Historically, paediatric vascular access in the author's hospital has been performed by medical staff. The most commonly used device has been the peripheral venous catheter (PVC). Other devices used included tunnelled lines (Hickman lines) or totally implanted ports, also referred to as subcutaneously implanted ports. The tunnelled lines and the subcutaneously implanted ports are inserted in theatre under general anaesthesia using fluoroscopy. The rationale for escalation from use of a PVC to a tunnelled line or implanted port, and assessment for the need for short- or long-term vascular access, was inconsistent and there was no strategy to recognise a patient's potential need for vascular access at an earlier point in their patient journey. More recently, the hospital introduced an algorithm on the use of vascular access devices to aid this escalation process.
The Trust intravascular team (IV team), which provides an adult line service, has the aim of providing the right line for the right patient at the right time, to support vessel health and preservation (Moureau et al, 2012). As a member of the Trust's IV team and a paediatric nurse by background, the author was aware of a number of requests for paediatric vascular access made to the adult service. This prompted the aim of establishing a nurse-led paediatric IV service.
The process
Training
The author's training began in the Trust's radiology department on peripherally inserted central catheter (PICC) insertion using fluoroscopy led by the consultant radiologists. This was followed by a supervision period working with an experienced senior sonographer. Achieving competency using fluoroscopy led to working closely with other members of the IV team to achieve competencies around standards for performing ECG-guided bedside PICC insertions and, finally, further specialist paediatric-focused training under the supervision of one of the paediatric intensive care unit (PICU) consultants.
Trial period
After discussions with the IV team lead and several meetings with stakeholders from the paediatric division, a small-scale trial was agreed and carried out. The trial period was planned for 3 months from October to December 2014 and targeted children aged 10 years and older. Given that this was a novel service, information was sent to all paediatric ward managers and paediatric clinicians, explaining about the trial. They were asked to record on a paper request form the details of children in their care who would require medium-term (1 to 2 weeks) or long-term (3 weeks and more) vascular access. The epic3 guidelines (Loveday et al, 2014), recommended that a PICC should be used for patients where medium-term intermittent access is required. The forms were collected weekly and analysed.
The trial period was expanded for another 2 years (2015-2016), which also served as the author's training and supervision period in paediatric vascular access device (VAD) insertion under the PICU consultants, by the end of which a total of 55 PICCs had been inserted in children (Table 1). It quickly became obvious that only a small number of paediatric patients were benefitting from the trial service. As a result, from January 2016, the age range was changed to 5 years and above.
| Year | Number of PICC inserted |
|---|---|
| 2014 | 6 |
| 2015 | 8 |
| 2016 | 41 |
| Total | 55 |
The success of the trial was used as the basis for a business case to seek approval for a new nurse-led paediatric vascular access service for non-complex PICCs, provided by a dedicated paediatric team.
Interim period
The interim service phase was started while awaiting approval for the business case. The introduction of the nurse-led paediatric vascular access service has been heavily dependent on the commitments of the Trust's IV team. The ratification of the business case continues to be a slow process; however, demand for the vascular access service continues to rise year on year (Table 2). In order to safely transit from the trial period to the interim period, a new operating procedure and guidelines had to be produced. These included the identification of a paediatric consultant with interest in vascular access to lead and be clinically responsible for the service. This responsibility was accepted by the consultant intensivist responsible for the author's paediatric specialist training. Furthermore, a training competency document, which set out the extended role competencies was drawn up. This allowed the author to request a post-insertion chest X-ray for paediatric patients, to confirm the PICC line tip was in the correct position before use. Among other documents drawn up was a request form for PICC insertion, which is now incorporated into the Trust's electronic order forms. Once the request has been submitted electronically, it is then processed, the patient is assessed by the author and given an appointment for insertion. In total, 301 PICCs were inserted during the interim period 2017–2019 (Table 2).
| Year | Number of PICC inserted |
|---|---|
| 2017 | 67 |
| 2018 | 100 |
| 2019 | 134 |
| Total | 301 |
Procedure
Every child requiring a PICC line is assessed and reviewed by the author in the presence of the parents and the nursing or medical team responsible for the child. This assessment includes scanning the arm area above the antecubital fossa to identify suitable veins. Using ultrasound, the veins commonly assessed are the basilic, brachial and cephalic veins. The choice of vein is dependent on the diameter of the vein in relation to the size of the catheter intended to be inserted. A catheter-to-vein diameter ratio of 1:3 is the aim, as recommended by Menéndez et al (2016). This means that the catheter should occupy one-third of the chosen vein in order to allow for adequate blood flow and avoid the risk of the formation of thrombosis in the vein.
