NURSING PATIENT CARE POLICY & PROCEDURE
To provide guidelines and procedures for the Venous Access Team (VAT) for the safe
insertion of peripherally inserted central venous catheters (PICCs) and midline catheters.
A. PICCs and Midline catheters placed at University Hospital, American Family Children’s
Hospital and The American Center are inserted by a qualified Venous Access Team (VAT)
RN who has had PICC and midline education and training, who demonstrates and
maintains competency as established by departmental standards.
B. A provider order is required prior to PICC placement. Midline catheters may be ordered by
providers or RNs and are evaluated for appropriateness by VAT staff.
A. A PICC is a central venous catheter that is inserted percutaneously through the veins of the
upper extremity or neck in adults and children and advanced until the tip is positioned in
the vena cava. In infants, the catheter may be inserted through the veins of the scalp or
B. Midline catheters used at UH are peripheral infusion devices measuring 8-10 cm long with
the tips terminating in either the basilic, cephalic, or brachial vein distal to the shoulder.
Refer to Nursing and Patient Care Policy 1.55 A, Midline Intravenous Peripheral Catheters:
Use, Maintenance and Removal (Adult).
IV. SELECTION CRITERIA AND ASSESSMENT
1. The smallest diameter PICC with the fewest lumens necessary to achieve the goals
of therapy is placed in order to minimize the risk of catheter-associated thrombosis
and catheter-related blood stream infections.
2. A thorough assessment of all clinical aspects is important in choosing a PICC as a
route of therapy for patients, including diagnosis, medical history, vascular access,
plan of treatment, and patient’s ability to participate in care.
3. Contraindications for a PICC placement include:
a. Past irradiation of prospective insertion site
b. Patient is known or suspected to be allergic to materials contained in catheter
c. Venous thrombosis or vascular surgical procedures at the prospective procedure
November 30, 2016
Nursing Manual (Red)
Policy #: 1.51 AP
Title: Insertion of Peripherally Inserted
Central Venous Catheters and Midline
Catheters for Venous Access Team (Adult
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4. For patients with a platelet count greater than 500,000 uL the primary ordering team
will be advised of the increased risk of axillo-subclavian clot with a PICC line.
5. The following are possible indications for PICC line placement:
a. Intravenous therapy that requires a CVAD for administration. Refer to
Intravenous Administration of Formulary Medications – Adult –
Inpatient/Ambulatory Clinical Practice Guideline for guidance regarding
medications that must be delivered via a central vascular access device.
b. Ongoing intravenous therapy post-hospitalization
c. Best option for venous access as determined by Venous Access Team
1. Indications for Use
a. Hospital admission of 5 days or longer
b. Poor venous access
c. Infusions appropriate for midline administration Refer to Intravenous
Administration of Formulary Medications – Adult – Inpatient/Ambulatory
Clinical Practice Guideline for guidance regarding medications that must be
delivered via a central vascular access device.
2. Placement and Identification
a. VAT will determine if the patient’s clinical needs meet indication for a midline
peripheral catheter and will place all midline catheters utilizing ultrasound
b. Signage will be posted (by VAT RN) in the patient’s room indicating:
i. Placement site and length of a midline catheter
ii. Insertion date and expected removal/change date
iii. No blood pressure cuff at or above the Midline insertion site.
iv. Not a central vascular Access device
V. PREPROCEDURE PREPARATION
A. Review PICC or Midline consult order in the patient’s clinical record.
B. Explain procedure to patient/caregiver; obtain written consent (UWH SR300350). If patient
is under 18 or unable to consent for self, obtain parental/guardian or POA/next-of-kin
consent. Consider having parent or Child Life Specialist present during line placement.
C. Prior to the procedure, perform the Universal Protocol according to Hospital
Administrative Policy 8.48, Operative, Invasive & Other Procedures, including:
1. Pre-procedure verifications
2. Time Out to verify:
a. Correct patient (two identifiers: name, medical record number or birth date)
b. Correct procedure
c. Correct site
d. Correct position
e. Correct equipment
3. Documentation of Universal Protocol
D. Perform hand hygiene according to Hospital Administrative Policy 13.08, Hand Hygiene.
E. Maximal sterile barrier precautions (sterile gown and gloves, head covering and mask) are
used when placing a PICC. Mask and sterile gloves to be used when placing a midline.
