A New Perspective for PICC Line Insertions

Cost Effectiveness and Outcomes Associated with an Independent PICC Service

John Davis, RN, BSN Kathy Kokotis, RN , BS, MBA
Abstract:
ICC line insertion has been traditionally performed by non-dedicated per diem nurses who place PICC lines in their spare time, Interventional Radiology or IV Teams. A new option has developed to place PICC lines at the bedside. This option is to utilize an outside contractual agency that guarantees an insertion success of 90%-100% of PICC line placements at the bedside. Per diem nursing PICC teams often have insertion success rates of 50%-70% with 30%-50% of patients going to radiology for line placement. These per diem teams also have hidden costs associated with repeated re-training. Is it cost-effective to continuously retrain PICC line nurses who maintain an insertion success rate of 50%-70% or is an independent PICC contractor an economic substitute? Insertion prociency is directly related to the concept practice makes perfect and the usage of modied seldinger technique and portable ultrasound. Can one train a per diem team to master the skill of utilizing high-tech tools in their spare time? Infusion Nurse Consultants began training per diem nursing PICC staff in 1998. Out of 100 nurses trained only 10 completed minimum Infusion Nursing Society Competency Guidelines. That is one out of every 10 nurses trained. As a result the organization embarked on offering independent PICC line insertions to contracted hospitals. In 2004, the service placed 900 PICC lines a month at a 98% insertion success rate at bedside. The author has discovered that the days of observing three PICC line insertions and placing three successful PICC lines does not lead to a 98% insertion success. A nurse who places PICC lines almost daily with high-tech tools masters that 90% insertion success. Hospital administrators should evaluate the cost losses and savings associated with the insertion success rate of their current PICC line inserters and consider the addition of an independent PICC contractor as an alternative option to reduce cost losses.

Introduction:
Since 1985, Peripherally Inserted Central Catheters (PICCs) has been the primary vascular access device utilized to deliver infusates in the alternate site market. The hospital marketplace started to place PICC lines in the 1990s. Today PICC lines are a commonly used vascular access device to deliver infusate therapy in both hospital and alternate site markets. In 2003, almost one million PICC lines were placed up from 200,000 PICC lines placed in 1996.1 Hospitals have adopted a wide range of PICC line program structures. Each type of structure has its pros and cons. Often the cons outweigh the pros especially in hospitals utilizing per diem nursing staff to place PICC lines

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Table 1 Major obstacles to in-house hospital PICC line placement

Problem Average time to place a PICC line is two hours Infusion Nursing Society (INS) published gure 60-180 minutes2 Causative Factor Nursing shortage does not allow for staff to leave patients for two hours to place a PICC line Result PICC lines placement is often delayed involving a patient discharge delay3,4,5 PICC lines are often referred to high operational cost areas such as operating room (OR) or radiology (IR)3,4 Staff is asked to place PICC lines on off hours involving excessive overtime costs and nurse burnout Staff often does not even complete minimum competency level let alone prociency level due to time element5 Prociency and competency in PICC line placement are not identical Competency in the literature has often been identied at (3) PICC line observations and (3) successful PICC line insertions (found in Bard Access PICC Manual).6 The average insertion success rate with traditional tools is documented at 65%1,3,4 Competency is often never achieved as a result of staff turnover Excessive waste of labor and supplies Patient trauma from repeated sticks Patient safety from repeated sticks Costly transfer of unsuccessful sticks to OR and IR3.4 Legal risk associated with non-prociency and autonomy Repeated lost training costs to train staff on insertion

Turnover of trained staff

or interventional radiology to place 100% of PICC lines ordered. The question becomes, is an independent contractual service which offers highly skilled trained staff to place PICC lines at a patients bedside another option?

