University Hospital Southampton NHS Foundation Trust (UHS) is an 1100 bed major tertiary centre providing services to >1.9 million people in south Hampshire and specialist services to >3 million people in South England and the Channel Islands.
A nurse led vascular access service was set up in 2007 with two half day lists a week in the fluoroscopy suite of Interventional Radiology. Demand soon exceeded capacity and with the additional pressures of staff shortages we had to review the service.
Following publication of NICE MTG 24 in 2015 we undertook a successful evaluation of Sherlock 3CG TCS. The system uses magnetic and electrocardiogram (ECG) tracking of the Peripherally Inserted Central Catheter (PICC) tip to detect and correct any error in PICC placement and to confirm correct tip positioning. This removes the need for chest X-ray (CXR) in most patients and allows a mobile service for PICC placement.
Aims and objectives
We evaluated Sherlock 3CG TCS to explore a more efficient method of PICC insertion for our patients and fulfil our Trust values to put patients first, work together and always improve. (UHS, 2018)
The key aim of the project was to redevelop our vascular access service so that we could provide a gold standard service for our patients, allowing us to reduce wait times and increase flexibility in our service.
A further aim was to improve the service for our multiple intensive care and high dependency patients by avoiding transfer of clinically unstable patients to fluoroscopy and by reducing the need for emergency acute central venous catheters for difficult intravenous access patients.
We are submitting our experience to provide feedback on the integration of Sherlock 3CG TCS to our service and the benefits we have seen in improving patient experience.
Reasons for implementing your project
UHS specialities include large regional intestinal failure, cystic fibrosis, oncology, cardiac and neurology units with a high number of intensive care and high dependency patients.
In 2013-2014, prior to the introduction of Sherlock 3CG TCS, we had an increase of more than 250 catheter insertions from 2013 to 2014, a 30% increase in workload. Waiting times increased from an average 3.4 days to 5.9 days in September 2014. This delayed the commencement of vital treatment regimens and also delayed timely discharge of patients.
Prior to 2015, the vascular access team was fully reliant on using a fluoroscopy room for two afternoon lists a week and requiring radiographer availability in order to undertake insertions. Should other urgent procedures arise, access to the fluoroscopy room was cancelled at short notice, delaying patients and lengthening our waiting list.
Delays in patient transfers to and from fluoroscopy and ward areas by porters also impacted the smooth running of the PICC list.
Patients requiring PICC insertions were not receiving a timely and efficient service, especially those patients with difficult venous access and patients in the Intensive Care Units. (UHS, Sherlock 3CG Business Case)
Prior to 2015 high dependency patients required transfer to the fluoroscopy room for PICC insertion but due to patient’s instability this would often be delayed until patients had improved enough to be transferred to ward areas.
To try to avoid delays, other forms of central access such as acute central venous catheters (CVCs) had to be inserted, usually by anaesthetists, in the emergency theatres at significant and unnecessary cost to the Trust. Non-tunnelled CVCs have a higher complication rate than PICC’s (Frykolm et al, 2014) and are also more uncomfortable for the patient.
The UHS Care of Central Line Policy limits the ward areas that can care for patients with acute non tunnelled CVCs to reduce risk to patients. This presents a logistical challenge to the Trust. As current recommendations are that these lines can only stay in situ for up to 7 days some patients required more than one device to complete their course of treatment. It was clear that something had to change.
Sherlock 3CG TCS had just received NICE Medical Technology Guidance 24 (NICE, 2015), which strongly supported us in writing a business case that Sherlock 3CG TCS could transform our service.
How did you implement the project
With support from our Radiology Team the case was approved to purchase and initiate the use of Sherlock equipment. A new member to the Vascular Access Team was pivotal and both this and Sherlock 3CG supported us to develop a robust and sustainable service.
By utilising Sherlock 3CG TCS we were able to take the device to new clinical areas without being dependent on fluoroscopy for placement. The insertion location still had to meet infection control requirements, having hand washing facilities to comply with national guidelines, enough space for a bed, any required monitoring equipment and free movement of the clinician to insert the PICC and maintain a sterile environment using full barrier protection (Loveday, 2014) as well as closable doors to ensure patient dignity, procedural integrity and appropriate air flow.
