5 Real world implementation examples

NHS contributors to this resource have worked with NICE to develop practical suggestions on how to implement the NICE guidance on SecurAcath. All 4 organisations use SecurAcath for peripherally inserted central catheters (PICCs). Table 1 gives a summary of the contributing sites' demographics.

Table 1 Contributor demographics

Site

Local project lead designation

Adopted for PICCs

Annual PICC placement

Comments

Aintree University Hospital NHS Foundation Trust

Intravenous access specialist nurse

2014

600

Trialling on all midlines since 2016. Annually place 400 midlines. PICC dislodgement rates reduced from 6 (pre-implementation) to 0.9 per 1,000 catheter days (post-implementation)

East Kent Hospitals University NHS Foundation Trust

Intravenous nurse practitioner and consultant anaesthetist

2014

2,000

Routinely used on non-tunnelled CVCs since 2015

The Royal Marsden Hospital NHS Trust

Intravenous therapy nurse consultant

2010

1,300

PICC dislodgement rates reduced from 5.4% (pre-implementation) to 4.8% (2012) and further to 1.5% (2016)

Velindre Cancer Centre

Intravenous access nurse specialist

2010

450 to 500

Use a locally developed algorithm to predict patients pain on removal and guide clinical management

Abbreviations: CVC, central venous catheter; PICC, peripherally inserted central catheter.

Aintree University Hospital NHS Foundation Trust

Aintree University Hospital NHS Foundation Trust is a large teaching hospital serving North Liverpool, South Sefton and Kirkby.

The current IV team was established in August 2014 and consists of 2 band 7 IV access specialist nurses and 1 clinical support assistant. The IV service was commissioned to insert medium- and long-term IV devices, to enable delivery of various therapies and reduce all IV-related infections and complications.

Before commissioning of the IV team in August 2013, interventional radiologists led on venous catheter insertion in the trust and PICCs were secured with an adhesive device (Grip-Lok). There were reports of high rates of exit site infections and migration (6 cases per 1,000 catheter days), and nurses had been worried about changing PICC dressings for fear of venous catheter migration.

One of the IV clinical nurse specialists who joined the team in 2014 had previous experience of SecurAcath, and had already seen reduced venous catheter migration and improved patient experience as a result of its use in another trust. A pilot phase was planned to include any patient needing a PICC for 1 week or more. The company provided training on placing, maintaining and removing SecurAcath devices. This included hands-on training and supervision when placing the first 10 devices, and virtual support while the team continued the pilot period for the placement of 20 more devices.

The results of the trial indicate a reduction in the migration rate from 6.0 to 0.9 cases per 1,000 catheter days. The team have found that using SecurAcath has not increased the appointment time needed for insertion. They have trailed various dilators and identified one (the Arrow Teleflex MST kit) that enables them to insert the catheter and SecurAcath without the need to 'nick' the skin.

Initial challenges were that it was hard to clean the grooves of the SecurAcath device if the insertion site leaked. They used to place gauze underneath and over the insertion site and change the dressing at 24 hours. The team now applies skin adhesive on the PICC insertion site, which helps to form a tight seal and has stopped the need for the 24 hour dressing change. From a sterility perspective the dressing can now be left for 7 days. Because dressing changes can take up to 30 minutes, the team has saved 2 to 3 hours a day by not needing to change the dressing at 24 hours.

SecurAcath is now used for all PICCs placed in the trust. A PICC booklet has been developed, which is given to every patient with a PICC line to share with their carers and other healthcare staff. This includes full details of the insertion and dressing changes, and advice to patients. There is also a graphic and instructions on SecurAcath removal.

The team have been piloting the use of SecurAcath for midlines since December 2016. Because of winter pressures on the service, they have decided to adopt a blanket approach to SecurAcath for all venous catheters to avoid the risk of migration and the need to replace the venous catheter. The rationale for this is that it is more cost effective to spend an additional £19 for a SecurAcath device than to bring the patient back to clinic in the event the venous catheter needs to be replaced.

The team will review the year-end report with complications, infections, migrations and replacement rates to compare with the previous 2 years to decide if they will continue with this approach.

Lessons learned

  • Be specific when asking patients about nickel allergy: ask if they have any metal allergies or any problems with jewellery.

  • Try different dilators to identify which will help position SecurAcath the best.

  • Identify how long the venous catheter is intended to be in place, to calculate if it will be cost effective.

East Kent University NHS Foundation Trust

East Kent is one of the largest hospital trusts in England, with 5 hospitals and community clinics serving a local population of around 759,000 people. The PICC line service is provided across 3 hospital sites in the trust by a team of 5 IV nurse practitioners. The team place over 2,000 PICCs every year, most of which are for chemotherapy. After-care and dressing changes are done by district nurses working in community clinics.