F. Identify and evaluate potential PICC/Midline access points, using ultrasound guidance to
identify any adjacent arterial flow. Determine most appropriate site.
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VI. MIDLINE PROCEDURE
2. Midline kit
3. Probe cover including sterile ultrasound gel
4. Bacteriostatic saline
5. Skin Marker (optional)
6. Sterile gloves – latex and powder free
7. Ultrasound gel – non-sterile
8. 2% chlorhexidine prep
9. Skin Prep
10. Insulin syringe
11. Alcohol prep pads
12. Smaller StatLock (optional)
13. Smaller extension set (optional)
14. Transparent dressing
15. Vascular access ultrasound
1. Assess patient with vascular ultrasound to determine target vein.
2. Assemble equipment, prepare a clean work area.
3. Position and prepare patient for procedure.
a. Trim hair from planned insertion site(s) as needed.
4. Perform hand hygiene according to Hospital Administrative Policy 13.08, Hand
Hygiene, and don mask and gloves.
5. Extend and support extremity/area to be cannulated.
6. Open up midline kit and remove top drape.
7. Place drape under the patient’s arm.
8. Vigorously clean area to be cannulated for 30 seconds with Chlorhexidine and allow
to dry for 30 seconds.
9. Open sterile equipment and drop on to sterile midline kit.
10. Clean end of the bacteriostatic saline bottle with an alcohol pad. Draw bacteriostatic
saline into sterile insulin syringe.
11. Perform hand hygiene according to Hospital Administrative Policy 13.08, Hand
12. Don sterile gloves.
13. Place fenestrated drape over the insertion site.
14. Prepare supplies, check equipment for defects.
15. Cover ultrasound probe being careful to maintain sterile field.
16. Tighten tourniquet, change gloves if using a traditional tourniquet vs the CBC
17. Inject prepared bacteriostatic normal saline wheal over planned insertion site.
18. Access Vein with Power Glide midline catheter.
19. Remove tourniquet once Power Glide has been successfully placed.
20. Flush the catheter with normal saline to clear any bloody reflux.
21. Use skin prep around the area, let dry.
22. Secure catheter with StatLock or alternative securement if indicated and apply
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transparent dressing with CHG unless contraindicated.
23. Secure extension set as needed.
1. Place Midline Alert sign at head of patient’s bed.
2. Complete the midline order and document insertion in the patient’s clinical record.
VII. PICC PROCEDURE
A. Equipment: Standardized insertion supply cart is used with the following:
1. Modified Seldinger Technique (MST)
a. Mask, head cover, sterile gown, sterile ¼ sheet, sterile towel 4-pack
b. Sterile gloves x 2
c. Ultrasound and coupling gel
d. Skin marker
f. Tape measure
g. 2% chlorhexidine (ChloraPrep®) x 2
h. Catheter PICC Kit
1. Perform hand hygiene according to Hospital Administrative Policy 13.08, Hand
Hygiene, and don mask, gloves and head covering.
2. Assemble equipment, prepare a clean work area.
3. Position patient to allow optimal access to insertion site for prepping, draping and
vessel access while maintaining patient comfort.
4. Prepare patient for procedure. Trim hair from planned insertion site(s) as needed.
5. Extend and support extremity/area to be cannulated.
6. Apply tourniquet loosely.
7. Use tape measure to determine anticipated length of catheter using established
8. Prepare sensor if using the Sapiens TCS tip location system:
a. Attach fin assembly to sensor and place sensor in holder.
b. Position sensor on patient’s chest with the top of sensor above the sternal notch
and centered on the sternum.
c. Prepare and attach external ECG electrodes to all three lead wires. Ensure
electrode locations are oil-free and completely dry.
i. Place black electrode lead wire on patient’s left shoulder.
ii. Place red electrode lead wire on lower left side inferior to the umbilicus
and laterally along the mid-axillary line.
9. Evaluate baseline ECG:
a. Turn on Sapiens TCS and note external waveform.
b. Verify that P-wave is present, identifiable and consistent on the main screen.
c. If no persistent or regular p-wave is identified, continue with procedure utilizing
magnetic tracking and external measurements followed by tip confirmation via
d. Adjust ECG scale as needed to ensure that entire ECG waveforms are visible in
the ECG window throughout the insertion procedure.
