their practice. However, there is clearly BJN significant work still to be done in this area. Conflict of interest: none
© 2013 MA Healthcare Ltd
Chu KS, Hsu JH,Wang SS et al (2004) Accurate central venous port — a catheter placement. Anesth Analg 98(4): 910–14 Dionisio P, Cavatorta F, Zollo A,Valenti M, Bajardi P (2001) The placement of central venous catheters in haemodialysis. J Vasc Access 2: 80–8 Hellerstein HK, Prichard WH, Lewis RL (1949) Recording of intracavity potentials through a single lumen, saline-filled cardiac catheter. Proc Soc Exp Med 71: 58 Infusion Nurses Society (2011) Infusion nursing standards of practice. J Infusion Nurs 34:1S. http://tinyurl.com/pq3xwwq (accessed 26 June 2013) Michelle EH, Thanh HN, Allen JC (2004) Optimising the patient positioning for PICC tip determination. Emerg Radiol 10(4): 186–9 Moureau NL (2010) Electorcardiogram-guided peripherally inserted central catheter placement and tip position. J Vasc Access 15(1): 8–14 Pittiruti M, La Graca A, Scoppettuolo G (2008) The EKG method for positioning the tip of peripherally inserted central catheters. J Vasc Access 13(4): 112–19 Pittiruti M, Bertollo D, Briglia E et al (2012) The intracavitary ECG method for positioning the tip of central venous catheters. J Vasc Access 13(3): 357–65 RCN IV Therapy Forum (2010) Standards for infusion therapy. http://tinyurl.com/6nrpm8 (accessed 26 June 2013) Sansivero GE (2012) What’s new in vascular access devices and technology? Br J Nurs 21(2): 4–9 Smith B, Renee M, Neuharth BS et al (2010) Intravenous electrocardiographic guidance for placement of peripherally inserted central catheters. J Electrocardiol 43: 274–8 Tian G, Zhu Y, Gou F, Xu H (2009) Efficiency of multi-faceted interventions in reducing complications of peripherally inserted central catheter in adult oncology patients. Support Cancer Care 18: 1293–8 Yap YS, Karapetis C, Lerose S et al (2006) Reducing the risk of peripherally inserted central catheter line complications in the oncology setting. Eur J Cancer Care 15(4): 342–7
S28
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
Performing a chest x-ray after insertion of a peripherally inserted central catheter (PICC) is recognised as the gold standard for checking that the tip of the catheter is correctly positioned in the lower third of the superior vena cava at the right atrial junction; however, numerous problems are associated with this practice. A recent technological advancement has been developed that utilises changes in a patient’s electrocardiograph (ECG) recorded from the tip of the PICC as a more reliable method. This evaluation discusses how a vascular access team in a large acute NHS Trust safely and successfully incorporated the use of ECG guidance technology for verification of PICC tip placement into their practice. Key words: Peripherally inserted central catheter ■ Electrocardiographguidance technology ■ Tip placement ■ Accurate verification method
T
he East Kent Hospitals University NHS Foundation Trust’s vascular access team has been established for about three years, and places approximately 1600 peripherally inserted central catheters (PICCs) each year. It is a multi-professional team consisting of four experienced vascular access nurses and anaesthetic consultants. Historically, PICCs were placed by a vascular access team member as a single-handed procedure at the bedside; PICC tip position was checked, postprocedurally, by radiological confirmation.The team all followed the same PICC insertion process, aiming to place the PICC via the basilic vein just above the anti-cubital fossa, and measure the proposed PICC length using a landmark technique. The choice of left or right arm insertion is left to the patient. Once placed, the tip of all central venous catheters, including PICCs, should lie in the lower third of the superior vena cava close to the entrance to the right atrium (Royal College of Nursing (RCN) intravenous (IV) Therapy Forum, 2010; Infusion Nurses Society, 2011). The correct positioning of a PICC is essential to avoid serious complications, such as thrombus, perforations, migrations and arrhythmia (Yap et al, 2006). However, using a landmark technique alone has shown that malpositions of the PICC tip on insertion can occur in as many as 20% of cases (Dionisio et al, 2001). As a result of this high malposition rate, the current recommended practice is to perform a post-procedural chest Gemma Oliver is the Vascular Access and Hospital-at-Home Matron, and Matt Jones is a Consultant Anaesthetist and Vascular Access Lead, East Kent Hospitals University NHS Foundation Trust, Kent Accepted for publication: June 2013
S24
