1. Occlusion Occurrences in Peripherally Inserted Central Venous Catheters Alison Yerkey, RN, BSN Judy Davidson, RN, MS, CCRN, FCCM

2. BACKGROUND The most common method for withdrawing blood samples from central venous catheters is the discard method The most common method for withdrawing blood samples from central venous catheters is the discard method In March 2006, a policy revision was made at Scripps Mercy Hospital in regards to the care and maintenance of peripherally inserted central venous catheters (PICC). In March 2006, a policy revision was made at Scripps Mercy Hospital in regards to the care and maintenance of peripherally inserted central venous catheters (PICC).

3. BACKGROUND Based on current literature and a goal to Based on current literature and a goal to ↓ iatrogenic blood loss, the push-pull method was introduced Following implementation, staff nurses verbally reported increased PICC line occlusions- no data Following implementation, staff nurses verbally reported increased PICC line occlusions- no data

4. QUESTION What are the possible causes of peripherally inserted central venous catheter (PICC) line occlusions in the adult medical-surgical patient at Scripps Mercy, San Diego? What are the possible causes of peripherally inserted central venous catheter (PICC) line occlusions in the adult medical-surgical patient at Scripps Mercy, San Diego?

5. METHODS Investigation ( IRB exempt: PI project) Investigation ( IRB exempt: PI project) –Qualitative  Identify staff values and practices –Quantitative  Identify actual occlusion rates Other Methods Other Methods –Literature synthesis –Semi-structured interviews –Participant observation

6. PROCEDURE Qualitative Qualitative –Verbal interviews over a two month period  Staff nurses  Five inpatient units  Two intensive care units  Two radiology PICC insertion nurses  Two IV nurses

7. PROCEDURE Quantitative Quantitative –Log completed by IV nurses for one month  Total amount of PICCs inserted  Date of insertion  Date of clot

8. RESULTS 10% of 97 PICC lines inserted resulted in occlusions 10% of 97 PICC lines inserted resulted in occlusions Occlusions occurred using both methods of sampling Occlusions occurred using both methods of sampling 87% of occluded PICCs required replacement 87% of occluded PICCs required replacement

9. Possible Causes for Occlusion 14 causes of catheter occlusion identified through interview and observation

10. POSSIBLE CAUSES Flushing technique Flushing technique 1.Delay in flushing following blood sampling 2.Insufficient flush volume (<10cc) 3.Unused ports not flushed 4.Not flushing after IVPBs and meds 5.Reliance on KVO rates to maintain patency 6.Inconsistency of flushing frequency 7.Differences in policy and practice regarding clamping 8.Heparin not used as indicated to flush Power PICC

11. Possible Causes 9. Delay to thrombolysis 9. Delay to thrombolysis Reteplase on formulary due to cost Reteplase on formulary due to cost Off-label use for catheter occlusions Off-label use for catheter occlusions IV team not comfortable with off-label use IV team not comfortable with off-label use Staff RNs not comfortable administering Staff RNs not comfortable administering 10. Use of heparin and 3cc syringe to de-clot

12. POSSIBLE CAUSES PICC Injection Cap – CLC 2000 PICC Injection Cap – CLC 2000 11. Absence of cap 12. Insufficient flushing causing cap to occlude 13. Failure to replace occluded cap

13. POSSIBLE CAUSES 14. Blood draw technique Inconsistent use of equipment Inconsistent use of equipment Syringe vs Vacutainer Syringe vs Vacutainer

14. RECOMMENDATIONS Salvage push-pull technique Salvage push-pull technique Focus action plan to ↓ other causes Focus action plan to ↓ other causes –Lit review to justify off-label use of Reteplase –Rewrite policy –Redesign competencies –Reinforce each of the 14 points of breakdown –Return demonstration by each nurse –Repeat collection and assessment of data

15. QUESTIONS