Structure of PICC Line Programs in Texas

In 1998, Infusion Nurse Consultants began to offer educational programs on PICC line insertion. One hundred nurses were educated to place PICC lines in a one year time period in 1998. The majority of local Texas hospitals had unstructured PICC line placement programs. PICC lines were placed by per diem nursing staff that attempted to place PICC lines in-between existing job duties. If they could not successfully place the PICC line or had no time to place the PICC line the patient was sent to Interventional Radiology or a surgeon for a vascular access device. A group of hospitals utilized home

infusion staff to place PICC lines inbetween their home infusion scheduling. Obstacles to the timely placement and successful placement of a PICC line were a consequence of this unstructured PICC placement design. These obstacles (Table 1) are directly related to the number of PICC line insertions a nurse has performed, the time per diem staff and radiology staff has to devote to PICC insertion and the method of PICC line introduction the clinical staff employs. The bottom line is Interventional Radiology was too busy to place PICC lines, nursing per diem teams lacked time, high-tech tools and prociency to place PICC lines and home infusion had to squeeze PICC line placements into their fully scheduled patient loads.

Bottom Line Associated With The Per Diem PICC Team

In 1998, the author started to instruct nurses in local hospitals and alternate

infusion sites on the placement of PICC lines. The classroom work involved an eight-hour didactic course with hands-on practicum. Each class had approximately 4-12 registered nurses. The majority of these nurses had full time clinical positions with the idea of placing PICC lines in their spare time between patient loads. Approximately 100 registered nurses attended the PICC courses in 19981999. Of those 100 attendees not one is currently placing PICC lines today. One would ask how this is possible. There are a multitude of problems associated with utilizing nurses to place PICC lines in ones spare time in between patient loads. A synopsis of the major issues related to in-house PICC line programs is found on (Table 1). The number one challenge in todays in-house PICC line process is time and the attainment of prociency.1,3,4 Patient safety is a prominent factor in todays healthcare envi-

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Table 2 Cost of Minimum PICC Line Training Competency

Competency Criteria 8-hour class attendance fee 8-hour class nursing labor cost for attendance 3 successful observations Nurse Trainee Cost $200 $240 $270 Comments Per person attendance fee Per person labor cost Labor cost used $308 an hour (3) Hours apiece as observation slows down process Based on (9) hours (3) Hours apiece as precepting slows down process Based on 50%1 competency rate (6 observed insertions to meet goal of 3) Based on 18 hours Based on 18 hours as above (3) unsuccessful Insertions Based on supply cost $150 1,3,4

3 successful observed insertions $540 Nurse Trainee (6 insertions to get to 3 successful insertions) 3 precepted observed insertions Nurse Preceptor Wasted supplies during learning curve Patient transferred to radiology for PICC placement Total cost $540 $450

Interventional Radiology in September 2003 there is now a threshold insertion success rate.12 The threshold for insertion success is 90% of all adult PICC lines ordered. The published literature indicates reported success rates of PICC line placement at 96% in radiology. A nursing organization has yet to publish a nursing benchmark, however the literature indicates a nursing success rate at bedside with skilled PICC nurses utilizing modied seldinger technique and portable ultrasound at an 85%-90%1,3,4 insertion success. To summarize; the insertion success of many per diem nursing PICC teams is at a 50%- 65%1,3,4 insertion success at the bedside but the success rate of a nurse whose primary function is the insertion of a PICC line with high-tech tools is at 85%-90%.

$3,000 Study by Cardella9 $1,000 apiece (3) unsuccessful insertions at bedside 5,240 Train one nurse was spent in nursing school in 1980 learning how to make four corner beds. In this litigious society can one justify minimum standards in performance of a high-tech skill? Press Ganey is a national company involved in hospital patient satisfaction scoring. On their web site www.pressganey.com one will nd that the venipuncture skill level of clinicians ranks in the top ten of patient complaints in todays hospitals.7 Published literature indicates that the successful placement of a PICC line is dependant on a skilled nurse instructed in the usage of modied seldinger technique and portable ultrasound. Nursing that is not utilizing these tools has an insertion success of 50% - 75%1,3,4 at the patients bedside. The major question now becomes, is it acceptable to provide a successful PICC insertion for one out of every two patients or nine out of every ten patients? There is no answer to what number of PICC line placements per year deem one to be competent or procient, however with the introduction of published Clinical Practice guidelines from the Society of