10. Vigorously prep 4x4 inch area around planned insertion site with ChloraPrep®
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applicator for 30 seconds, allow to dry for 30 seconds.
11. Open sterile kit to create sterile work area. Perform hand hygiene, and don sterile
gloves and gown. Re-prep 4x4 inch area around planned insertion site with
ChloraPrep® applicator for 30 seconds, allow to dry for 30 seconds (do not blot,
wave or blow dry).
12. Examine all equipment for any defects. Have assistance available, if necessary, to
preserve sterile field.
13. Apply sterile drapes, towels, and sterile sheet to establish full barrier precautions.
Place a sterile fenestrated drape over the insertion site.
14. When using ultrasound guidance, cover probe with sterile sheath provided in PICC
Kit using sterile technique.
15. Tighten tourniquet using sterile towel.
16. Draw up 1% lidocaine from kit and inject wheal over planned insertion site.
17. Access Vein
a. Perform venipuncture with 21 gauge needle bevel up, using ultrasound guidance.
A 20 gauge or 22 gauge Angiocath may be used in place of a needle.
b. Insert guidewire through needle past needle bevel and into vein, passing no
further than the level of the shoulder. Remove needle leaving guidewire in place.
c. Remove tourniquet.
d. Perform small dermatotomy with safety scalpel at guidewire insertion point.
e. Thread microintroducer over guidewire and into vein.
f. Trim catheter, taking care to withdraw stylet first.
g. Remove guidewire.
h. Remove dilator from Microintroducer.
18. Insert catheter
a. Using magnetic tracking navigation with Sapiens TCS technology:
i. Thread catheter into peel away sheath until magnetic tracking icon appears
or approximately 10 cm and stop inserting catheter.
ii. Attach saline-filled syringe. Flush catheter with saline and wait for
intravascular waveform to stabilize.
iii. Attach catheter stylet to fin assembly.
iv. Palpate the fin assembly through the drape.
v. Form and pinch the drape around the fin assembly.
vi. Place the stylet connector on the bottom end of the fin assembly and slide
the connector forward until fully seated.
vii. Lay catheter on sterile field.
19. Maintain catheter position and withdraw peel-away sheath, removing sheath from
around catheter in increments.
a. Verify that P-wave on the intravascular ECG is present, identifiable and
consistent on the main screen of the Sapien’s TCS.
b. Continue insertion until the magnetic navigation shows the stylet icon moving
c. Continue to slowly advance catheter until the catheter is inserted to the external
measurement determined prior to insertion.
d. Slowly adjust catheter tip position until maximum P-wave amplitude is reached.
e. Compare main screen waveform to reference screen waveform while closely
monitoring for negative P-wave deflection.
i. NOTE: The P-wave may continue to increase in amplitude when initial
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negative deflection is noted. In this case, adjust catheter tip position to
maximum P-wave amplitude with no negative deflection.
ii. WARNING: Do not rely on ECG signal detection for catheter tip
positioning when there are no observable changes in the P-wave. In this
case, rely on magnetic navigation and external measurement for tip
positioning and use chest x-ray to confirm catheter tip location.
f. Advance or retract catheter from maximum P-wave to place tip in desired
i. Catheter insertion when not using magnetic tracking or tip location
system: Thread the catheter tip into the peel-away sheath, advancing
slowly in 2 cm increments.
20. Continue to advance catheter, pausing at intervals to confirm appropriate blood
return, until tip advances into vena cava. Maintain catheter position and withdraw
peel-away sheath, removing sheath from around catheter in increments.
21. Advance catheter to the desired marking on catheter based on tip location system or
on predetermined external measurement.
22. Flush all lumens with normal saline to clear any bloody reflux.
23. Secure catheter with StatLock®, or alternative securement if indicated, and apply
CHG transparent dressing per Nursing Patient Care Policy 1.56 AP, Central Vascular
Access Device Use, Maintenance and Removal, Adult and Pediatric.
VIII. COMPLETION OF PROCEDURE
1. Release conditional chest x-ray order for catheter tip confirmation when tip location
system was not used or unable to determine tip location.
a. Active orders will state, “Do not use PICC Line until placement is confirmed”.
b. Ordering provider must confirm catheter tip placement with radiologist.
c. Once catheter tip placement is confirmed, ordering provider will modify active
order to “PICC ready for use”.
