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Incorporating Peripherally Inserted
Central Catheters (PICC) into hospital
clinical practice

An example of evidence based process



                                    Lucia Garate Echenique
                              Nursing Research Supervisor
                     lucia.garateechenique@osakidetza.net
Background
INCORPORATING TECHNOLOGY INTO HOSPITAL
  CLINICAL PRACTICE




                              REQUEST TO
                          PURCHASING COMMITTEE



                        ACCEPTANCE    REJECTION
Background
 • Incorporating technology into hospital clinical practice

                                     FEARS   ECONOMICAL
      ACHIEVEMENT OF
   MANAGEMENT OBJETIVES                       RESURCES
                             PREVIOUS
                           CONCESSIONS
                                              PROFESSIONAL
                                                ATTITUD



                        PURCHASING                PATIENT
                         COMMITTEE              PREFERENCES



IMPRESSIONS OF       PREVIOUS
CLINICAL BENEFIT    PURCHASES/
                   INVESTMENTS
Background
PICC : Peripherally Inserted Central Catheter

     Long-term: Third generation polyurethane or silicone
     Inserted in upper arms: Peripherally inserted
     End of catheter in superior cava vein
     Can be inserted at bed-side by trained nurses
Background

   LIFE CYCLE OF
HEALTH TECHNOLOGY




    EMERGING
  TECHNOLOGIES
Background
“Technologies have occasionally had rapid development and
   dissemination in the health care system (…) influenced by factors
   such as social pressure, commercial pressure, the enthusiasm of
   health professionals, lack of barriers to their implementation or the
   existence of technical difficulties for evaluation. This fact has led
   sometimes to further demonstrate its ineffectiveness and even
   harm.”

The EARLY ASSESSMENT OF EMERGING TECHNOLOGIES aims:

    1. To identify characteristics in terms of improvement in clinical
       practice, adverse effects, ethical and economic aspects.
    2. To Help in the decision-making
    3. To Prevent the undesirable consequences of the introduction
       of new health technologies.
Objective
• To describe the evidence-based incorporation of
  PICC for cancer patients in the Araba University
  Hospital.
Methods
1) Bibliographic review: January 2010-June 2010
2) Nurses education/ training
3) Protocol desining: prior, insertion, postinsertion, education
    for patients.
4) Database monitoring: success in placement, incidences,
    duration, reasons for withdrawal, complications. June
    2011.
5) Request to the Purchasing Commitee.
    Acceptance: PICC (October 2010) & Ultrasound (Febreary
    2011).
6) Observational prospective study
PATIENTS INTERVENTIONS COMPARISONS        OUTCOME


 Cancer           PICC         CVC         DURATION
 Patient       PLACEMENT   Implantable   COMPLICATION
                              Ports      SATISFACTION
                            Peripheral
                            Cathethers
      UptoDATE
     Tripdatabase                          MEDLINE
         DARE                 MESH/        EMBASE
      Cochrane               EMTREE        CINAHL
     EMB Reviews



                                         130 documents
                                            retrieved
Methods
                 Depth: 0.5-1 cm
                  Depth: 0.5-1 cm




                                          Diameter: 0,4 - -11
                                           Diameter: 0,4
                                               cm.
                                                cm.




Microseldinger
  Technique                         Ultrasound
PREINSERTION



  INSERTION




POST INSERTION




 MAINTENANCE
                        PATIENT
                       EDUCATION
    Evidence Based
PROTOCOL DEVELOPMENT
Methods




  Observational
Prospective Study
Methods

   Request to the
Purchasing Committee
10
                              15
                                   20
                                        25




                 0
                     5
  jun
        -1
             0
   ju
     l-1
Au           0
     g-
        1
se 0
    p-
        10
 oc
     t-1
          0
 no
     v-
        1
D 0
  ec
      -1
Ja 0
    n-
        11
                                             95,8% to Cancer Patients




 fe
    b-
        1
m 1
   ar
       -1
Ap 1
     r-1
m 1
   ay
       -1
          1
  ju
    n-
        11
   ju
                                                                        N=218 Inserted in Araba University Hospital




      l-1
au 1
    g-
        1
se 1
    p-
        11
 oc
     t-1
 no 1
     v-
        1
de 1
    c-
        11
 ja
    n-
        11
                                                                                                                      Results
Results
 100   100        100        100                                 100        100    100      100
                                                                                                  95 94
  90                                         91             90                         92
                                                                       84
  80                                                   80
                        75
  70
                                                  66
  60
                                        56                                        54
% 50         50                    50
  40
  30
  20
         INSERTION SUCCESS RATE 96.3% (CI 95%: 92.9 – 98.1)
  10
   0
           10