Before the introduction of SecurAcath in 2014, most PICCs were secured with an adhesive stabilisation device (StatLock) which needed to be replaced at every dressing change. The team were aware of a high number of reported incidences of accidental dislodgement and venous catheter migration, particularly during dressing changes in the community. Venous catheter migrations of up to 12 cm had been reported in 80% of patients, with half of these needing PICC removal and replacement with an additional visit to hospital and a repeat procedure.

The team estimated the cost of putting in a new PICC to be £150 to £200 for materials alone, plus 45 minutes of nurse clinic time for the procedure. Inpatient PICC placement service is part of a block contract and outpatient chemotherapy catheters are a standalone episode of care paid for by the CCGs via Healthcare Resource Group.

The team became aware of SecurAcath in 2013, when a patient from a different hospital presented for review with the device in place. Following feedback from the patient, the team recognised SecurAcath's potential to solve the problems with PICC migration they were experiencing and decided to undertake a trial evaluation period.

The lead IV nurse practitioner approached the trust's procurement department with a proposal to trial the SecurAcath device on 50 patients and evaluate the results. This approval was needed because StatLock costs between £4 and £5, while SecurAcath costs approximately £19.

The lead IV nurse practitioner then selected 50 consecutively presenting patients over 1 month. The main selection criteria were patients: having chemotherapy, needing a long-term PICC, who may pull out venous catheters, or with excess skin moisture.

Following the trial the team evaluated the results and found that use of SecurAcath provided significant cost savings compared with their previous practice. The costs of a typical number of PICC replacements in 1 month was the equivalent of the cost of SecurAcath for 1 year. Because the cost of PICC replacement outweighed the cost of SecurAcath, the hospital procurement team agreed to the plans to adopt SecurAcath.

Since 2014, there have been only 2 incidences of catheter migration (1 by a non-compliant patient, and 1 accidently pulled out by a patient's partner).

The lead IV nurse specialist now offers cascade training on the device and dressing changes to hospital based staff. Hospital and community staff are invited to watch the device being removed and only staff who can confidently remove the device are allowed to do so.

On one of the critical care units within the trust (consisting of 11 beds), the critical care team considered and trialled various options for securing venous catheters. Following the successful implementation of SecurAcath for PICCs, the critical care team decided to try the device with standard central venous catheters in order to provide safe and effective vascular access and to reduce exit site infections. They have now been using it in routine practice since 2015. Because of the weight of the catheter, which can often be 4 lumens, the team also use Grip-Lok for added stability. Figures from the past 12 months at East Kent show that the critical care services have ordered 490 SecurAcath devices.

Lessons learned

  • Ensure staff are appropriately trained, gaining experiential learning both from the company and other organisations using the device.

  • Persevere with the learning curve; using SecurAcath can be daunting and extra time may be needed to ensure correct placement.

  • Have a key person within the organisation to cascade learning and act as a central point of contact for enquiries.

The Royal Marsden NHS Foundation Trust

The Royal Marsden NHS Foundation Trust is a specialist hospital dedicated to cancer diagnosis, treatment, research and education. There are 2 hospital sites (Chelsea, London, and Sutton, Surrey) and a medical day-care unit at Kingston Hospital. The Royal Marsden also provides community services in the London borough of Sutton and the trust is currently establishing a mobile day unit. The catchment area spans from Oxford to the south coast.

The trust has 18 nurses who place over 1,300 PICCs every year. Most of these are placed in an outpatient setting, for people who need chemotherapy delivered at home. Some patients need a PICC for antibiotics or total parenteral nutrition after surgery, or because of poor peripheral access.

For over 10 years the team used StatLock, which needed to be replaced every 2 weeks or so at dressing change. Problems included dislodgements, particularly during dressing changes, skin irritation, venous catheter malpositions and recurrent replacements.

Because of these problems, the team had been researching alternative methods to secure PICCs. They first became aware of SecurAcath in 2009 when the lead IV access nurse saw it in use at an early design phase in another country, and was keen to try it out once it was available in the UK.

In 2011, the nurse consultant for IV therapy established a project team which included other clinicians to develop an evaluation protocol for the use of SecurAcath across the trust. They spoke to the company and to clinicians overseas who had already adopted the device to gain as much advice and information as they could before implementation.

The project team looked at the malposition and dislodgement rates experienced within the service and calculated the time and resources needed for PICC replacements (room, staff, equipment, X-ray or fluoroscopy if needed).

The evaluation protocol was taken to the trust's 'clinical product review committee' with a rationale for conducting an evaluation. Two members of staff were then trained in inserting SecurAcath and an evaluation was done of 30 consecutive patients. The team gathered feedback from staff and patients on how they felt about insertion and removal, and evaluated the risks and long-term savings which could be achieved with fewer PICC replacements.