The Costly Retraining Cycle of the Per Diem PICC Nurse:

Crawford5 documented in 2000 that the PICC program at Bryan LGH Medical Center in Lincoln, Nebraska had trained (59) RNs to place PICC lines and had (56) RNs actually complete minimum competency (95%). This rate is high compared to what the authors have experienced in their PICC courses. In courses conducted by Infusion Nurse Consultants, 1 of 10 or approximately 10% of PICC course attendees actually completed the minimum competency level of three insertions and observations. However, Crawford5 did indicate that of the (59) trained; (20) nurses have resigned due to relocation, personal reasons, or alternative employment and (9) have no time to place PICC lines. The program experienced a 50% loss in trained personnel from 1996-1999. What are the operational losses associated with this per diem structure? Crawford5 concluded that the cost of training was $300-$400 per nurse. That cannot be correct based on the assumption of (3) successful observations and (3) successful insertions. An analysis of true costs is represented in (Table 2). Basic minimum cost of training for one nurse is $5,240 versus the cited cost of $300$400 per nurse. Crawford5 had a 50% (29 nurses) attrition rate of trained staff

ronment. What is considered procient? Is it watch three! Do three! Teach one! Does one attain an insertion success rate of 90% placement of all PICC orders at the bedside by placing three PICC lines? A position paper released by the Infusion Nursing Society (INS) indicates that the observation of (3) successful PICC line insertions and the monitored placement by preceptor of (3) successful PICC line insertions is considered minimum standard of competency.6 Performing three insertions in what time period makes one competent on PICC line insertions? One week? One month? Or one year? These are all questions that have not been addressed in the literature to date. If a clinical nurse performs a peripheral venipuncture three times a year does that deem them to be procient with a 90% insertion success rate or even minimally competent to perform the procedure? Performing three successful PICC line insertions represents 0.29% of nursing work hours in one year. Does that time element deem prociency or even maintain a minimum competency? A greater time element

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in two years representing a hospital operational dollar loss of $151,960 in two years. Crawford5 spent an operational cost of $309,160 to train the 59 nurses in two years. Often facilities fail to consider the entire picture when estimating training costs. They assume the cost of a PICC course alone and do not consider the labor and supplies involved in training.

Table 3 Cost of unsuccessful PICC line insertion referred to radiology

Materials and Labor Material cost of unsuccessful insertion at bedside by nursing Radiology Referral Total Cost Total Cost for 69 insertions Operational Costs $60 (2 hours @ $308 and hour) $150 supplies1,3,4 $210 Total $1,000 (Stated by Cardella)9 $1,210 $83,490 in one year would have been sent to the IR department. Cardellas9 study is based on the results of a full time IV Team placing PICC lines in addition to other vascular access duties. If the IV Team in Cardellas9 study has an insertion success of 71% for PICC line insertion what success rate does a per diem PICC team represent (50%-70%)? Fong(2001)10 out of Dartmouth-Hitchcock Medical Center prospectively compared the rate of successful PICC line placements by nursing at the bedside to those in radiology over a one and one-half year time period. This study shows that nursing was able to place 192/322 PICC lines successfully, for an insertion success of 60%.10 The end result is 40% of PICC lines were transferred to radiology.10 Would 60% insertion success be deemed procient and acceptable? The cost loss of sending 130 cases to radiology would be a minimum nancial loss of $130,000 a year to a chief nancial ofcer. Fong10 concludes it is cost-effective to have nursing perform PICC line insertions at the bedside. However with a 60% prociency in placement that statement could be questionable. If a contractual service can once again guarantee an insertion success of 90%-97% at the bedside the cost savings could outweigh the usage of an in-house nursing PICC program. The operational savings with a 90% prociency rate and reduction in stafng could easily offset the costs associated with the hiring of an independent contractor. Neuman11 in his study stated that to be cost-effective in placement of a PICC line by nursing at the bedside one must deliver a minimum insertion success rate of 80%,

Cost-Losses Associated with Unsuccessful PICC Line Insertion:

