Expert Team Aims to Reduce Risks of Peripheral IV Catheterization Through Patient Screening, Clinical Education

More than 2.7 million peripherally inserted central catheters (PICCs) are placed in acute care facilities in the United States each year, according to a report on the vascular-access devices market. While PICC lines offer many advantages, complications can occur, including infection and thrombosis. A dedicated team of nurses at Cleveland Clinic’s main campus helps prevent problems.

“Patients go to a cardiologist when they have heart issues. Likewise, they should receive care from vascular-access specialists when they have vascular-access needs,” explains Shelly Altizer, MSN, RN, VA-BC, nurse manager of the Vascular-Access PICC Team at Cleveland Clinic.

The team includes 21 nurses who screen patients with orders for PICCs and midline catheters, insert the lines at the bedside and educate patients and nurses. Team members are also part of the Vascular-Access Affinity Group.

“We standardize best practices and ensure clinical excellence around vascular access through professional development and workforce education,” says Altizer, who chairs the group.

Screening patients

When a healthcare provider places an order for a PICC or midline catheter, a member of the PICC team initiates an extensive screening process.

“We thoroughly review the patient’s chart, including their medical and surgical history, before we go to the bedside,” says Altizer. They consider:

• Indications for the line – “We want to make sure the ordered line is right for the patient and there are no contraindications,” says Altizer. The team evaluates the therapy and medications that the patient will receive and how long the treatment is required. For instance, if the patient requires a line for frequent blood draws, a PICC may be a better choice than a midline catheter.
• Imaging results – Nurses examine x-rays and ultrasound images to see if the patient has a history of deep vein thrombosis (DVT) in their upper arms, a mass in the chest cavity, axillary clips or other factors that may affect the line.
• Lab work – In particular, the nurses consider the patient’s kidney function. If the patient has a history of kidney disease and may require an arteriovenous fistula for dialysis in the future, a PICC or midline could affect the success of the fistula.
• Cardiac devices – For example, if the patient has a pacemaker, the nurse would typically insert the line on the opposite side.

Inserting lines at the bedside

Once the screening process is complete, work at the bedside begins. The nurses assess the patient’s blood vessels, including the health and location of their veins. They also consider the catheter-to-vein ratio to minimize the risk for DVT.

“We don’t want to insert a catheter that takes up a large portion of the vein,” says Altizer.

After the vessel assessment, the nurses insert the PICC or midline. They also troubleshoot as needed. For example, they may help access ports or administer Cathflo®, which restores function to central venous access devices.

Bedside line placement has several advantages.

“Patients don’t have to wait for an interventional radiology room to become available, so you don’t have delays in patient care and treatment,” explains Altizer. “The team also sees outpatients, if needed, so they don’t have to cancel or reschedule appointments due to vascular-access needs. This is not only more convenient for patients, it can also help avoid unnecessary costs.”

Educating clinical nurses

When a nurse on the Vascular-Access PICC Team inserts a fresh line, they also seize the opportunity to remind clinical nurses about maintenance tasks, including dressing changes.

As an expert in vascular access, Altizer offers the following advice to clinical nurses:

• Know how to maintain, monitor and utilize central lines. “We want to reduce any risk of central line-associated bloodstream infections,” says Altizer. “All clinical nurses should have the skills needed to change dressings, scrub the hub and understand when tubing needs to be replaced.”
• Designate a vascular access champion on each unit, if possible. The champion should advocate for the proper care and maintenance of central lines and provide educational resources to clinical nurses.
• Identify vascular access resources. In addition to a vascular-access team, other experts may include providers in interventional radiology or the emergency department. “It’s important to know whom to reach out to if you have questions,” says Altizer.

Achieving quality metrics

“Our PICC team members have so much knowledge in vascular access and associated devices. They belong to professional organizations, receive board certifications and stay up to date on evidence-based practices,” says Altizer.

The metrics at main campus support the value of a dedicated team. In 2021, the Vascular Access PICC Team inserted thousands of central lines, with an associated blood infection rate of just 0.4%.

“Of course, we would love that number to be zero, but it shows that our rigorous infection prevention procedures, coupled with our first-time success rate inserting lines, reduces possible complications,” says Altizer. “And that increases patient satisfaction.”