x-ray and confirm the PICC position against anatomical landmarks (Chu et al, 2004; Pittiruti et al, 2008; Sansivero, 2012). However, this procedure is far from ideal because it can add time, cost and radiation exposure implications (Smith et al, 2010); it can also be imprecise and subject to observer variability (Moureau, 2010), as well as then requiring possible PICC repositioning. Local audit data concurred with this evidence. Up to 15% of PICCs inserted within the Trust could require post-procedural adjustment or even reinsertion as a result of being too long, too short, up the jugular vein or inappropriately looped in the venous anatomy (Table 1). There could also be a time delay in between placing the PICC and the post-procedural x-ray being performed, leading to delays in IV treatment. In the past 20 years, there have been successful developments in technology, enabling the central catheter position to be checked using analysis of the patient’s eclectrocardiograph (ECG) rhythms, measured from the tip of the catheter as guidance; this has recently been considered for PICC placement. First described by Hellerstein et al in 1949, changes in the P wave measured from the tip of a central venous catheter can be clearly identified as it passes from the superior vena cava through the cavo-atrial junction and into the right atrium (Figure 1). Using a specialist ECG system, the PICC is attached to lead II of the ECG system via a purpose-built saline adaptor (e.g. Vygocard). A column of saline is then used to transmit the ECG signal to the end of the PICC. The morphology of the P wave, when measured from the catheter tip as it is passes from the superior vena cava through to the right atrium, can be clearly identified (Sansivero, 2012). Using the elevation in the P wave as verification that the central venous catheter is in a correct position has been shown to more frequently result in correct positioning of the catheter tip compared with conventional methods (Pittiruti et al, 2008). In 2011 the first ECG guidance system was introduced to the UK market and given British Standards Institution CE certification (Nautilus®, S.C. Romedex International, Romania).
Literature search In order to plan the proposed implementation of the UK ECG system, a literature review was undertaken to evaluate existing knowledge in relation to the topic. A literature search strategy was considered on how to identify appropriate pertinent research and evidence. The search engines considered appropriate for obtaining evidence relevant to this study included CINAHL, MEDLINE, EMBASE, British nursing index, Cochrane Collaboration and Google Scholar. The key words that were used were echocardiogram (ECG and EKG), peripherally inserted central line (and PICC), central line and chest x-ray. It
© 2013 MA Healthcare Ltd
Abstract
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
picc verification became evident that there is not a significant amount of literature surrounding the areas being studied. In light of this, and for the purpose of completeness, an incremental approach was also applied and the reference lists from articles obtained via the search engines were reviewed and any missing key literature obtained. The evidence was reviewed and deliberated with regards to the accuracy, efficiency, cost and safety of the procedures.
Table 1. Peripherally inserted central catheter placement within East Kent Hospitals University NHS Foundation Trust from May to October 2011 Total number of PICCs placed with follow-up chest radiograph
597
Placement satisfactory
509 (85%)
Placement unsatisfactory
88 (15%)
– too short
13
– too long
45
Two literature review aims
– looped up the jugular vein
17
The first aim was to review the evidence regarding postprocedural chest x-rays and their efficiency in establishing correct PICC tip position. Current evidence suggests that chest x-rays are at present the recognised method of confirmation of PICC placement (Pittruiti et al, 2008; RCN IV Therapy Forum, 2010; Sansivero, 2012). However, the literature review revealed several criticisms of this procedure. Three main themes were identified: ■■ There can be a time delay between placing the PICC and starting IV treatment while the patient waits for the confirmation x-ray and for it to be reported ■■ Some PICCs will require post-procedural adjustments, resulting in further interventions and x-rays. In some cases this may result in the PICC having to be replaced and a potential delay in commencing IV therapy (Tian et al, 2009) ■■ The accuracy of post-procedure chest x-rays seems questionable, and interpretation is often operator-dependent; for example, Michelle et al (2004) identified that up to 40% of chest x-ray readings following PICC insertion were discrepant. The second aim was to establish the evidence surrounding ECG-guided PICC (and central venous catheter) placement.