Procedures are performed under sterile conditions and all PICCs were inserted by the author and assisted by an IV team or paediatric staff member as Trust policy states that this should be a two-person procedure.
Measurements
First, the child is placed in a supine position with the intended arm for insertion extended at a 90 degree angle to the body and supported by a board (for older children) or on the bed (for younger children). The child's arm is then measured to calculate the length of PICC line required. This is determined by using the Rountree method (1991) of measuring from the insertion site across the axilla to the right head of the clavicular notch. A vein within the middle third of the upper arm (green zone in Figure 1) or the proximal third (yellow zone in Figure 1), as described by Dawson (2011), is then chosen and the vein is scanned by ultrasound.
Cleaning the area
Next, scrubbing in occurs and the donning of sterile gown, mask, hat, and gloves. The patient's arm is cleaned with 2% chlorhexidine in a 70% alcohol solution. If the patient is allergic to chlorhexidine, an iodine–based solution is used to ensure sterility of the intended site of insertion, before a sterile drape is applied over the patient's arm and body from head to toe to maintain a sterile environment. Only the area of the intended insertion zone is visible through the drape, which is designed to enable restricted access to the intended access/insertion area. After cleaning, the insertion area is allowed to dry completely.
Administering local anaesthesia
The next step involves the covering of the ultrasound probe with a sterile probe cover, secured with an elastic band, to ensure the cover remains tightly around the probe. Subsequently, with the ultrasound probe held in the author's non-dominant hand, local anaesthesia is administered subcutaneously based on the patient's weight. The use of the ultrasound probe ensures that the local anaesthesia is injected into the area immediate around the targeted vein and not into the vein.
Accessing the vein
The access needle is then inserted into the vein, using the ultrasound image as a guide. Once access is gained, a guide wire is inserted through the needle and the needle is removed, leaving the guide wire behind in the vein. At this point, a little skin puncture at the insertion site, guided by the guide wire, is made and this is followed by the introduction of a micro-puncture with peel-away set through the exposed end of the guide wire to dilate the skin, soft tissue and the vein. This makes it possible for the catheter, trimmed to the desired length, to be passed into the vein through the peel-away set once the guide wire and micro-introducer are removed. Once the catheter has been introduced into the vein, to the desired length, an ultrasound scan of the neck, specifically the internal jugular vein on the side of the insertion arm, as well as the contralateral subclavian vein, is taken to ensure the catheter is not visible in those veins.
Securing the line
The line is then secured in situ by using a securement device. A Biopatch is applied and the insertion site is covered with a transparent semi-permeable dressing. A check and count of all used sharps and guide wires is made at this point and all clinical waste is disposed of appropriately.
Post-procedural X-ray
Next, the child is sent to the radiology department or a mobile post-procedural chest X-ray is performed at the bedside to confirm the PICC tip location. A well-placed tip has been defined as been located in the superior vena cava or cavo-atrial junction (Yamagishi et al, 2018) particularly the lower third (Ling et al, 2019). The line cannot be used until the post-insertion chest X-ray is performed, reviewed and reported as correctly positioned by a doctor or radiologist.
