Care and cost-utility indicators for
high-flow PICC catheters: a study
Paloma Ruiz Hernández, Juan Luis González López,
Juliana González Martín, Beatriz Rivas Eguía
nutrition. In order to fill this gap IV Team was founded, initiated by the Intravenous Nurses Society (INS). Intravenous therapy teams (IVTT) provide care, education and
An IVTT is a multidisciplinary outfit comprising expert supervision of the patient with a central line, and his/her family.
nurses in the control and care of intravascular lines working This article discusses the creation of an IVTT in the Hospital
in coordination with Vascular Radiology Services, receiving Clínico San Carlos of Madrid, Spain, demonstrating its effectiveness
technical and medical support for their part, and performing using cost-utility analysis and outcomes indicators. In 2009 the
care and close supervision of the patient with a central line, IVTT began using a high-flow peripherally inserted central catheter
while educating health professionals, patients and their family. (PICC) with its target population of chronic patients dependent
The use of peripherally inserted central catheters (PICCs) on central venous catheters or prolonged IV treatment. The team
has increased exponentially since they were first used to designed activity, welfare, educational and economic indicators. Of
administer IV therapy in the 1980s, especially in recent years. the 98 catheters placed, 80% of patients achieved a positive response;
Today, PICCs are the second-most implanted central venous 42% of catheters were removed after death and 30% by the end of
lines worldwide, only surpassed by tunnelled central venous treatment. Four percent were removed due to infection. The average
catheters (TCVC) for acute treatments.
implantation duration was 45 days. The economic study showed an
An IVTT formed of skilled nurses trained in the insertion increasing cost saving compared to peripheral catheters after 90 days
of these catheters significantly reduces iatrogenic risks, of implantation, and after 77 days compared to central venous
costs and workloads, increasing the safety and welfare of catheters. This translated into an immediate saving of €161 (£133.70)
patients (Eggimann et al, 2000; Sherertz et al, 2000; Carrero and €303.83 (£252.31) per catheter over Hickman lines and ports,
Caballero, 2006a). A study in the use of PICCs compared as well as reduced risks, length of hospital stays and costs. The study
with traditional central lines has shown a marked reduction shows PICC to be cost-effective with reported benefits to patients,
in both local infection at the insertion site (5.8% for PICCs, professionals and organizations. The creation of the IVTT has resulted
compared with 24.7%) and catheter sepsis (1.4% compared in improvements to care and the management of resources.
with 5.2%) (Gómez Luque et al, 2002). In addition, the placement of PICCs by nursing staff trained in this procedure Key words: Intravenous therapy team
results in fewer complications than surgically placed CVC, in n PICC cannulation relation to length of time of catheter insertion, morbidity and n Quality indicators n Cost-utility cost (Abi-Nader, 1993; Lam et al, 1994; Crowley et al, 1997; Ng et al, 1997; Soifer et al, 1998; Skiest et al, 2000; Brenner ntravenous therapy teams (IVTT) have been operating et al, 2003; Maki et al, 2006). for more than 20 years in the US, where they are known Published data on cost-effectiveness of PICCs are favourable as IV teams, and in Spain have their own association, the for a number of treatments, including chemotherapy (Gabriel, Asociación de Equipos de Terapia Intravenosa (Intravenous 2003), and mid- to long-term IV therapy or hyperosmolar Therapy Team Association) that promotes them. However, IV treatment (5 < pH < 9 or osmolarity > 900 mOsm/L), as pharmacists were the first to note the need for the creation in cases of total parenteral nutrition (TPN) (Steiger, 2002; of a dedicated IV association to address shortcomings in the Shaw, 2008) and home parenteral nutrition (HPN) (Brenner, care of patients with endogenous treatment at home and, in 2003; Gabriel, 2005). Table 1 shows a list of substances for particular, to eliminate the drawbacks of home parenteral peripheral and central infusion, according to the patient's pH and osmolarity. Paloma Ruiz Hernández is Medical Oncology Nurse, Hospital Nurses working with cancer patients are becoming more Clínico San Carlos of Madrid; Juan Luis González López is Material aware of the need for patients to have an ‘insurance' means Resources Coordinator and Associate Professor, Complutense of venous access in the long-term. Against this background, University of Madrid; Juliana González Martín is Medical Oncology the Hospital Clínico San Carlos established an IVTT formed Nurse Supervisor, Hospital Clínico San Carlos of Madrid; Beatriz Rivas of expert vascular access nurses from the Medical Oncology Eguía is Medical Oncology Nurse, Hospital Clínico San Carlos of Unit. The team's objectives include to train nurses to choose Madrid, Spain. which is the most appropriate device, cannulation or referral to a medical professional, to maintain venous access, and, Accepted for publication: January 2011 in turn, teach the patient and his/her family, as well as British Journal of Nursing, 2011 (Intravenous Supplement), Vol 20, No 4 Care quality
Table 1. Therapy for peripheral or central infusion
Peripheral infusion
Calcium gluconate From: Trissel (2002); Gahart and Nazareno (2010) professionals, about the care of catheters, demonstrating its cost-utility based on performance indicators as targets.