– looped in the subclavian/innominate vein
13
PICCs=peripherally inserted central catheters
Figure 1. Changes in P wave measured by electrocardiograph at the tip of the peripherally inserted central catheter can clearly show placement in the right atrium. Original image from Dr Mauro Pittiruti, used courtesy of Vygon UK
© 2013 MA Healthcare Ltd
This search conversely found that all three of the criticisms of post-procedural chest x-rays were cited as advantages of the ECG-guided PICC system, in that:
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
S25
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
There is also little evidence regarding the actual procedure and how complicated it is to perform or build into existing practice.
Pilot
Figure 2. Electrocardiograph-guided placement of a peripherally inserted central catheter ■■ There
is no time delay in starting treatment as the system gives an instant result ■■ There is no post-procedural PICC adjustment required as the system works with live placement results, giving 100% accuracy (Pittiruti et al, 2008, 2012) ■■ The studies performed so far state that it is easy to read and not open to variable interpretation. However, criticisms of the ECG-based approach have also been reported in the literature—for example, that the system is not suitable for everyone (e.g. patients in atrial fibrillation or with pacemakers; Pittiruti et al, 2008), that expensive equipment is required (Tian et al, 2009) and that it requires clinician education (Moureau, 2010). The current UK policy and local policies were also reviewed at this stage in relation to best practice for PICC position confirmation. The major pertinent policies, for example the RCN’s standards for infusion therapy (RCN IV Therapy Forum, 2010) and the Infusion Nurses Society (2011) guidelines, all advocate the use of chest x-ray post-procedure. However, both policies were written before the ECG-guided system was launched in the UK. The evidence behind ECG-guided PICC placement so far appears consistently positive with regard to confirmation of the PICC tip within the cavo-atrial junction. There is strong evidence to support ECG-guided PICC placement from a procedural perspective. However, there are some significant gaps in the evidence; importantly, there are no UK-based studies and there is only one nurse-led study (Moureau, 2010). Corresponding PICC position on X-ray
Surface
Surface ECG
Practical challenges The team places PICCs as a completely single-handed procedure at the bedside, so it was necessary to understand during the pilot whether the system could be incorporated into existing clinical practice. The team found that the following challenges needed to be considered and overcome with the implementation of the ECG system.
Maximal P wave The recommendation is that the PICC tip is left in position where the P wave of the ECG is at maximal height. During the pilot it became apparent that there could be a vast discrepancy in individual patients’ P wave height at maximal position; in some patients this was half the height of the QRS complex and in others it was higher than the QRS complex. In order to guarantee that the maximal height of the P wave had been achieved, a process was developed whereby the PICC was inserted until the P wave showed a negative deflection or started to get smaller in size, indicating placement in the right atrium. The PICC was then pulled back until the negative deflection had disappeared and the maximal P wave achieved.
Figure 3. Electrocardiograph (ECG)-guided placement of the peripherally inserted central catheter (PICC) with radiological confirmation
During the pilot it was assessed whether it was possible for the operator to remain sterile and still work the ECG system single-handedly, and the solution to this seemed to be preparation; the parts of the process where the operator may need to touch the unsterile system were reviewed and solutions found. Groundwork can be done before the sterile part of the process commences—for example, attaching the ECG leads to the patient and lead II that attaches to the end of the PICC put in a convenient, easily reachable location.The ECG system can
© 2013 MA Healthcare Ltd
Intravascular
The ECG system as part of a single-handed, sterile procedure
Intravascular ECG taken from end of PICC
S26
The emerging themes in the literature were important to consider when moving forward and planning the proposed implementation of the system. As a result of the apparent gaps in the literature, it was decided that a pilot study should be performed. The pilot was conducted within the Trust on one site by the authors. The ECG verification system was used on 20 consenting patients with PICCs being placed under ECG control (Figure 2); then a post-procedural chest x-ray was performed and PICC position reviewed. The main aims of the implementation pilot were to establish: ■■ Whether the ECG-guided PICC placement system was reliable and correct ■■ Whether ECG-guided placement could be integrated into existing practice, improve efficiency and enhance patient care The team rapidly became confident with the system, and the pilot showed the tip location of all 20 PICCs to be radiologically in the lower third of the superior vena cava/right atrium junction; an example of this is shown in Figure 3.