           11
           10




             1




           11
   Au 0




             1
            0




           11
           10




           11




            1
            1




           11
           11




            1
           10




            0




           11




           11
         l-1




         l-1
          -1



          -1
        t- 1




        t-1
         -1




        r-1
        v-




        v-
       n-




       n-
       n-




       g-




       n-
       g-

       p-




       b-




       p-




       c-
      ar



      ay
      ju




      ju
      ec
    oc




    oc
   Ap
   no




   no
     ju




     ju




    ja
   Ja




   au




   de
    fe
   se




   se
   m



   m
   D
Results

       Withdrawed
N                      90
       Catheters

Mean                147.6

Median               99.5

Stand. Dev.         122,.2

Mín.                  9,0

Max.                533.0

              25     50,0

Percentiles   50     99.5

              75    235.5
Results
                                    TOTAL: 24,031 Catheter Days
                                    Nº of Adverse Effects: 49
                                    Adverse Effect TOTAL CATHETER DAYS = 24.031
                                                   95% CI: 1.5-2.7 /1,000 Catheter-Days
                              1
                           0,9
Complication/1,000




                           0,8
                                        0,40
  Catheter-Days




                           0,7         0,66
                           0,6
                           0,5                                               0,24
                           0,4
                                                                          0,29                                         0,16
                           0,3                                                                                                                           0,08                           0,08
                                                                                                            0,20                                0,2
                           0,2
                           0,1                                                                                                                                              0,04
                              0
                                                )                               )                                                                    )                              )
                                            6
                                                                             =7                                   5)                              =5                              =1
                                       n =1                               (n                                    n=                              (n                          (   n
                                     l(                               n                                     (                               n
                                                                   tio                               si
                                                                                                        s                                                              ia
                                   va                                                                                                   tio                       em
                               o                              ec                                bo                             ru
                                                                                                                                    c
                                                                                                                                                                er
                             em                           .Inf                             om                                st                               ct
                           .R                                                          r                                 b
                         id                         u   sp                          Th                                  O                                Ba
                     c
IMPLANTED PORT                           PICC                          Results
 247 €                              95€

 Operating Theatre                  Hospitalisation Room
 90 min                             60 min
                                                                       CENTRAL VENOUS
 1 Surgeon                          1 Nurse                          DEVICES CONSUMPTION
 1 Nurse                            1 Auxiliary Nursign Care              (2008-2012)

400                          0,40
350
               336
300                                                            308
                                            0,24               280
250
                                                                     Implanted Port
200
               214                                            0,16
                                                                     Drum
                                                                      0,08            0,08
150                                                                  CVC
               112                                                   PICC
100
                                                              29
50
 0             0
                                                               18
          08            09         10          11        12
       20            20         20          20        20
Discussion
• PICC are an example of how technology can be incorporated
  into hospital practice based on evidence criteria.


• However, the vast amount of technology hospitals manage and
  the effort needed to search, read, and create evidence
  constitute important difficulties to be faced in the technology
  incorporation processes.


• In hospital routine this proccess may be insufficiently
  protected. The creation of hospital based technology
  evaluation committes could support the proccess of
  incorporation technology following evidence-based criteria.
Incorporating Peripherally Inserted Central Catheters (PICC) into hospital clinical practice
Implications for Practice


• PICC is now an available, safe, and cost-effective central
  venous device in our hospital, preferable to other devices for
  cancer patients.


• When the process of adquiring technology in hospitals involves
  practicioners, researchers, material resources responsibles,
  and managers it is easier to incorporate technology which is
  relevant and appropriate, in both scientific and economical terms,
  to clinical practice.
Thank you

      Eskerrik Asko

                  Gracias


                             Lucia Garate Echenique
                        Nursing Research Supervisor

                lucia.garateechenique@osakidetza.net

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Incorporating Peripherally Inserted Central Catheters (PICC) into hospital clinical practice