To this end, the PICCs used by the IV team were high- flow catheters, owing to its less invasive micropuncture technique compared to a traditional PICC, allowing for easier and less bloody insertion.
PICC insertion
The intravenous therapy team (IVTT), working mainly in
the Medical Oncology Unit, is primarily devoted to the
placement, care, maintenance and monitoring of PICCs
(Gabriel, 2005; Collaborative Intravenous Nursing Service,
2008). This group of professionals will be at the forefront of what to do and use in terms of human and material resources, with team training.
In 2009, the authors' hospital introduced the high-flow Figure 1. High-flow PICC catheter
PICC (Figure 1), a catheter made of polyurethane and radiopaque of 5 Fr gauge. The PICC facilitates access to ■ Educate and train in the use of intravenous PICCs to peripheral veins in a minimal y invasive procedure, with hospital nurses (Todd, 1998) microintroducer and modified Seldinger technique (Figures 2 ■ Provide technical support to other hospital services both and 3) which al ows the injection of contrast medium. Using for the central line care, and for new ways cannulation in this technique—blind modified Seldinger technique with difficult venous access micropunction—the catheter is placed into one of the large ■ High-flow PICCs placed in both cancer patients other cubital veins and threaded into the superior cava vein above the patients of the hospital as required right atrium (Figure 4). In this hospital the primary use is for ■ Coordinate with Interventional Vascular Radiology for radiology control post-implantation (Figure 5), and the chronic referral of patients who require the placement of CVCs patient population who depend on a central venous catheter or ■ Educate the patient and family when they are required to prolonged IV therapy as set out in Center of Disease Control take a catheter home. Development of fact sheets for the and Prevention (CDC) criteria category IB (O'Grady et al, patient and family 2002). In these cases, PICC wil be the first choice and will ■ Ensure extraluminal catheter care with patients' agreement primarily ensure that essential central line access is achieved, ■ Developing data collection sheets which reflect the efficacy while preserving most of the patient's venous access.
■ Ensure intraluminal care, providing necessary guidelines for IVTT functions, objectives and operation
the use of drugs to be infused, changing access ports and connectors, use of a dilute heparin to flush and seal, and The IVTT performs the following functions: use of fibrinolytics ■ To receive and respond to new cancer patients to evaluate ■ Create protocols for insertion and maintenance of each and recommend the type of catheter they need British Journal of Nursing, 2011 (Intravenous Supplement), Vol 20, No 4 Figure 2. Blind
modified Seldinger
technique with

advance guidewire
and introduce
Figure 3. …
Removing dilator
and guidewire, insert
and advance catheter,
retract and remove
sheath and complete
■ Create manuals for ambulatory patients who are undergoing self-care at home Brachiocephalic vein ■ Data collection for monthly reporting and recording the activity of the complications associated with use of Superior vena cava intravenous catheters ■ Epidemiological surveillance and control. IVTT objectives
■ Reduce the number of patients in the hospital, improving vascular care through training ■ Reduce the number of patients suffering from phlebitis, ■ Reduce the number of patients receiving chemotherapy for peripheral vein through the placement of PICCs ■ Reduce the number of patients requiring hospital admission to receive one cycle of chemotherapy have not placed central catheter ■ Increase the number of nurses trained in central venous catheter in Hospital (category IA; Crnich and Maki, 2005). ■ Reduce the number of catheter-associated infections (Maki Figure 4. Catheter placement
et al, 2006; Carrero Caballero, 2006b).
