The Queen Elizabeth Hospital in Gateshead forms part of Gateshead Health NHS Foundation Trust. It is a 580-bed acute hospital providing a range of services including medical, surgical, maternity, palliative care and critical care.
A vascular access service was set up in November 2018 with the team consisting of a Consultant anaesthetist as medical lead, a senior nurse and a specialist Radiographer. Initially 2 sessions per week were provided in the interventional suite of Radiology to enable PICC and other long-term venous access devices to be placed, however demand for the service grew quickly and staffing capacity could not meet demand. We have since recruited a further 2 members to the team, one nurse and one radiographer to meet the demand for vascular access devices.
Aims and objectives
The Trust has a strong focus on the 7 R’s of vascular access; Right line, Right patient, Right time, Right clinician, Right vessel, Right tool, Right healthcare worker.
It was evident that this was not being adhered to as many patients with fragile veins were receiving multiple cannulas by often inexperienced staff without consideration of a longer-term option.
The driver behind introducing Sherlock 3CG TCS was to transform the vascular access services within the Trust and protect patient’s vessel health by ensuring appropriate services could be accessed in a timely manner to provide a robust service. We implemented the use of Sherlock 3CG Tip Confirmation System (TCS) in order to provide a more timely, flexible and accessible vascular access service and to reduce the restrictions of relying on access to an interventional Radiology room.
The main aim was to ensure the patient received the right line at the right time, ideally within 24 hours, and to reduce unnecessary cannulations and venepuncture, the main focus and priority being that of patient care, safety and experience. Another intended benefit to our patients was to ensure that any patients who were clinically too unwell to transfer could have their line placed at their bedside ensuring their stability was not compromised during transfer, this included patients on critical care.
Reasons for implementing your project
It was highlighted that a major barrier to providing patients with a PICC in a timely manner was access to an interventional suite and so alternative models were explored. Following research and NICE guidance on the use of Sherlock 3CG TCS for PICC placement, an evaluation and audit of this system was undertaken.
The Site Rite 8 with Sherlock 3CG TCS enables real time tracking of the PICC device allowing the operator to detect and correct any placement issues, reducing the risk of catheter malposition while ECG technology allows the placer to confirm correct catheter tip placement and confirm proximity to the cavoatrial junction.
This removes the need for confirmation chest x-ray, reducing the risks associated with exposure to ionising radiation and allowing for more timely placement and use of the line. Using Sherlock 3CG TCS reduces inpatient stay time as it provides a more timely service through bedside placements, reduces the risk of missed IV doses due to lack of venous access, reduces portering time and reduces time required for image interpretation and reporting. Prior to the formation of our team there was a gap in the provision of venous access services throughout the Trust.
Patients received multiple cannulas with no option of a PICC. PICCs were introduced to the Trust in November 2018 to bridge the gap between peripheral cannulation, midlines, acute central lines and tunnelled/implanted devices. The need for PICCs was quickly recognised throughout inpatient areas and numbers increased rapidly meaning access to a fluoroscopy room became a problem. The impact of this was that patients were not receiving their lines in a timely manner resulting in a suboptimal device being inserted, namely acute CVCs, which ideally would only be placed in ITU or theatre.
Patients were on occasion discharged to ward areas with acute CVCs due to lack of provisions. The result of this was unnecessary use of anaesthetist time and risk to the patients from inappropriate device placement. Other impacts include lack of venous access for essential medications and delay in diagnostic procedures, the result of this being delays in starting treatment and consequentially delays in discharge. Audits within the Trust showed on average 60 missed doses of IV medications per month with the reason being ‘IV access not possible’, delaying treatment and putting patients at risk of deterioration due to not receiving essential medications in a timely manner.
How did you implement the project
A malpositioned line resulted in the patient undergoing further procedures, additional exposure to radiation and/or insertion of a suboptimal device. Patients requiring insertion using fluoroscopy could be waiting up to 5 days for line placement.
With support from the Consultant lead of the vascular access service, along with the nurse lead and the two specialist radiographers within the team, discussions took place around the potential of an evaluation agreement in order to assess and audit Sherlock 3CG TCS and agree use. Initially all PICCs continued to be placed in the interventional suite using Sherlock 3CG TCS with 3CG technology, a confirmation fluoroscopy image was then taken to confirm accuracy of PICC tip.
The BD clinical specialist provided staff with onsite competency based training and on-going support which was extremely beneficial to the team. Following the evaluation in the IR suite and confirmation of accuracy the team began to place PICCs at the bedside with a confirmation chest x-ray in order to assess its suitability in the environment in which we would be utilising it. This included consideration of infection control EPIC3 or other guidelines and ergonomics, which were also assessed during this time, all ensuring optimum patient safety and care. Over a period of 6 months an audit of 64 line placements where the patient had an easily identifiable, consistent p-wave was completed which confirmed accuracy of the system, 100% correlation between radiological findings and Sherlock 3CG TCS.
Following presentation of these results it was agreed that in suitable patients, Sherlock 3CG TCS could be used without the need for confirmation chest x-ray. Following the successful outcome of the device evaluation and implementation of the technology, a successful bid was made to use Trust charitable funds in order to purchase the Sherlock 3CG TCS equipment.
The use of Sherlock 3CG TCS has allowed us to provide a more robust and timely vascular access service which is not reliant on access to a fluoroscopy room. PICCs can be placed at the patient’s bedside which not only reduces the risks associated with exposure to ionising radiation, but also has a resource implication.
For example, fewer staff are required, no radiographer is required for screening and the use of portering services is eliminated. There is also no pressure or interruption on the radiology services as an interventional room is not required.
The service is now mobile meaning lines can be inserted when required at the patient’s bedside which is particularly beneficial for critically unwell or unstable patients and also for patients with known infections where transfer could cause clinical risk or risk of infection spread.
Patients requiring mid-long term venous access now have access to a PICC via the vascular access service and will have their device placed within 24 hours of requesting where previously waits were up to 5 days as access to a fluoroscopy room was limited.
Prior to the introduction of Sherlock 3GC TCS 40 lines were placed within 8 months. Within the first 8 months of using Sherlock 3CG TCS 151 PICCs were placed Trust wide (1.25 PICC lines per week prior to Sherlock 3CG TCS, now increased to 4.1 PICCs per week). This has an impact on the use of resources within the Trust in terms of radiology/portering as mentioned above.
The use of PICC also reduces the time and cost associated with multiple cannulations. The patient’s safety and experience is also improved, as well as their long term vessel health as they are no longer receiving multiple attempts at cannulation with referrals made for a longer term options at an earlier opportunity, ensuring the patient is receiving the right line at the right time. The service originated from 2 practitioners placing PICCs with Sherlock 3CG TCS, but due to growth which has far exceeded expectations there are now 4 practitioners trained and placing PICCs within the team in. Patient experience has been greatly improved as they can receive treatment without delay in an environment which is familiar to them. This reduces patient anxiety and associated distress.
Key learning points
Line insertions are recorded and all inpatients are reviewed at least weekly to ensure appropriate care and maintenance. An audit of complications is completed in order to assess any statistical trends in terms of infection rates, line migration or any other areas which may highlight any areas for improvement.
Results from recent audits have highlighted key areas for improvement including issues with ward-based line care and maintenance, training on the use of PICCs and missed IV medications due to no IV access. Knowledge of these issues has allowed us to prioritise training across the Trust to ensure patients are receiving optimal, safe care in terms of venous access. The indications for longer term venous access has changed meaning earlier referral to the established vascular access team, which in turn preserves patient’s vessel health lowering the risk of patients having long term venous access issues.