The pilot evaluation was considered to be a success and the team then rolled out the use of SecurAcath across the service. The team estimated that their average PICC placement time was 3 months; this equates to replacing StatLock 6 times, whereas SecurAcath can remain in position for the duration. At the time this resulted in a net saving of £7.22 per patient for a successful PICC placement (that is, not needing replacement).

All placements are now done by the nurses trained to place PICCs. Nurses on the day unit have been trained in device removal by a member of the team; they are then observed until they reach competency and can confidently remove the device while unsupervised.

In the first year of implementation (2012), 561 PICCs were placed with SecurAcath; of these, 27 (4.8%) needed replacing because of dislodgement. By 2016, 98% of all PICCs placed were secured with SecurAcath. Of the 1,030 PICCs placed using the device in 2016, the dislodgement rate had reduced to 1.5% (15 replacements, mainly inpatients).

The team have developed an insertion and removal chart that records whether there have been any difficulties. These are scanned and sent to the lead IV access nurse to maintain a central record.

Lessons learned

  • Use an increased catheter length, because an extra few centimetres are needed to accommodate the SecurAcath. If there is insufficient length this may result in the catheter 'kinking'.

  • Do a 'surgical nick' to the skin below the cannula before the introducer is placed, otherwise the introducer needs to be 'corkscrewed' into position. This nick also allows the arms of the SecurAcath to be positioned.

  • Using an insertion and removal chart and recording complications centrally can help monitor post-implementation impact.

Velindre Cancer Centre

The Velindre Cancer Centre in Cardiff provides specialist cancer treatment services to over 1.5 million people across south east Wales and beyond. The IV access nurse specialist team places between 450 and 500 PICCs each year. Most of these (98%) are for chemotherapy treatment in outpatients. The average dwell time is 3 months.

In 2012, nurses at the hospital placed 460 PICCs. The PICCs were managed over an approximate 50-mile radius in a variety of locations including the community, cottage hospitals, district general hospitals, teaching hospitals and hospices. Venous catheters were secured using wound closure strips and an adhesive securement device with a semi-permeable dressing to cover both. Previously, nursing staff had noted many episodes of catheter migration, from a few centimetres (needing no intervention) to significant movement needing catheter replacement. During 2012, 21 PICCs were replaced as a direct result of migration, costing around £5,250.

A member of the IV nurse specialist team had seen SecurAcath presented at a National Infusion and Vascular Access Society conference. At the time it was being used in the US for 5 French catheters, and could not be sourced in the UK for the 4 French catheter size the hospital used. The team contacted the company, and having sourced the correct size they proposed a trial period during which PICCs were placed with SecurAcath in 31 people.

  • All SecurAcath devices were placed successfully: 70% with ease, 19% with slight difficulty and 11% with difficulty because of it being a tight fit to place SecurAcath to the side of the PICC.

  • No patients reported any pain during placement as local anaesthetic was used as routine practice.

  • All PICCs were measured routinely during dwell time and on removal. Only 1 catheter moved by 1 cm.

  • Twenty eight patients (83%) were very satisfied with the device and reported no pain; 3 patients complained of pain and the devices were removed.

  • There were removal difficulties in 25% of cases, including: problems folding the lower portion of the device together to allow the pins to meet; removing the anchor from the skin because of resistance; and pain experienced by patients.

The team was surprised to see the incidence of PICC-related infection initially rise from 1% to 12% (4 out of 31 people). This caused great concern and when reviewed, some nurses reported not doing routine cleansing because of their unfamiliarity with the device. About 8 months after the first SecurAcath was placed, following staff training, a repeat assessment of the infection rates of 100 PICCs placed with a SecurAcath was done. Only 2 of these developed infections.

Device removal caused the most dissatisfaction among staff. Further training was organised, with experienced staff attending a 20-minute session focused on how to identify a potentially painful removal and the administration of local anaesthetic at the exit site. Staff who are not prescribers were able to use a patient group direction (see NICE Medicines practice guideline Patient Group Directions) written specifically for this purpose.

The evidence gathered from the evaluation enabled the organisation to proceed with the routine use of SecurAcath. The team now place between 450 and 500 PICCs per year using SecurAcath and estimate a cost saving of £25 per placement (assuming a 3-month dwell time).

The overwhelming benefit of the device is migration prevention. This has had a significant impact on the hospital's PICC insertion service and chemotherapy clinics by minimising the nursing time dedicated to the investigation and management of migrated PICCs and, consequently, has led to further significant cost savings.

Lessons learned

  • Infection rates were initially high in the evaluation as a result of unfamiliarity with the device. This has been successfully resolved after widespread training sessions.

  • Having an algorithm for predicting patients most likely to experience pain on removal has improved the patient experience by prompting the use of local anaesthetic.

  • Additional securement (StatLock) should be used on dual lumen catheters if they have multiple infusion lines, because the weight can pull the venous catheter through the SecurAcath device.


This page was last updated: 05 June 2017