British Journal of Nursing, 2011 (Intravenous Supplement), Vol 20, No 4 Care quality
Vascular radiology PICC application Not complications Not exceptional cases Exceptional cases Care control monthly Intravascular expert Vascular radiology Patient information Radiology control Figure 6. Algorithm for PICC implantation
and maintenance of any other central or peripheral catheter The IVTT receives patients to assess the need for CVC, in long-term treatment, such as cancer, results in significant depending on the medical diagnosis, prescribed treatment cost savings and reduced workload, which would be sufficient and prognosis. Patients are sent from their medical oncology grounds to approve the introduction (González López and consultation in the case of outpatients, or from other hospital González Martín, 2006). consultations (e.g. cardiology, gastroenterology); inpatients The economic impact that the IV team unit had in our receive the request for assessment by the nurse responsible for hospital, especially in relation to high-flow PICC placement, the patient (Figure 6).
is set out below. Each high-flow PICC implantation (the Patient assessment takes place in the following sequence: model introduced in our hospital), at a cost of €140 (£116), ■ The diagnosis and prognosis replaced one of the following techniques: ■ Need for IV therapies (Kiernan, 1997; Dolan, 1999) ■ Peripheral intravenous catheters (PIVC): according to
■ Vascular capacity of patient and potential risks protocol, the catheter is changed every 72 hours. The cost ■ The patient's knowledge and preference: an informed is €1.40/unit (£1.16), and equipped with safety devices. patient may express a preferred option ■ If needed, therapy begins with the introduction of a high- flow PICC and, if peripheral vascular capacity allows, will proceed to the implementation of it in the drive ■ IVTT refers patient to Interventional Radiology Vascular when: PICC implantation is not possible in the unit; patient's needs require a Hickman catheter; patient safety requires a cover over a port catheter.
Economic impact of the establishment of IVTT
The first major difference between the PICC implemented
by IVTT and other types of catheters that can be substituted
in certain cases, is that PICCs can be placed by a nursing
assistant, who can perform alongside properly trained nurses
and interventional radiologists. In this way, the IVTT reduces
the workload and delays in implementation requests generated
by the hospital's oncology service. If the cost savings of having
a nurse rather than a specialist radiologist and a vascular
radiology room with fluoroscopy; therefore, the establishment
Figure 5. Radiology control
British Journal of Nursing, 2011 (Intravenous Supplement), Vol 20, No 4 ■ Port catheter (Port-a-cath): these long-term-catheters
Table 2. Objective outcome indicators (%)
are contraindicated in the case of parenteral nutrition. The cost is €433.82 (£361), in addition to the cost of surgical Indicator 1. Number of nurses trained in the Oncology Unit × 100 implantation interventional radiology, so its replacement Total number of unit nurses by high-flow PICC, where this is feasible, represents an Indicator 2. Number of nurses trained in other Hospital Units × 100 immediate saving of more than €303.83 (£253). Total number hospital nurses However, the above cost savings can not be described Indicator 3. Patients informed of the technique and risks of catheterization as anything other than the tip of the iceberg, as the use of Patients with implanted PICC catheters PICCs also yields cost savings arising from decline in rates of catheter-associated infection, and its haemodynamic and Indicator 4. Number of PICC catheters placed in the units × 100 mechanical complications, as well as the increased outpatient Total number of catheters treatments, with a subsequent reduction in hospital stays. Indicator 5. Number of infections associated with catheter PICCs Total number of PICCs implanted Indicator 6. Number of infections associated with catheters PICCs Although the need to create an IVTT was identified in Total number of infections associated with CVC 2006, its implementation was delayed pending assessment of the healthcare impact of introduction of the new technique, which was designed to measure activity indicators—welfare, educational and economic. The hospital set a number of outcomes indicators by which to measure the objectives of the IVTT: ■ Objective 1: ‘Training in use of high-flow PICCs by Medical Oncology Unit nurses and training of nurses from other units of the hospital.' There will be an annual vascular access seminar for all nurses interested in participating. Indicator 1 and 2 (Table 2) ■ Objective 2: ‘Inform patients of advantages and disadvantages of high-flow PICCs over other types of catheters.' PICCs are placed directly into the unit with nursing staff, allowing immediate administration of drugs, TPN, QTP, transfusions with a lower rate of complication. PICC is not without risks, as with any other invasive technique. Indicator 3 (Table 2) Figure 7. Number of PICC catheter cannulated in 2010 to date