Linking PICC line insertion success to economic costs can be demonstrated by utilizing one of the largest published PICC line studies. Cardella (1996)9 in Hershey, Pennsylvania discussed placement of PICC lines by a dedicated IV Team with back up in radiology for unsuccessful attempts at insertion. Cardella (1996)9 indicates that from December 1, 1993 to December 31, 1994 the radiology department placed 179 PICC lines. Nurses had referred 132 of the 179 PICC lines or 74% of PICC lines to radiology as a difcult placement.9 Nursing attempted but was unsuccessful with 69/132 PICC line insertions and no attempt was made to place 63/132 PICC lines at the bedside.9 Nursing did successfully place 324 PICC lines at the bedside during this one-year time period.9 What does this data indicate? A skilled competent professional IV Team utilizing traditional methods of PICC line introduction rather than high-tech tools had an insertion success rate of 71% (132 (IR)/456 (total.)9 Is a 71% insertion success rate at bedside acceptable if an outside contractual agency can guarantee an insertion success rate of 97%? This is a nancial and patient safety consideration that should be investigated. Sixteen percent of all PICC lines placed by IR were due to unsuccessful attempts. Fourteen percent of all PICC lines being placed in IR could not even be attempted at the bedside. This represented 63 patients that were automatically sent to IR. Several questions come into play when the prociency rate of PICC placement at the bedside falls below the 90% insertion success rate. These questions include:

What patient safety and satisfaction issues result from transporting 29% of all PICC line orders to radiology? What percentage of these transported patients are ICU based and are on ventilators and drips that are subjected to a safety risk? What level of condence does the attending physician ordering the PICC line placement have in the IV Team which must send 29% of their patients to radiology for placement? Does the attending physician nd himself or herself directly referring their PICC line placements to radiology for procient placement, thereby bypassing the IV Team? One must consider the cost implications to Cardellas9 data. What are the costs of transferring 29% of PICC line placements to radiology? What are the costs of 16% unsuccessful PICC line insertions by the IV Team. The cost of a missed PICC line insertion would include the nursing labor cost and materials, as well as the cost of a radiology referral. The total cost of 69 missed attempts with referrals to radiology is $83,490 in operational cost loss (Table 3). The cost of direct referral without attempt was $1,030 per patient which includes one hour of nursing assessment and the IR referral. The total cost of 63 direct referrals by the IV team without attempt is $64,890. This makes the full total of 29% of PICC referrals to IR at a $148,380 cost loss per year to the hospital administrator. A prociency of 90% instead of 71% competency on the part of the IV Team would have saved the facility $103,380 in operational costs and only 45 cases

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otherwise it is more costly to maintain PICC insertion at the bedside by nursing versus sending a PICC line to radiology for placement. The authors take that theory one step further to costeffectively place a PICC line at bedside one must maintain a minimum insertion success of 90% or one should entertain the idea of a contractual agency to place PICC lines as an alternative approach. The bottom line to this discussion is that one cannot maintain a 90% insertion success rate unless one performs PICC line insertions 100% of their time with high-tech tools. Those individuals that place PICC lines in their spare time can expect to achieve a maximum insertion success of 50%-70% with traditional tools and those IV Teams that place PICC lines without high-tech tools such as modied seldinger technique and portable ultrasound cannot expect to achieve a higher insertion success rate of 50%-70% at bedside with traditional technique. Unsuccessful PICC insertions result in an economical loss of materials and labor for the hospital, concerns for patient safety during transport and compromised attending physician satisfaction.

Change in Philosophy: Independent PICC Line Insertion

In 1999, Infusion Nurse Consultants recognized the need for prociency in PICC line insertion at the patients bedside. The object was to provide a 90% insertion success of all PICC line referrals, decrease the potential for adverse patient outcomes, reduce patient transport to radiology, and to save hospital operational costs. An independent contracting service was initiated and marketed to local hospitals that had a per diem PICC Team, 100% of PICC line placements in radiology or an IV Team that utilized traditional PICC line insertion tools.1,3,4 Minimum competency criteria for full-time PICC line nurses are considered (50) successful insertions utilizing modied seldinger technique and portable ultrasound. Nurses are observed for competency in performing (5) PICC line insertions, PICC line declotting, PICC line suturing, and PICC line exchange. The service pro-

vides all materials to place a PICC lines and guarantees a policy of No placement / No charge. In other words the service guarantees a 100% insertion success rate. Nurses contracted with the service must maintain a 90% insertion success rate on all patient assignments. Those not meeting minimum criteria are precepted at bedside or eliminated from the service. A success rate below 90% of all PICC lines ordered is not considered acceptable to maintain in-house competency standards. For the time period Jan 1 Aug 31, 2003 the prociency in PICC line placement was 98% of all ordered placements. That means only 2% of placements (12 month) failed and were sent to the radiologist or surgeon out of 650 orders a month. In essence the company boasts a No Placement / No Charge guarantee as a result of this 98% success rate. Almost 100% of PICC line patients referred are attempted; there is no automatic deferral of a line to radiology. In addition, staff must meet 98% of all quality initiatives or performance initiatives on documentation, patient follow-up, patient teaching, and clinical review of radiology lms, patient satisfaction surveys and physician orders. If a consultant falls below this performance for two months they are not considered procient and are eliminated. The program has grown from zero insertions in 1998 to almost 700 PICC line insertions a month and 900 patient contacts. Currently over thirty hospitals are serviced in the Fort Worth Dallas metroplex. There are 20 independent nurses working for Infusion Nursing Consultants. It is an ungoing challenge for our institution dedicated to PICC placement to maintain our prociency criteria. It must be an insurmountable challenge for some institutions without the same dedication to reach a 90% insertion success rate. Going above and beyond in providing service is our motto. Many independent contractors stop at just providing a procient PICC line insertion. Although a 98% prociency rate is remarkable the ultimate goal is achieving the completion of infusate therapy without complication. Infusion Nurse Consultants have added a patient outcome tracking device. Hospitals with per diem PICC

line insertion programs rarely have an outcome monitoring system, and hospitals with a dedicated IV Team often do not have an outcome tracking system. The end result is just as important as the initiation of service. Hospitals can be provided with infection rates, occlusion rates, and patient pull out rates, thrombosis rates, breakage rates, phlebitis rates and completion of therapy without complication rates. Re-education of staff to improve complication rates is provided with the help of Infusion Nurse Consultants to each unit of service, medical oor or department. New outcome data is tracked to conrm improvement related to the education provided. In 2003, the overall diagnosed infection rate for PICC lines was less than 2%, and thrombosis rate was less than 2%. Both of these rates fall within the Society of Interventional Radiology Quality Threshold Benchmarks.12 Currently our new goal is to track the timeliness of PICC orders. Can we decrease the patient length of stay by proactive PICC insertion at or near patient admission. We are reviewing all patients for admit date versus PICC order date and diagnosis with the intent of identifying clinical pathways for our customers.

Conclusion:
Prociency in PICC line insertion is the goal. That prociency is dened as PICC line insertion success by nursing at the bedside at 90% or greater. Many hospitals comply with the Infusion Nursing Society minimum competency criteria to place PICC lines, but that minimum competency does not guarantee a 90% insertion success rate for PICC placements. The usage of an independent contractor dedicated to competent cost-effective PICC line insertion is another option. This service can substitute for a per diem nursing PICC team process or sending 100% of PICC lines to radiology. Cost savings by utilizing an independent contractor can offset the cost losses associated with these unstructured PICC programs. Hospitals that employ an IV Team to place PICC lines should compare the success rates of their teams to that of a proposed independent con-

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tractor. It may be feasible to hire an outside contractor to place unsuccessful PICC lines prior to sending a patient to radiology or to refer all PICC line placements to radiology. It is important to clearly evaluate your prospective contractor closely before signing up. Not all contractors are created equal. The author has taken the liberty of creating a list of consultant expectations when shopping around for a service.

of Nurse Examiner verication of license, OHSA compliance, HIPAA compliance, age-specic competencies, code of conduct, health records, yearly and random drug screens, job descriptions, current CVs and certicate of malpractice insurance.

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Criteria utilized to evaluate an independent contractor placing PICC lines:

Outcome data should be provided on infection, occlusion, thrombosis, phlebitis, patient pull out and breakage. Corrective action, solutions and education should be provided by your contractor.

All nursing staff utilized by the contractual service must maintain a minimum competency rate on PICC insertion of 90% or above. Infection rate should be reported by the contracted service to the customer and that rate must be less than 2% of overall placements. Patients must be provided with a teaching guide and individual one on one teaching. Documentation should be provided by the contractor to ascertain patient consent and comprehension.

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Ongoing prospective data should be gathered and provided by your contractor on insertion complications, insertion documentation, patient teaching, and dressing change. Statistical data should be provided monthly on each clinicians personal insertion success. Each facility should receive a monthly report on total services rendered with success and non-success No place/No charge guarantee should be provided

for the placement of PICC lines. It is clearly important to evaluate all aspects of your current program and ask yourself: Are my patients safe and satised with nursing performance at PICC placement? Are my nurses performing at a 90% insertion success rate which is the acceptable standard of care? How much money am I currently spending on labor and supplies versus utilizing an independent PICC contractor? Maybe it is time to re-evaluate your PICC program and review options that have traditionally been out of the box thinking;, the independent PICC contractor versus the per diem PICC nurse program. n John Davis graduated in 1984 from University of Texas Nursing School and has practiced nursing for almost twenty years. Johns clinical background is endoscopy, neonatal ICU, perioperative surgery and infusion therapy. John has managed an independent infusion company as the Chief Executive Ofcer specializing in the training and placement of PICC lines since 1998. Kathy Kokotis graduated in 1984 from Purdue University School of nursing. In addition to her nursing background she has a Bachelors degree in Biology and a Masters degree in Business Administration. She has practiced in the elds of infection control and cardiology. She has been in the eld of vascular access since 1987. Currently she is an independent consultant in vascular access with a emphasis on nance and reimbursement.

Yearly credentialing will be provided to the hospital on each consultant employed by the contractor. This information given to the customer includes; yearly competencies, background checks, Board

Consultant should provide oncall placement and troubleshooting of complications 24 hours a day seven days a week This manuscripts purpose is to discuss the expected insertion success rate

R E F E R E N C E S
1. Kokotis K. New trends in vascular access therapy. JVAD. Summer 2001; 7-17. 2. Terry J, Baranowski L, Lonsway RA, Hedrick C. Intravenous Therapy Clinical Principles and Practice. 1st ed. Philadelphia: WB Saunders Company; 1998: 1-6. 3. Santolucito JB. A retrospective evaluation of the timeliness of physician initiated PICC referrals. JVAD. Fall 2001;20-26. 4. Royer T. Nurse-driven interventional technology. JIN. 2001;24(5):326-331. 5. Crawford M, Soukup SM, Woods SS, et al. Peripherally inserted central catheter program. Nursing clinics of North America. June 2000;35(2):349-360. 6. Blackburn R, Kokotis K, eds. Bard Access Systems Vascular Access Device, Selection and Management Manual. Salt Lake City: Bard Access Systems; June 2001. 7. Website for www.press-ganey.com patient satisfaction 8. Fitzpatrick MA, Steltzer TM. Salary Survey 2002. Nursing Management. 2002;33(7):20-24. 9. Cardella JF. Cardella K. Cumulative experience with 1,273 peripherally inserted central catheters at a single institution. Journal of Intravenous Radiology. 1996;(7):5-13. 10. Fong NI, Holtzman SR, Bettmann MA. Peripherally inserted central catheters outcome as a function of the operator. J Vas Interv Radiol 2001; 12:723-729. 11. Neuman ML, Murphy BD, Rosen MP. Bedside placement of peripherally inserted central catheters: a cost-effectiveness analysis. Radiology. 1998;206(2):423-428. 12. Lewis CA. Allen TE. Burke DR. et al Quality Improvement Guidelines for Central Venous Access J Vas Interv Radiol 2003;14:S231-235.

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