During the set up and implementation stage, clinical support and training provided from the company sales and clinical team were greatly appreciated. The clinical training was supported by a practicing company clinician who uses Sherlock 3CG TCS in their own clinical practice, with the clinical training provided onsite for both a new PICC trainee placer and for our proficient PICC placers, allowing continuation of service provision with no offsite training costs. During the training programme confidence was quickly built in use of the equipment and interpretation of display.
We purchased two Sherlock 3CG Tip Confirmation Systems, which had initial financial implications; this in the long term has been outweighed by the benefits they provide. The Sherlock 3CG TCS devices are both used independently as described and we have retained our two fluoroscopy lists, which we hope to use in the future for the placement of tunnelled catheters.
Sherlock 3CG TCS has definitely improved the quality of patient care by earlier insertion of catheters promoting vessel health preservation using the vein sizing tool, by increasing our reliability, increasing the speed patients gain access to their treatment through insertion of an appropriate vascular access device for their IV therapy, increasing the speed of discharge when patients are awaiting catheter insertion for discharge to home care. This is achieved by enabling bedside placements and reducing the need and associated wait for chest x-rays to confirm tip position. (Barton 2016, Bidgood 2016)
2017/18 1244 insertions
2012/13 638 insertions
Sherlock 3CG TCS and improved staffing, have both contributed to reducing waiting time from up to 5.9 days in 2014 to 1.5 days in 2018 and we have been able to almost double our insertions.
We measured progress quantitatively by looking at PICC insertion numbers and waiting times. We received great qualitative feedback from the high care areas. Most of these patients would have had a short term acute central venous catheter, with potentially more complications. We have been able to change this by inserting PICCs at the bedside and have seen improved patient care pathways.
We have also reduced the need for porters and their resources can now be used in other areas of the hospital.
Working with our Interventional Radiology (IR) consultants we compared accuracy of PICC tip with Sherlock 3CG TCS vs. CXR. It was concluded that all PICC tip positions where maximum P-Wave elevation was visible on Sherlock 3CG TCS were reported as being in a safe position for use. Evidence gathered allowed us to discontinue routine CXRs for patients who had placements with Sherlock 3CG TCS. This also reduced the need for porters, their resources could be used in other areas of the hospital.
Sherlock 3CG TCS has provided a cost saving to radiology increased the speed and efficiency of the service.
Reflecting on how far the service has come in the last three years, since we have embraced the use of Sherlock 3CG TCS, we are extremely proud and pleased that by using NICE guidance MTG 24 we have established an efficient and high quality service, improved patient care, always acting in line with current up to date guidelines (RCN, INS, IPS); we would like to add that none of which could be achieved without the collaborative working with many teams throughout UHS.
Key learning points
SMART goals, simple but crucial for any service development plan.
Contact vascular access teams that use Sherlock 3CG TCS to see their service and equipment in use.
Ensure all online courses and the company training are completed before instigating.
When starting the trial, ensure governance pathways and infection prevention team involved from the beginning, in order to make the transition as smooth as possible.
Set out a clear expanded scope of practice, adding to your standard operating procedures-points can be expanded upon once the Sherlock 3CG TCS is fully integrated but is good to have a starting framework.
Discuss with your radiology team before implementing in order to obtain their support. This is particularly important if undertaking your own study to review Sherlock 3CG TCS against chest x-ray (CXR). This is not necessary when implementing the NICE recommendation; however I feel it is important when gaining confidence in using the equipment as it provides comparisons for ECG tracking and the tip position on CXR unless you have an experienced Sherlock 3CG TCS user as part of your team.
Be aware that the company catheters are the only compatible catheters currently with Sherlock 3CG TCS in dedicated procedure packs.
It is useful to start circulating posters around the ward/arranging teaching sessions so that nursing staff become more familiar with the new catheter. Speak to all area leads about the change.
Also these catheters are power injectable so discuss with CT departments about setting up a systematic review and start training radiographers on good catheter handling, what to look for and how to safely connect.
We set up a one week drop-in training session on PICC care and maintenance, including Sherlock 3CG TCS and the importance of checking documentation which had a lot of very positive feedback. We would highly recommend organising such training, in addition to regular teaching, if that is feasible in your department.