The adoption of The Sherlock 3CG Tip Confirmation System for placement of peripherally inserted central catheters, at Queen Elizabeth Hospital, Birmingham

Aim: To create a nurse led vascular access service

Objectives:

• Standardise practice and increase capacity by creating a more efficient and effective PICC insertion service
• Decrease delays  in drug and nutritiontherapy
• Refreshing and rebranding the existing IV team and separating the infection control and vascular access functions
• trial the Sherlock 3CG TCS in the new vascular access team.
• Improve patient experience and outcomes
• Reduce costs

A nurse led IV team was established in 2008 in response to the initiatives Saving Lives and Epic 2 (Pratt et al. 2007). The purpose of the team was to oversee the education of both medical and nursing staff, with the aim of reducing health care-related infections caused by vascular access issues.

In March 2013, the consultant nurse manager of the team started an internal review of all PICC insertions across the trust. The objective was to standardise practice and increase capacity by creating a more efficient PICC service and improving delays in antibiotics therapy.

Stage 1 of the service review involved identifying staff who were placing PICCs, where they were doing this and the lines they were using. This found that PICCs were routinely inserted in the renal unit, interventional radiology, oncology and haematology.

The procedure for PICC placement was the same in each area, using the traditional method of ultrasound measurement and chest X-ray for confirmation.

Stage 2 of the review was to identify all PICC placement methods and systems available and to consult on these both internally and externally.

Following this 6 month review, the areas in the trust identified for improvement were interventional radiology, where the staff were keen to release capacity, and oncology, where additional support and training was needed. 

The consultant nurse recommended refreshing and rebranding the existing IV team and separating the infection control and vascular access functions. It was also decided to trial the Sherlock 3CG TCS in the new vascular access team. These recommendations were agreed by the Chief Operating Officer and Executive Chief Nurse.

A Senior Charge Nurse with appropriate experience was appointed in January 2014 to lead and develop a team of 4 band 6 nurses and provide additional support to the 3 existing oncology nurse PICC placers. The vascular access and oncology nurses had the training provided by the company for the Sherlock 3CG TCS and within 3 months were trained to competency. Placements are now done either in a clean room or at the bedside with full sterile procedure. A health care assistant maintains asepsis and operates the machinery.

A validation audit was done in May 2014 by a consultant radiologist who reviewed the X-rays and ECGs of 38 oncology and haematology patients with a Sherlock 3CG TCS-inserted PICC in April 2014. Of the 38 lines, 36 (95%) were categorised as acceptable and 2 as being out of position. Of the 2 out of position, 1 was deemed to be just inside the right atrium and the other had been accidentally pulled out by 3 cm between insertion and the time of X-ray. However, all PICCs were deemed as safe for use. Using the magnetic real- time tracking system also identified that 10 of the lines had migrated out of position during the insertion (internal jugular, brachio cephalic, contralateral). The inserter was able to re-manipulate all of the misdirected lines into a correct position. This avoided re-insertions, inconvenience to patients and added cost.

The consultant concluded that the system was safe for use but highlighted that it was not possible to accurately validate an ECG confirmation system using this method, and that an X-ray would need to be taken at the exact time of insertion to verify the line’s tip position with the ECG read out. He advised that all clinicians using the Sherlock 3CG TCS should be properly trained in its use and if there is any doubt when confirming a PICC tip position when using the system, a chest X-ray should be requested and reviewed by a medic.

An expanded practice protocol for registered nurses to insert peripherally inserted central catheters (PICC) and confirm position of PICC was agreed and signed off by the Executive Chief Nurse and Medical Director in July 2014.

An Excel spreadsheet recording all PICC placements referred to the team is kept for audit purposes. A 3‑month review of 131 people referred to the vascular access team for PICC insertions between May and August 2014 showed that:

• 126 of 131 were able to be inserted using the Sherlock 3CG TCS (5 were referred to interventional radiology; anatomical abnormalities or trauma, meaning the navigation plate could not be seated on the person’s chest)
• 110 of 126 ECG confirmations (87%) of the Sherlock 3CG TCS PICC tip positions were completed (16 people needed chest X-ray to confirm tip position due to atrial fibrillation or contra-indication to ECG but all were able to use the navigation system).

The team has done cost-benefit analyses and shown that there is a cost saving in delivering a nurse-led service using the Sherlock 3CG TCS. The team plans to submit a business case for additional band 6 nurses (and Sherlock 3CG TCS devices) to expand the service to cover the whole trust and all PICC placements.

The waiting time from referral to PICC insertion during this 12‑week period was compared with the 12 weeks prior to the service starting. PICCs placed within 24 hours increased from 19% to 75%. Full results are shown in table 3.

Table 3: Waiting times pre- and post-implementation of the Sherlock 3CG TCS

There is the potential in the future to identify other nurses in the trust who could be trained as PICC placers, instead of them referring to the vascular access service (such as nutrition nurses and critical care nurses). The long term plan is to ‘up skill’ the workforce where numbers of PICCs placed in their areas would enable competency to be maintained.

This case study has been adapted from the NICE medical technology adoption support for the Sherlock 3CG Tip Confirmation System for placement of peripherally inserted central catheters – insights from the NHS, which presents adoption experiences at 6 NHS sites. Overall key learning for all of the sites were:

• Before implementation, collect baseline data on current PICC placements, malpositions and adjustments.
• Ensure that all stakeholders are consulted and ensure any relevant groups and committees are informed.
• Oversee a trial period for training before independent placing to increase clinical confidence.
• Build robust protocols for the correct insertions of PICCs.
• Once independent placing with the Sherlock 3CG TCS has been established, continue to perform chest X-rays for a locally agreed pilot period. Identify a lead clinical sponsor to act as an external assessor of these X-rays. Once this has been agreed, the protocol for PICC placements can amended so that routine X-rays are no longer needed.
• Develop data collection mechanisms to monitor PICC placements using the Sherlock 3CG TCS.