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
picc verification also be turned on and prepared at this time. Once the sterile PICC placement procedure was underway, the authors examined and tested a method to see if any of the system that needed to be touched could be done through a sterile gauze barrier, such as connecting the unsterile ECG lead II to the saline adapter and using the system’s touchpad.
Initial PICC length The PICC length was found to be particularly important when using the ECG system; if the PICC length is too short it may not reach the point in the superior vena cava where the P wave morphology starts to change, potentially leading to misleading negative results. It is therefore important not to cut the PICC too short.
Time added to procedure Although there is a small increase in the total procedure time associated with using the ECG-guided system, the team felt it only added a few minutes to the overall procedure time. The time taken to order an x-ray, wait for the results, interpret the results and then act on any misplaced central venous catheters was felt to be far greater.
Getting a good trace Time needs to be spent to ensure that a good ECG trace is obtained from the tip of the PICC, and it was found to be important not to rush the insertion and allow the ECG trace time to settle. This is because any operator movement of the PICC seriously affects the quality of the displayed ECG trace. The patient needs to remain relatively still for this part of the procedure to reduce interference. It is also essential to ensure that the PICC is well flushed to ensure that there is a continuous column of saline within the PICC to enable electrical conductivity from the tip to the electrode. The ECG trace from a valved PICC needs to be taken while continuously gently flushing the PICC to ensure the valve is open and that a continuous column of saline is present from the PICC tip to the ECG lead.
Patients with cardiac history
© 2013 MA Healthcare Ltd
It was necessary to establish if each patient had any known cardiac history before PICC insertion. Additional assessment questions needed to be asked to establish if the patient had any cardiac history, particularly of atrial fibrillation or the presence of a pacemaker (as the ECG system is relatively ineffective on this group of patients). Asking this before laying the sterile insertion trolley and opening the ECG lead (saline adapter) prevents the lead being opened unnecessarily and the costs associated with this. Plans can also be made for a post-procedural x-ray. Although there were changes in practice required, the pilot team felt that the system was relatively easy to use and that it could safely be embedded into clinical practice. Funding and purchase were approved for three systems, and the procedure was rolled out to the rest of the vascular access team.
Rolling out the system In order to embed the procedure into practice it was important to consider the wider implications of this change in practice. The rest of the vascular access team needed to be trained on
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
the ECG system. All members were given individual training by the matron and consultant until they were confident with the new process.They were well supported and encouraged to seek back-up if they had any concerns with individual patients. The vascular access nurses needed to feel confident in this process as they have the individual responsibility for signing off any PICCs they place as correctly sited and fit for use. It was also necessary to educate the rest of the staff in the hospital as to why a post-procedural x-ray was no longer required. The ward staff predominantly seemed happy with the process if the vascular access team were able to take responsibility for confirming PICC position. They were interested in the procedure and there was little resistance to the rolling out of this technology. The Trust’s PICC insertion paperwork was adjusted to reflect the change in practice; the guidelines were also reviewed and rewritten to incorporate the new process, and appropriate competencies developed. The team has now successfully placed over 2000 PICCs under sole ECG guidance, and our findings and data are in line with the growing body of international evidence that supports the use of ECG guidance as an accurate verification method for PICC tip position.
Benefits Since introducing the system there have been numerous benefits found, including: ■■ A release of clinical time—it is no longer necessary to revisit patients to adjust the PICC position, as the ECG system gives real-time, accurate confirmation that the PICC tip is in the correct position at the cavo-atrial junction ■■ The system allows for prompt initiation of infusion therapy and immediate release of the PICC for use. Not needing to wait for x-rays before commencing IV treatment or relying on others to check x-rays has significantly improved patient flow and increased patient satisfaction with the process ■■ There is a significant cost reduction associated with no longer performing chest x-rays. Based on the Trust’s estimated cost of £35 per x-ray and cost of additional equipment being £12 per procedure, this was found to be a saving of £23 per procedure. The initial outlay for three ECG systems meant that there was a saving of approximately £15 500 in the first year. The use of this system in the following years equates to a saving of approximately £38 000 each year for the Trust. This does not take into consideration the cost of any repeat x-rays required if the PICC position is incorrect, or indeed the cost of staff time associated with organising and analysing the repeat radiograph ■■ Elimination of x-ray exposure to patient and clinician—this also opens up the procedure for patients for whom x-rays are
Key points n Correct placement of peripherally inserted central catheters (PICCs) is essential to avoid potential complications n Current practice recommends radiological confirmation of PICC position (chest x-ray); however, there can be problems associated with this practice n An electrocardiograph-guidance system can be safely and costeffectively incorporated into existing PICC placement practice n Immediate confirmation of PICC tip position allows for immediate commencement of intravenous therapy, thus improving patient care
S27
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
not recommended, such as pregnant women.