Location and type of lumen
All PICCs were placed either by the bedside, dedicated treatment rooms, radiology department or in theatres if the children were already in theatre for another procedure that required general anaesthesia (Table 3). In the PICU the lines were also performed at the bedside, under sedation or while intubated. The majority of the PICC lines inserted (Table 4) were single-lumen as these were needed just for antibiotics and fluids. Occasional blood sampling was carried out using the lines as well. In certain cases, particularly on surgical wards, double-lumen lines were inserted for children requiring total parenteral nutrition (TPN). This ensured that a dedicated lumen was reserved for the TPN, while the other lumen was free for other purposes.
| Theatre, radiology (general anaesthesia) | Treatment room (intravenous sedation) | Bedside | |
|---|---|---|---|
| 2017 | 12 | 22 | 33 |
| 2018 | 39 | 16 | 45 |
| 2019 | 64 | 14 | 56 |
| Total | 115 | 52 | 134 |
| Year | Double lumen | Single lumen |
|---|---|---|
| 2014 | 0 | 6 |
| 2015 | 0 | 8 |
| 2016 | 17 | 24 |
| 2017 | 15 | 52 |
| 2018 | 90 | 10 |
| 2019 | 15 | 119 |
| Total | 137 | 219 |
Discussion
The use of peripheral cannulas can be beneficial in some patients. However, PICC lines provide far more advantages such as long-term access for patients with difficult vascular access, clinical instability, or a complex infusion regimen (Rosche and Stehr, 2018). Using a PICC prevents multiple VAD insertions, thereby preventing injuries such as extravasation and infiltration commonly associated with cannulas, as well as reducing the number of potentially painful and upsetting procedures for young patients. Furthermore, the use of PICC lines frequently allows for the timely discharge of paediatric patients from hospital to the community team for further treatment, such as the administering of ongoing antibiotics at home, thereby freeing up valuable hospital beds.
Obtaining vascular access in children is typically a multidisciplinary task, involving surgical, medical, nursing, radiology, laboratory, and other specialties such as play specialists and the pain team. Play specialists have a written protocol designed to provide non-pharmacological interventions to reduce any distress experienced by the child before and during the procedure. The involvement of the pain team allows for management and monitoring of Entonox for children old enough to receive it and for whom it is not contraindicated. Successful PICC line insertion relies on good communication and planning around the procedure to enable the psychological and pain relief needs of the children to be met. For children where distraction or Entonox are not effective, the administration of intravenous (IV) sedation drugs in accordance with Trust policy on painful procedures is applied. Careful assessment of the child is undertaken by the IV team nurse and the medical team responsible for requesting the PICC line. During the insertion, a member of the medical staff competent in managing respiratory arrest will be present to administer the drug and a nurse will monitor vital signs during and after the procedure in line with Trust policy on administration of IV sedation. Where a child requires planned elective surgery or an intervention in theatre, the PICC line will be inserted by the author while under general anaesthetic.
Uptake of the nurse-led PICC line insertion service
The slow uptake of the service between 2014 and 2015 can be explained in three ways.
Progress and the service today
The author's lack of experience was quickly overcome with commitment, hard work, shadowing the consultants, involvement in the assessment of the children and drawing on the experience of working with adults who had small veins that were difficult to access. Above all, working with and observing such a highly skilled paediatric team ensured a prompt and confident application of the skills needed in this setting.
Since 2016, the service has received much more recognition in the Trust. The author has become skilled and has gained valuable experience in effective assessment and better decision making in terms of planning and multidisciplinary involvement. As more successful PICC line insertions occurred, the author was called on more often to perform the service. Consequently, today, the numbers of lines inserted continues to increase and the youngest child the author has worked with was 4 weeks old.
Conclusion
Inserting PICCs for the paediatric population as a vascular access specialist in the Trust has given the author the opportunity to positively influence the vascular access care and treatment of patients by ensuring that these children can have the right line at the right time. This makes the experience positive for patients, families and staff. The patients are subjected to fewer PVC access attempts, and more prompt and early referrals for PICC insertion are made. The nurses and doctors are able to focus on the child's treatment without the worry of having to make frequent attempts to secure vascular access.
One other measure of success is the collaborative work undertaken with some local hospitals where the author's hospital has accepted paediatric patients from local district general hospitals for PICC insertion as day patients.
In the future, the author aims to track and capture information on line-related infection, phlebitis, thrombosis, malposition, length of catheter dwelling, and completion of treatment.
This specialist approach has created a foundation for multi-departmental collaboration and a there are plans to fully fund and establish a separate, expanded nurse-led paediatric vascular access team, with two full-time nurses, in the Trust.