  • 1. Incorporating Peripherally Inserted Central Catheters (PICC) into hospital clinical practice An example of evidence based process Lucia Garate Echenique Nursing Research Supervisor lucia.garateechenique@osakidetza.net
  • 2. Background INCORPORATING TECHNOLOGY INTO HOSPITAL CLINICAL PRACTICE REQUEST TO PURCHASING COMMITTEE ACCEPTANCE REJECTION
  • 3. Background • Incorporating technology into hospital clinical practice FEARS ECONOMICAL ACHIEVEMENT OF MANAGEMENT OBJETIVES RESURCES PREVIOUS CONCESSIONS PROFESSIONAL ATTITUD PURCHASING PATIENT COMMITTEE PREFERENCES IMPRESSIONS OF PREVIOUS CLINICAL BENEFIT PURCHASES/ INVESTMENTS
  • 4. Background PICC : Peripherally Inserted Central Catheter  Long-term: Third generation polyurethane or silicone  Inserted in upper arms: Peripherally inserted  End of catheter in superior cava vein  Can be inserted at bed-side by trained nurses
  • 5. Background LIFE CYCLE OF HEALTH TECHNOLOGY EMERGING TECHNOLOGIES
  • 6. Background “Technologies have occasionally had rapid development and dissemination in the health care system (…) influenced by factors such as social pressure, commercial pressure, the enthusiasm of health professionals, lack of barriers to their implementation or the existence of technical difficulties for evaluation. This fact has led sometimes to further demonstrate its ineffectiveness and even harm.” The EARLY ASSESSMENT OF EMERGING TECHNOLOGIES aims: 1. To identify characteristics in terms of improvement in clinical practice, adverse effects, ethical and economic aspects. 2. To Help in the decision-making 3. To Prevent the undesirable consequences of the introduction of new health technologies.
  • 7. Objective • To describe the evidence-based incorporation of PICC for cancer patients in the Araba University Hospital.
  • 8. Methods 1) Bibliographic review: January 2010-June 2010 2) Nurses education/ training 3) Protocol desining: prior, insertion, postinsertion, education for patients. 4) Database monitoring: success in placement, incidences, duration, reasons for withdrawal, complications. June 2011. 5) Request to the Purchasing Commitee. Acceptance: PICC (October 2010) & Ultrasound (Febreary 2011). 6) Observational prospective study
  • 9. PATIENTS INTERVENTIONS COMPARISONS OUTCOME Cancer PICC CVC DURATION Patient PLACEMENT Implantable COMPLICATION Ports SATISFACTION Peripheral Cathethers UptoDATE Tripdatabase MEDLINE DARE MESH/ EMBASE Cochrane EMTREE CINAHL EMB Reviews 130 documents retrieved
  • 10. Methods Depth: 0.5-1 cm Depth: 0.5-1 cm Diameter: 0,4 - -11 Diameter: 0,4 cm. cm. Microseldinger Technique Ultrasound
  • 11. PREINSERTION INSERTION POST INSERTION MAINTENANCE PATIENT EDUCATION Evidence Based PROTOCOL DEVELOPMENT
  • 13. Methods Request to the Purchasing Committee
  • 14. 10 15 20 25 0 5 jun -1 0 ju l-1 Au 0 g- 1 se 0 p- 10 oc t-1 0 no v- 1 D 0 ec -1 Ja 0 n- 11 95,8% to Cancer Patients fe b- 1 m 1 ar -1 Ap 1 r-1 m 1 ay -1 1 ju n- 11 ju N=218 Inserted in Araba University Hospital l-1 au 1 g- 1 se 1 p- 11 oc t-1 no 1 v- 1 de 1 c- 11 ja n- 11 Results
  • 15. Results 100 100 100 100 100 100 100 100 95 94 90 91 90 92 84 80 80 75 70 66 60 56 54 % 50 50 50 40 30 20 INSERTION SUCCESS RATE 96.3% (CI 95%: 92.9 – 98.1) 10 0 10 11 10 1 11 Au 0 1 0 11 10 11 1 1 11 11 1 10 0 11 11 l-1 l-1 -1 -1 t- 1 t-1 -1 r-1 v- v- n- n- n- g- n- g- p- b- p- c- ar ay ju ju ec oc oc Ap no no ju ju ja Ja au de fe se se m m D
  • 16. Results Withdrawed N 90 Catheters Mean 147.6 Median 99.5 Stand. Dev. 122,.2 Mín. 9,0 Max. 533.0 25 50,0 Percentiles 50 99.5 75 235.5
  • 17. Results TOTAL: 24,031 Catheter Days Nº of Adverse Effects: 49 Adverse Effect TOTAL CATHETER DAYS = 24.031 95% CI: 1.5-2.7 /1,000 Catheter-Days 1 0,9 Complication/1,000 0,8 0,40 Catheter-Days 0,7 0,66 0,6 0,5 0,24 0,4 0,29 0,16 0,3 0,08 0,08 0,20 0,2 0,2 0,1 0,04 0 ) ) ) ) 6 =7 5) =5 =1 n =1 (n n= (n ( n l( n ( n tio si s ia va tio em o ec bo ru c er em .Inf om st ct .R r b id u sp Th O Ba c
  • 18. IMPLANTED PORT PICC Results 247 € 95€ Operating Theatre Hospitalisation Room 90 min 60 min CENTRAL VENOUS 1 Surgeon 1 Nurse DEVICES CONSUMPTION 1 Nurse 1 Auxiliary Nursign Care (2008-2012) 400 0,40 350 336 300 308 0,24 280 250 Implanted Port 200 214 0,16 Drum 0,08 0,08 150 CVC 112 PICC 100 29 50 0 0 18 08 09 10 11 12 20 20 20 20 20
  • 19. Discussion • PICC are an example of how technology can be incorporated into hospital practice based on evidence criteria. • However, the vast amount of technology hospitals manage and the effort needed to search, read, and create evidence constitute important difficulties to be faced in the technology incorporation processes. • In hospital routine this proccess may be insufficiently protected. The creation of hospital based technology evaluation committes could support the proccess of incorporation technology following evidence-based criteria.
  • 21. Implications for Practice • PICC is now an available, safe, and cost-effective central venous device in our hospital, preferable to other devices for cancer patients. • When the process of adquiring technology in hospitals involves practicioners, researchers, material resources responsibles, and managers it is easier to incorporate technology which is relevant and appropriate, in both scientific and economical terms, to clinical practice.
  • 22. Thank you Eskerrik Asko Gracias Lucia Garate Echenique Nursing Research Supervisor lucia.garateechenique@osakidetza.net

