patients are critical, so they need continuous
infusion of noradrenaline, morphine, midazolam,
several antibiotics, etc. Using a multi-lumen
device allows for just one device for multiple
simultaneous infusions.”
To help improve vas cular access management,
Cortés and her colleagues decided to learn to insert
PICCs and midline catheters. She and two other ICU
nurse colleagues completed private training
courses in Spain and abroad. Cortés and her two
colleagues then approached the hospital board and
requested PICCs for use in the ICU. PICC use in the
ICU is now significant (Cortés ICU uses Becton,
Dickinson, and Company’s PowerPICC ® s), and the
number of nursing personnel trained to cannulate
PICCs and midline catheters has steadily grown.
With 14 nurses now trained in cannulation, Cortés’
In addition to clinical
considerations, Pinelli and
Cortés also postulate that PICC
use has had a positive economic
impact in their hospitals
ICU now has around-the-clock coverage of
personnel trained for PICC cannulation. Cortés
subsequently received additional inservice training
from C.R. Bard (which is owned by Becton,
Dickinson and Company) and other private courses,
and is now an official instructor for cannulation
training. She attends vascular access conferences
like WoCoVa (World Congress Vascular Access) and
drives keeping her practice up to date with the
latest in VAD technology and practices.
Cortés’ efforts to champion PICC adoption was
not without hurdles, however. “At the beginning,
the biggest enemy we had to fight against were the
nurses. For many people, it’s difficult to change, to
learn new things. [Some nurses] felt like ‘Oh my
gosh, another thing to learn, another thing to do,
it’s another job for us.’ They thought it was going
to increase our work. We had confrontations with
some people because of that, but at this moment,
most of them have changed their minds. The clinical
benefits [of PICCs] were so high that even those
[originally skeptical] nurses have changed their
minds. They are very happy with the use of PICCs.”
Clinical advantages of PICCs
Cortés and Pinelli are both strong proponents of
PICC use in appropriate patient types in their
respective settings. In addition to the ability to
infuse multiple medications/collect samples
simultaneously and the ability to place PICCs at
the bedside with advances in placement technique,
Cortés and Pinelli outline several other clinical
advantages of PICCs.
Preserve vein integrity; reduced long-term injury
to patient veins
For Cortés, the most important benefit of PICCs
is preserving the veins of the patient, and “…not
provoking more harm than necessary. Once you
have injured the vein, it takes time to heal.
Sometimes the damage is too severe, and it may
not heal. The most important thing to me is that
you are not provoking pain, you are not provoking
more injury than necessary.”
High patient acceptance/preference (reduced
patient discomfort due to fewer punctures)
At the front lines of VAD placement, Cortés reports
that in her experience many patients have a high
acceptance of and preference for PICCs over other
VADs. The continuity of a single VAD across the
patient journey and the availability of multi-lumen
PICCs may reduce the number of needlesticks for the
patient, potentially limiting overall discomfort/pain
that comes with multiple cannulisations.
Clinical limitations of PICCs
Like any VAD, there are clinical limitations and
contraindications to PICC use. For instance, PICCs
should not be used in an emergent situation, as
PICCs are not designed to be cannulated as
quickly as other VADs.
Pinelli also mentions that PICCs should not be
used in patients with limited arm mobility. “You
need to show that the patient can move his/her
arm. Chronic kidney disease is an absolute
contraindication because that patient could
need to use that arm during dialysis. The risk
of thrombosis if a patient can’t move their arm
is too high.” PICCs should always be used in
accordance with their indication for use. 3
Economic considerations
In addition to clinical considerations, Pinelli and
Cortés also postulate that PICC use has had a
positive economic impact in their hospitals. From
a resource perspective, Pinelli and Cortés report
that using a single PICC instead of several other
VADs may save time and resources that would be
needed to place multiple VADs. 6 Pinelli further
adds that VAD placement by radiologists in his
hospital is costly, and the shift to bedside PICC
placement circumvents this need and creates cost
savings. In his experience, Pinelli says “risk-
adjusted cost of PICC use is lower, due to
potential complications if a PICC is not used, the
cumulative cost of several devices, and staff time.
A PICC is more expensive than a CICC, but if you
consider the potential cost of … mechanical
complications like a pneumothorax, and the cost
of time you spend using different devices,
altogether I think you save money at the end.”
Future perspectives
Dr Fulvio Pinelli and nurse Noemí Cortés have both
successfully adopted PICC utilisation into their
everyday practice, Pinelli with oncology patients
receiving chemotherapy and Cortés with patients
in the ICU. Both providers have observed significant
benefits in improving both short-term and
long-term patient care across various patient types
and clinical situations. As a result, Pinelli and
Cortés have become strong champions of PICC
adoption and advocate for greater clinically
appropriate PICC use within their hospitals and
their respective spheres of influence. Nurse Cortés’
experience also demonstrates the opportunity for
nurses to catalyse optimal VAD management. Both
Pinelli and Cortés wanted to share their experience
with PICCs in the hopes that other institutions can
apply these learnings to their organisations and
ultimately benefit more patients in the future.
62
HHE 2018 | hospitalhealthcare.com
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