PICC Line Placement

Oh so carefully, slowly thread the line. No, no, too far! Pull back just a bit. Now that feels right. Just a smidge more and it’s in place. There, all done. Hopefully! You aren’t really done until a trip to radiology confirms the PICC line you just placed is exactly positioned. Then the patient can begin treatment.

Despite impressive skills honed through knowledge and repetition, up until now PICC line nurses were never quite sure a line was properly placed until confirmed by X-ray.

That has changed at Medical City Dallas Hospital, Dallas. A new FDA-approved device guides and positions PICC line insertion using real-time catheter tip location information. Seven months after starting to use the device, nurses have been able to shave off several hours between line insertion and the patient beginning therapy.

“When you’re done inserting the line, you can walk out of the room and know the line is ready to use,” said Laurel Merritt, BSN, RN, VA-BC, PICC team supervisor at Medical City. “You don’t need to wait for an X-ray.”

The Introduction

The five-nurse PICC team at the 700-bed Medical City Dallas Hospital first learned about Bard Access’s Sapiens TCS and its companion, the Sherlock II Tip Location System, from the manufacturer’s representative.

“We liked the idea of not having to use a chest X-ray,” said Max Holder, RN, CEN, VA-BC, PICC nurse. “As it was described to us, using the device would shorten post-insertion delays.”

Which it did! Merritt estimates patients are beginning treatment 2-3 hours sooner now that a chest X-ray isn’t required to confirm the line is in place.

The technology is approved for patients who have multiple drips, require IV antibiotics or total parenteral nutrition. “It is not approved for patients with pacemakers, atrial fibrillation and children under 12,” Merritt explained.

Making the conversion from doing it the old way to the new was an adjustment for this team with 80+ years of collective experience. “I was guarded at first; I’ve been doing this a certain way for 9 years, putting in PICCs all day, every day,” Merritt told ADVANCE. “However, this new device is easy to use and we love it. No one wants to go back to doing a chest X-ray.”

How It Works

Using the placement technology puts a little more preparation time on the front-end of the procedure, Merritt explained, but makes up for it by the fact when the line is placed, the patient is ready for therapy. The lightweight device ¾ “weighing about 4 pounds and the size of a netbook,” Holder said ¾ has two parts, a tip location system and a small ECG monitor.

Basically, the nurse begins the procedure with an introduction to the patient, explaining the process and answering any questions. “We then place the patient’s arm on the table, apply a tourniquet and scan the vessels, looking for the best one for the size of catheter we’ll use,” Holder detailed. “We place our leads and once that’s done, we place the tip location device on the patient’s chest, and fit the electrode fin into the back of that device, which works like ultrasound.

PICC TEAM: The five-member Medical City PICC team includes Kim Cha BSN, RN, CMSRN; Misti Heckaman, RN; Max Holder RN, CEN, VA-BC; Laurel Merritt BSN, RN, VA-BC; and Leigh Ann Anderson BSN, RN. courtesy Medical City Dallas Hospital

“Once in, we thread a catheter that has an internal wire with magnets on the tip into the vein. The ultrasound switches to the sensor, that’s the Sherlock Tip Location System, which senses the micro-magnetic field as I thread the catheter,” Holder continued. “So first I am watching the tip location device on the ultrasound monitor in Sherlock mode, then I’m concentrating on the Sapiens monitor and the internal rhythm. I want the P-wave as big as can be without having negative deflection. It’s all very visual.”

Holder compared it to tying your shoes by looking in a mirror ¾ “a lot of interpretive skills are required.”

“You watch that rhythm,” Merritt added. “There’s at least 60-90 seconds when you’re fine tuning the tip of the catheter.” Sometimes, more than one PICC nurse will watch the screen during a procedure, she said. “At a certain point in the process, your main area of interest is that screen.”

The Training

Getting to this point of ease with the device was not difficult for a team that averages eight to 12 PICC line insertions a day.

“We were trained by the manufacturer with an online class we could complete on our own,” Merritt said. “Then a nurse from the company spent 8 hours with us, ran us through the process and joined us as we did the procedure on several patients.”

Holder said the team had a benchmark of 100 patients to do using both the old procedure, which confirmed placement via X-ray, and the new procedure, where the technology confirmed placement. “By the time hospital policy was written and adopted, we had done another 100 lines, so we were sure this new technology is 100 percent accurate. Chest X-rays confirmed we were right on the money.”

“It can measure as little as half a centimeter in accuracy,” Merritt added. “When the PICC line is in the right place, patient outcomes are better.”

Less exposure to X-rays and eliminating the need for and costs of imaging tests offsets the cost of the unit to the hospital.

“The team loves this process,” Merritt said. “Now no one misses doing a chest X-ray. Patients love it too. Several patients admitted it’s wonderful not to have to wait for an X-ray. Treatment can begin immediately and outpatients can go home right away.”

Gail O. Guterl is a frequent contributor to ADVANCE.

About The Author

Each year more than 350,000 professionals advance their career with Elite Learning.