Keys to success
Summary
The authors identified that there were several keys to implementing this technology successfully: ■■ The full literature review that was performed before introducing the system enabled the team to assess fully the strengths and limitations of the process; this then enabled the implementation to be carefully planned ■■ During the pilot, time was taken to consider how to build the ECG guidance into practice, aiming for minimal disruption to the existing process. This was carefully considered so that the system was seen to enhance practice and improve patient flow ■■ Although there is a learning curve associated with the procedure, all the PICCs in the Trust are placed by a dedicated team so only a core of five staff had to be trained. Once the matron and consultant were trained and confident, the training was then disseminated to the rest of the team members. They were all given individual training and support until they were confident in their practice ■■ The team comprises senior nurses, but is led by a consultant anaesthetist, who is enthusiastic about supporting the senior nurses in developing new skills. This level of clinical leadership has enabled the team to feel supported, and having access to senior clinical guidance and support when necessary has enabled themrapidly to develop confidence in the system and procedure.
As well as concurring with current research, our experience as a UK team performing bedside PICC insertion single-handedly adds a significant extra dimension to the current available evidence.The team continues successfully to place PICCs under sole ECG guidance and finds the addition of the system a positive enhancement of their practice. However, there is clearly BJN significant work still to be done in this area. Conflict of interest: none
© 2013 MA Healthcare Ltd
Chu KS, Hsu JH,Wang SS et al (2004) Accurate central venous port — a catheter placement. Anesth Analg 98(4): 910–14 Dionisio P, Cavatorta F, Zollo A,Valenti M, Bajardi P (2001) The placement of central venous catheters in haemodialysis. J Vasc Access 2: 80–8 Hellerstein HK, Prichard WH, Lewis RL (1949) Recording of intracavity potentials through a single lumen, saline-filled cardiac catheter. Proc Soc Exp Med 71: 58 Infusion Nurses Society (2011) Infusion nursing standards of practice. J Infusion Nurs 34:1S. http://tinyurl.com/pq3xwwq (accessed 26 June 2013) Michelle EH, Thanh HN, Allen JC (2004) Optimising the patient positioning for PICC tip determination. Emerg Radiol 10(4): 186–9 Moureau NL (2010) Electorcardiogram-guided peripherally inserted central catheter placement and tip position. J Vasc Access 15(1): 8–14 Pittiruti M, La Graca A, Scoppettuolo G (2008) The EKG method for positioning the tip of peripherally inserted central catheters. J Vasc Access 13(4): 112–19 Pittiruti M, Bertollo D, Briglia E et al (2012) The intracavitary ECG method for positioning the tip of central venous catheters. J Vasc Access 13(3): 357–65 RCN IV Therapy Forum (2010) Standards for infusion therapy. http://tinyurl.com/6nrpm8 (accessed 26 June 2013) Sansivero GE (2012) What’s new in vascular access devices and technology? Br J Nurs 21(2): 4–9 Smith B, Renee M, Neuharth BS et al (2010) Intravenous electrocardiographic guidance for placement of peripherally inserted central catheters. J Electrocardiol 43: 274–8 Tian G, Zhu Y, Gou F, Xu H (2009) Efficiency of multi-faceted interventions in reducing complications of peripherally inserted central catheter in adult oncology patients. Support Cancer Care 18: 1293–8 Yap YS, Karapetis C, Lerose S et al (2006) Reducing the risk of peripherally inserted central catheter line complications in the oncology setting. Eur J Cancer Care 15(4): 342–7
S28
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 14
British Journal of Nursing.Downloaded from magonlinelibrary.com by 130.088.090.140 on January 22, 2015. For personal use only. No other uses without permission. . All rights reserved.