1. Midline catheters may be used immediately after insertion.
2. HFFY #7831 - “Midline Health Facts for You” reference will be posted in the room
for the inpatient midline recipient. See attachment in the “Related” section of U-
A. Document the following in the patient's clinical record:
1. Reason for placement
2. Type and route of analgesia used
3. Catheter type, size (gauge or French), number of lumens, length inserted in
centimeters, and catheter lot number
4. Insertion arm and vein used, including veins attempted unsuccessfully
5. Insertion procedure note with summary of complications including any difficulties
accessing vein or threading catheter
6. Intra- and post-procedural pain rating
7. Every 8 hour observation of patient and insertion site for post-insertion complications
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8. Documentation of patient education including review of HFFY #5093, Understanding
your Peripherally Inserted Central Catheter (PICC) (or #6621, Spanish version).
9. Plan for venous access if PICC placement was unsuccessful
10. Informed Consent UWH #300350
B. Notify provider if any of the following occur:
1. Inability to insert PICC
2. Excessive bleeding at insertion site
3. Arterial puncture
4. Pain in the arm or chest
5. Numbness or tingling in arm/hand
6. Cardiac arrhythmias
7. Tip placement outside the vena cava unresolved with noninvasive techniques
8. Post insertion complications including tenderness, pain, redness, swelling, heat,
infiltration/extravasation, or numbness/tingling
X. UWHC CROSS REFERENCES
A. AFCH/Pediatric Guidelines – Pediatric Vascular Access Flow Diagram
B. Delegation Protocol 16, Central Venous Access Device Clearance
C. Guidelines for Flushing/Locking of Venous Access Devices in Adult/Pediatric
D. Guidelines for Central Venous Access Device Occlusion – Adult/Pediatric/Neonatal
E. Health Facts For You 5093, Understanding your Peripherally Inserted Central Catheter
F. Health Facts For You 6621, Understanding your Peripherally Inserted Central Catheter
(PICC) – Spanish Version
G. Health Facts For You 7831, Your Midline Intravascular Catheter
H. Hospital Administrative Policy 8.48, Operative, Invasive and Other Procedures
I. Hospital Administrative Policy 13.08, Hand Hygiene
J. Nursing and Patient Care Policy 1.55 A, Midline Intravenous Peripheral Catheters: Use,
Maintenance and Removal (Adult)
K. Nursing Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult and Pediatric)
A. AVA Position Statement Use of Real Time Imaging Modalities for Placement of
Central Venous Access Devices, p1-5.
B. Bard Access Systems, INC Product insert for the Polyurethane PICC with MicroEZ
C. Blackburn, P., & Kokotis, K. (2003). Vascular Access Device Selection, Insertion, and
Management; Bard Access Systems, INC.
D. Davis, J., & Kokotis, K. (2004). A new perspective for PICC line insertions. JAVA,
E. Dobson, L., & Wong, D. (2001). Development of a Successful PICC Insertion Program.
F. Fry, C., & Aholt, D. (2001). Local Anesthesia Prior to the Insertion of Peripherally
Page 8 of 8
Inserted Central Catheters. J Infusion Nursing, 24(6).
G. Grove, J., & Pevec, W. (2000). Venous Thrombosis Related to Peripherally Inserted
Central Catheters. JVIR, 11, 837-840.
H. Hospital Infection Control Practices Advisory Committee (HICPAC) (2011).
Guidelines for the Prevention of Intravascular Catheter-Related Infections.
I. Hunter, M. (2007). Peripherally Inserted Central Catheter Placement at the Speed of
Sound. Nutrition in Clinical Practice, 22(4), 406-411.
J. Infusion Nurses Society (2016). Infusion Therapy Standards of Practice. Journal of
Infusion Nursing, 39(1S), ISSN 1533-1458.
K. Pettit, J. (2007). Technological Advances for PICC Placement and Management.
Advances in Neonatal Care, 7(3), 122-131.
L. Smith-Temple, J., & Young-Johnson, J. (2009). Nurses’ guide to clinical procedures,
5.12 administering intradermal medications (pp.202-206). Lippincott Williams &
Wilkins: Philadelphia, PA.
XII. REVIEWED BY
Clinical Nurse Specialist, Infusion
Nurse Manager, Venous Access Team
Nursing Education Specialist
Venous Access Team
Nursing Patient Care Policy and Procedure Committee, November 2016
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer