Nurses revamp IV therapy: One stick lasts months
PICCs cut complications, costs of therapies
Needles. Patients dread them, yet hundreds owe their lives to the medications they deliver. So you can imagine the excitement at Lehigh Valley Hospital (LVH) in Allentown, PA, when staff learned about an intravenous (IV) therapy device that stays in place for months instead of three to five days as with older methods.
The new device, a peripherally inserted central catheter (PICC), frees people to go home and resume normal activities. One woman actually received intermittent cancer chemotherapy for two years from one PICC insertion. PICCs also can deliver antibiotics, antivirals, and nutritional therapies.
Application at bedside
PICCs are flexible, IV-access tubes of silicone or polymer, 20 to 24 inches long. The catheter goes into one of the large veins of the upper arm and advances into a larger vein near the heart. Unlike older IV devices, PICC insertion is not an operative procedure. In fact, LVH nurses do them at the bedside.
Compare that to invasive subclavian (beneath the clavicle) insertions performed by physicians. Sites had to be changed every five days due to venous irritation from the caustic medications. The other alternative, a Hickman catheter, involves surgical insertion into the chest wall. In either case, the complication rates were high.
Costs of maintaining the older devices also are high. While they have to be changed every four days after the patient goes home, the PICC only requires a weekly dressing change. That alone saves $812 per patient in home care costs. (For comparative insertion costs, see table, "Estimated Cost of Insertion of Catheters," p. 126.)
Nurses recognize trend before it starts
When the LVH nurses saw their first PICC patient five years ago, they knew more were on the way, recalls Mary Agnes Fox, RN, MSN administrator of patient care services. So they wasted no time developing a protocol to take care of them. Fox and colleagues sold the project to the administration and medical staff as an initial policy "for care of the occasional patient with a PICC," she says.
Foreseeing the overlap between subacute and home care, they recognized that success depended on building seamless communications between the bedside and home care providers and an interdisciplinary nursing team.
True to the nurses’ intuition, PICC volume rose to 120 insertions in six months following the first patient’s admission. Today, the monthly average is 100. To Fox’s knowledge, the LVH team is the only one in the Lehigh Valley, a region 50 miles northwest of Philadelphia. (See graph, "Number of PICC Insertions," for quarterly rates of PICC insertions since 1994, p. 126.)
In the absence of readily accessible role models, the LVH nurses mapped their own way using patients’ perceptions and needs as a guiding principle. Patients’ feedback indicated a desire for a comfortable, durable, and reliable IV system.
The PICC team grew from its original 1.8 full-time equivalents (FTEs) to the present 2.8 FTEs, costing $141,055 a year. Quantifiable cost savings of the project are $372,459 a year. (For a breakdown of the savings, see chart, "Summarization of Justifications and Cost Benefits," p. 125.)
Fox credits the team’s success to the following factors:
• Clinical training with built-in continuous quality improvement.
At first, key nursing staff received training sessions in PICC procedures so they could provide clinical support and instruction to staff nurses and troubleshoot problems. However, maintaining competency was difficult due to sporadic clinical exposure. Now PICC team members themselves provide case-by-case bedside teaching of staff nurses at the time of insertion. The four team members can handle almost any type of clinical situation because they come from backgrounds in emergency, medical/surgical, and home infusion care. In addition to on-site consultation for insertions, the team is on call 12 hours every day.
• Standardized PICC care policies and procedures across care continuum.
The PICC team hosts quarterly inservices for about 30 Lehigh Valley Home Care nurses. Topics include troubleshooting, catheter maintenance, and redressing. A smaller core group of home care nurses receives insertion training. The team also teaches catheter insertion and maintenance techniques to nurses from long-term care institutions and other hospitals in the area.
• Support from administrative and medical staff.
Approval of top management lent credibility to the initiative, and that helped the nurses gather key players. Represented on the original planning group were the infection control department, physicians, pharmacy, radiology, and materials management.
• Sensitivity to patients’ needs for information and support.
To ensure the best care outcomes, a PICC team nurse screens IV patients, identifying those whose health status and family or community support make a PICC home-maintenance plan feasible.
For likely candidates, the nurse contacts the patient’s insurance plan, infusion pharmacies, and the home care agency that will be involved. Patient and family teaching begins at the bedside on the day of insertion. The team wrote a detailed booklet, titled Home Advisor, illustrating the step-by-step procedures for home management.
The hallmark of this project is its rapidity in moving people back to their familiar surroundings, where they heal best. "Patients are happy to go home after a short hospital stay, and this is not an operative procedure. They like that," says Fox. By other measures, the project is equally laudable:
1. Medical staff satisfaction.
The PICC team averages 4.42 points out of a possible 5, compared to 3.95 for 30 other LVH clinical cost centers.
2. Cost benefits.
Length of stay savings for PICC patients over other IV procedures: $90,720.
3. Clinical outcomes.
The infection rate is 0.3%, or seven infections for 2,282 insertions; 90% to 95% of the PICCs remain in place until conclusion of therapy.
4. Overall performance excellence award.
The PICC team won the prestigious 1997 Quality Valley, USA Team Award, in Lehigh Valley’s all-industries competition.
Sources
For more on designing PICC teams and patient care guidelines, contact:
• Mary Agnes Fox, Patient Care Services, Lehigh Valley Hospital, Cedar Crest & I-78, P.O. Box 689, Allentown, PA 18105-1556. Telephone: (610) 861-2500. Fax: (610) 402-1674.
For clinical details, see:
• Driscoll M, Buckenmyer C, Spirk M, et al. Inserting and maintaining peripherally inserted central catheters. MEDSURG Nursing 1997; 6:350-358.
For the IV nursing standards of practice revised January 1998, contact:
• Intravenous Nursing Society, Fresh Pond Square, 10 Fawcett St., Cambridge, MA 02138. Telephone: membership services, (800) 694-0298. World Wide Web: http://www.ins1.org. Cost: $40 for nonmembers, $10 for members. The Web site details the guidelines, but they are not downloadable.
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