Objective 3: ‘Increasing the number of high-flow PICCs placed in To this the cost of daily withdrawals, the daily intake of the Oncology Unit in relation to other types of catheters.' Given dilution heparin solutions for cleaning PIVC, and time the benefit that the catheter provides to patients, nursing costs of nursing and other materials used are added. This staff, and the hospital in terms of resource sustainability, represents an approximate total cost, only material, €52.2/ the objective was to exponentially increase the number of month using biomaterial, or £43.41. Therefore, each PICC high-flow PICCs implanted. Indicator 4 (Table 2) would be profitable from a purely economic point of ■ Objective 4: ‘To reduce the incidence of catheter related-bloodstream view, from approximately 3 months of implantation. PICC infections (CR-BSI) rates in our unit and throughout the hospital implantation may continue up to 6–12 months, so the as an indicator of clinical care.' The literature reports a lower savings would be increased rate of CR-BSI with the use of PICCs compared with ■ Central pathways (CVC): according to protocol these are
other CVCs. Indicators 5 and 6 (Table 2). changed every 15 days at a cost of €12.62/unit (£10.49), to which the authors add everyday use of heparin, and the time of interventional radiology and use of fluoroscopy. All PICCs were cannulated by nurses trained in the placement Without factoring in the expense of vascular interventional and care of such catheters. At the time of writing, a total of radiology, we calculate a monthly cost of €54.44 (£45), 98 high-flow PICCs had been placed (our estimate of the meaning the substitution of PICC would be economically total number of catheters placed at year end is 140 catheters), viable from approximately 77 days of implantation. compared with 45 catheters placed in 2009 (Figure 7). Follow- ■ Hickman central catheter: the placement of these
up and other features were recorded in a database: patient long-term catheters is performed by interventional diagnosis, insertion causes, site of implantation, removal causes radiology. Not including medical and fluoroscopy time and number of days the catheter was placed. All results will also costs, the unit price is €301 (£250), being a more be included in a report by Bard Ltd, with the working title: A invasive method and with greater risks for the patient. Registry Study to Explore the Routine Use of PICCs in Europe. The implementation of high-flow PICCs as an alternative Of the 98 PICCs cannulated, 88 were high-flow catheters means an immediate saving of €161 (£134), to which must single-lumen cannulated by expert nurses, and seven be added monthly costs of heparinization of the catheter of high-flow catheters double-lumen cannulated for vascular approximately €15.90 (£13). radiology. Insertion causes were (Figure 8): British Journal of Nursing, 2011 (Intravenous Supplement), Vol 20, No 4 Care quality
■ Parenteral nutrition (48%) ■ Poor integrity peripheral veins (29%) ■ Treatment with chemotherapy (16%) ■ Antibiotic therapy (7%). Removal causes were mainly end of treatment (30%) and death (42%). Only 4% were withdrawn due to confirmed infection (Figure 9). The average length of time the catheter was implanted was 45 days.
Catheters implanted by IVTT has been found to be an
effective, safer and cheaper alternative for patients who
require long-term NTP, and for whom use of port catheter is
contraindicated. High-flow PICCs are indicated to preserve Figure 8. PICC insertion causes
the peripheral vascular system of the upper limbs, eliminating punctures and reducing pain and discomfort, prevent hospitalization of patients to administer certain treatments and substantially reduce the risk of catheter sepsis.
From an economic point of view, the use of high-flow PICCs showed an increased saving compared with peripheral
catheterization after 93 days of implantation, and 77 days
with regard to CVC, assuming an immediate saving of €161
(£134) and €303.83 (£253) for of Hickman and port
catheters. Use of high-flow PICCs also reduced risks and
helped reduce hospital stays and their associated costs. BJN
Acknowledgement: The authors would like to acknowledge the contribution of the reviewer Fernández Muñiz L, the database Figure 9. PICC removal causes
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British Journal of Nursing, 2011 (Intravenous Supplement), Vol 20, No 4


Secondary open-angle glaucomas

Thomas F. Freddo, O.D., Ph.D., F.A.A.O. Professor of Optometry University of Waterloo  Ocular injury; recent or old Secondary to Iritis  Phacolytic Ghost cell Melanomalytic Steroid-induced Pigmentary glaucoma Exfoliative glaucoma Note especially deep ciliary body band and posterior dislocation of iris root. Follows non-penetrating blunt trauma – Important to remember that not all patients can document a traumatic event. Gonio all young patients with unilateral cataract.Following blunt trauma recession develops often, especially if associated hyphemaR/O ruptured globe – no gonio for first 2-3 weeks. Gonio both eyes to compare. Use goniolens not prism.Only 5-20% of those with recession will develop glaucoma, but it can occur at any time after the injury.More common if recession greater than 180 degrees.Prostaglandin analogs have a theoretical benefit because the trabecular meshwork is thought to be dysfunctional. Otherwise, initial med therapy similar to other OAGs