Notas do Editor

  1. As Osteba implicitly acknowledges, incorporation of technology into clinical practice is not always based in scientific evidence criteria. In our hospital the incorporation of new technology is usually as follows: Clinicians hear about new technologies in congresses or meetings. Comercial agent offers the product to clinicians or material resources responsible. Clinicians test the product, in best of cases, read about the product. If they like it, they request it to the purchasing commitee, providing bibliographic references, use description… Purchasing commettee makes the decision. The purchasing commitee is integrated by: Director Económico-Financiero        HUA Director Médico                              HUA………..Delega en Subdirector Médico          HUA Directora Enfermería                       HUA………..Delega en Responsable de RR.MM   HUA Subdirectora Económica Compras   HUA Responsable Gestión Económica    HUA Responsable Compras Txagorritxu  And asks for the following information in the application form: +Justify the need of the product or device +Expected benefits/ Beneficios esperados con la adquisición del nuevo producto/técnica referidos a: +Safety and technical quality +Work organization changes +Improvement in diagnosis or therapeutic techniques +Economical impact +Use of technology in other hospitals +Bibliography supporting the benefits of the new product/ device or technique. Calidad técnica y seguridad Modificaciones en la metodología de trabajo Beneficios referidos al paciente Mejoría de las técnicas diagnosticas/terapéuticas empleadas Impacto económico Referencia de su uso en otros hospitales Soporte bibliográfico: existencia de evidencia científica de los beneficios de la utilización del nuevo producto ó técnica.
  2. As Osteba implicitly acknowledges, incorporation of technology into clinical practice is not always based in scientific evidence criteria. In our hospital the incorporation of new technology is usually as follows: Comercial agent offers the product to clinicians or material resources responsible. Clinicians test the product, in best of cases, read about the product. If they like it, they request it to the purchasing commitee, providing bibliographic references, use description… Purchasing commettee makes the decision. The purchasing commitee is integrated by: Director Económico-Financiero        HUA Director Médico                              HUA………..Delega en Subdirector Médico          HUA Directora Enfermería                       HUA………..Delega en Responsable de RR.MM   HUA Subdirectora Económica Compras   HUA Responsable Gestión Económica    HUA Responsable Compras Txagorritxu  And asks for the following information in the application sheet: Justificación de la necesidad ó conveniencia de su incorporación Beneficios esperados con la adquisición del nuevo producto/técnica referidos a: Calidad técnica y seguridad Modificaciones en la metodología de trabajo Beneficios referidos al paciente Mejoría de las técnicas diagnosticas/terapéuticas empleadas Impacto económico Referencia de su uso en otros hospitales Soporte bibliográfico: existencia de evidencia científica de los beneficios de la utilización del nuevo producto ó técnica.
  3. This is what we have try to do with PICC. Purchasing Commitee doors seem to be closed at that time. How did we opened them? This is an example of evidence criteria process.
  4. The results of the bibliographical search and some clinical practice guidelines supported the PICC use for cancer patients going into quimotherapy. So we decided start using it, monitooring closelly all the results achived. With this aim a database was designed. In this database the nursign supervisor and main lider of this project of incorporating PICC to the hospital practice, recorded every PICC placement and every incidence ocurred with them. Data were recorded from the very begining, June 2010, and are at the moment still being recorded.
  5. Una diapositiva con el aprendizaje de las enfermeras: investigacion (busqueda y lectura critica), profundización en conocimientos de terapia intravenosa, y por ultima técnica de inserción de PICC (Pata de pavo y ecógrafo). Fruto de esto fueron las mismas enfermeras de la planta las que diseñaron los protocolos de insercion, mantenimiento y adiestramiento a pacientes. Nurses Education and Trainning Programme: Research methodology, IV therapy, simulated practice and real practice.
  6. Including learining period
  7. Actualizar datos
  8. Others like catheter migration, catheter damage, inflammation at the insertion point
  9. From Jan 2012 to Jun 2012 were consumed 12. Cancer of colon screening started 2011. Direct cost Indirect staff/facilities costs
  10. I wonder if in