Peripherally inserted central catheters (PICCs) are increasingly being used to manage patients with acute and chronic conditions to facilitate medium- to long-term administration of intravenous therapy, including fluids, blood products, chemotherapy, nutrition, antibiotics, and/or medication that cannot be given peripherally due to the risk of irritation to the vascular endothelium. PICCs can stay in situ for weeks or months, or until therapy is completed, if there are no complications.
Historically, at King's College Hospital, when a PICC is inserted, the standard practice has been to apply a small gauze pressure dressing at the insertion site to absorb any post-insertion oozing and provide protection. The dressing is then changed within 24–48 hours to assess for post-insertion complications and apply a Biopatch; dressings are changed weekly thereafter, or sooner if they become compromised. In 2016, the practice of applying a gauze pressure dressing at insertion was changed at the King's Princess Royal Hospital site.
After Kings took over responsibility for the site, there was a noticeable increase in demand for PICC insertion at the hospital in the first quarter of 2014. About 6 months later the PICC service was started to accommodate the increased demand. After 18 months it became apparent that a different approach was needed because first, there was no post-insertion oozing with a large percentage of the dressings when changed and second, there was an increased risk of migration and other complications.
The initiative was introduced primarily to reduce incidence of complications at the first post-insertion dressing change and, as a secondary measure, to cut expenditure on equipment/consumables.
In January 2016, the application of Biopatch at insertion of PICCs started. The dressing is applied if there is no active bleeding at the insertion site prior to securement and dressing application. Verbal and written instruction and information is then given to patients and nurses that the dressing should be changed only if there is noticeable bleeding/oozing within 24–48 hours that has soiled the dressing. Otherwise, it should be changed in 7 days unless it becomes compromised (wet, loose, soiled etc).
The details of every insertion were recorded on an Excel spreadsheet. In 2016, we conducted 24-48 hours post-insertion surveillance review (for inpatients and outpatients) of PICCs for any complications. In 2017, information on 24–48 hours dressing changes was gathered. Over the 24 months of data collection, a total of 592 PICCs had the dressing applied at insertion (2016, n=257; 2017, n=335), of which 545 (92%) did not require a 24–48 hour dressing change. The remaining 47 (8%) required one at 24–48 hours (2016, n=23; 2017, n=24). Of the 545 that did not need changing, 409 (75%) were single lumen (SL) and 136 (25%) double lumen (DL). Based on the 2016–17 cost per unit (excluding Biopatch) for dressing equipment, average cost for dressing an SL PICC was £7.22 and DL £8.27.
The individual cost per unit was calculated, giving a potential cost avoidance over the 24 months of about £4078. On the face of it, this does not seem significant; however, taking the total number of PICCs inserted across the two main Trust sites annually (about 1600) and applying the same percentage split (75%=1200 SL; 25%=400 DL) gives an estimated cost avoidance of almost £24 000 over 24 months, or £12 000 a year.
The number of migrations occurring at first dressing was also reduced by 83% (2014–15, n=6; 2016–17, n=1). the procedure can take up to 30 minutes, so another benefit is the time saved in not having to do the 24–48 hour change, and action any inadvertent complications. The initiative has resulted in a better patient experience, cost savings due to reduced equipment use and fewer complications.
For hospitals that use Biopatch adopting this practice can reduce expenditure and increase productivity. Potential savings are based solely on the cost of dressing equipment and do not consider the costs of replacing a PICC due to migration, potential complications such infection and associated treatment costs, or and the nursing time required.