Vascular Access

PICC Team Improves Service To Patients While Decreasing Work For Staff

Delays in the placement of catheters used in intravenous therapy were causing increased lengths of stay and decreased satisfaction among many of the 2500 Health System adult inpatients requiring this type of procedure each year.

But, when a team got together and studied the process using Michigan Quality System techniques, it discovered 14 major problem areas and developed solutions for each that will not only improve service to patients but will cut down on work for our employees.

The Background

The Health System uses peripherally inserted central catheter (PICC) lines to treat patients requiring medium to long-term intravenous -- or IV -- therapy. A "PICC" line is a type of long, flexible tube that is inserted into a vein in the arm and then threaded into a larger vein in the central part of the body just above the heart. The procedure is performed under local anesthetic by a specially trained nurse in either a hospital or outpatient facility. After the PICC line is placed, a chest x-ray is required to verify correct positioning of the line.

The therapy provided through the catheters ranges from antibiotics for patients with infections to chemotherapy for cancer patients. PICC lines are also used when patients experience difficulties with vascular access, such as irritation at the site of smaller veins typically used with IVs.

Vascular Access Services' new paradigm is "the right line at the right time." The goal is a PICC line placement on the first try and to place 85 percent of the lines within 12 hours of the order and 100 percent within 24 hours.

Currently, only 43 percent of PICC lines are placed within 12 hours of the order, and only 61 percent are placed within 24 hours of the order. Placing of PICC lines is complicated: although only a small percentage of the requests to Vascular Access Services are for PICC-line placement, VAS nurses spend more than a third of their time on these complex line placements.

It should be noted that when VAS nurses are unable to place PICC lines, patients are then referred to Interventional Radiology where another attempt is made - resulting in further delays.
When Interventional Radiology gets involved, 23 percent of the PICC lines are placed within 12 hours of the referral from VAS, and 49 percent are placed within 24 hours.

When you combine the two approaches - using VAS nurses and Interventional Radiology -- the percentage of time that PICC line placement is completed accurately on the first try is just 30 percent. This reduction in first time quality is due to process problems, including missing orders or the need for clarification from a physician.

With the goal of streamlining the PICC line process from beginning to end, the UMHS PICC Line Placement team, with representatives from the Department of Radiology, Interventional Radiology, Vascular Access Services, Inpatient Clerical, and the Faculty Group Practice, participated in a two-day lean workshop facilitated by General Motors in March 2005 to identify core problem areas in the process, using lean management principles modeled on the business philosophy for quality originated by the Toyota Motor Corporation.

Additionally, a leadership panel assembled, including:
Margaret Calarco
Harry Granito
David Spahlinger
John Billi
Anthony Denton
Reed Dunnick

Mapping the Problem

The team identified five problem areas:

* Long wait times - The team found that patients who need PICC lines are waiting too long, due to delays that occur in between each step of the PICC line placement process – from beginning to end. For instance, when a nurse goes to a room to place a PICC line and finds that there is no written order, a wait time results. From this point, the nurse has to page a physician, wait for the order to be written, and return to the room for a second time to attempt placement of the PICC line. The wait time that occurs as a result of this missing order can take up to 14 hours.

* Long lead times - The team found that the amount of time from when the PICC order was first written to the time the line was actually placed was too long.

* Discrepancies between paper orders and electronic referrals. The team found that although electronic referrals were submitted through the VAS web site, a paper order issued by a physician was still required prior to PICC line placement.

* Orders for incorrect types of vascular access. The team found that this error occurs when there is a lack of knowledge about which type of vascular access line is best suited to the patient/therapeutic plan. For instance, a peripheral line might be ordered when in fact the more appropriate order would be for a PICC line.

*Lack of automatic updates regarding patient location/status. The team found that there is no system in place to track changes and/or updates in patient location and status. As a result, patients are often not available and/or in the room when a PICC nurse comes to insert the line.

Using value stream mapping and other tools, the team developed a visible diagram of the PICC line process to better understand work flow. Then, team members accompanied VAS PICC nurses on the job to observe the steps and sequence leading up to patient PICC line placement. From there, the team consulted VAS management personnel for further input to refine the current state map. Then, the team identified areas of waste that were slowing down the process. Finally, members developed a future state map and implementation plan.

Pinpointing Problems - and Solutions

After collecting data, the team identified 14 major areas of waste and recommendations for eliminating it. Five of the areas are highlighted below:

A. People Motion - VAS nurses travel to a patient where:

1. There is no PICC order in the chart and/or the patient is not in the room; and
2. The patient won't consent to the procedure.

Recommended Interventions:

1. Use assistive personnel to travel to the inpatient unit to verify the paper order, locate the patient, explain the procedure, obtain the necessary consent and schedule the procedure with unit clerk;
2. Educate consented patients on PICC process;
3. Use the referral process through e-signature. Although this was suggested, the team determined that there is no e-signature capability at this time; and
4. Investigate inpatient centralized scheduling software to assist in appointment scheduling.

B. Waiting

1. The patient has concerns about the procedure or isn't aware of the PICC order when VAS nurse arrives; and
2. Interventional Radiology patients are not given set appointments.

Recommended Interventions:

1. Use assistive personnel to travel to the inpatient unit to verify the paper order, locate the patient, explain the procedure, obtain the necessary consent and schedule the procedure with unit clerk; and
2. Schedule PICC patients into PICC slots determined by demand data. This would be accomplished by using data from past referral volumes (by day) to determine how many daily slots Interventional Radiology needs to accommodate the demand.

C. Processing

Information flow for PICC orders requiring readjustment is through the ordering physician. After a PICC line is placed (and before that line can be used) the patient must be sent to Radiology for a chest X-ray to verify correct positioning of the line. If the radiologist determines that readjustment is necessary, he/she will contact the ordering physician to let them know. This results in multiple orders and delays.

Recommended Interventions:

1. Radiologist to page VAS nurse directly to readjust PICC line (using original order). It is recommended that when readjustment of the PICC line is required, the radiologist contact the VAS nurse directly (instead of contacting the ordering physician) to give instructions for repositioning the line. Afterward, a repeat x-ray is performed; and
2. Investigate option of portable X-ray for PICC confirmation. The team found that the use of portable X-ray equipment was not feasible due to substandard quality in the X-ray equipment available.

D. Overproduction

PICC referrals are being processed for patients who have been transferred to another room or who no longer need PICC.

Recommended Interventions:

1. Use existing personnel in a new role to travel to the inpatient unit to verify the paper order, locate the patient, explain the procedure, obtain the necessary consent, and schedule the procedure with unit clerk;
2. Investigate whether a dedicated VAS procedure room/area will streamline work; and
3. Create a plan for when queue reaches threshold level. There is a need to prioritize patients when the queue reaches threshold level. For instance, when a threshold of 10 patients is established for a particular period and there are actually more than 12 patients in the queue, it is necessary to prioritize patients based on need and/or bring in additional staff to assist with higher volume.

E. Material Movement

Routing the paper requisition for a chestX-ray causes delays. After a PICC line is placed (and before that line can be used) the patient must be sent to Radiology for a chest X-ray to verify correct placement of the line. Currently, the VAS nurse writes an order for the Xray and sends it to Radiology via the hospital's pneumatic tube mailing system (much like the tube used at a drive-in window at the bank).

Recommended Interventions:

1. PICC nurse to fax requisition to X-ray and leave paper copy in patient's chart. This process would eliminate the use of outdated pneumatic tube mailing system and replace with fax transmission;
2. X-ray staff to make photocopy of requisition for internal routing purposes; and
3. X-ray staff to perform daily check on fax machine to ensure proper function.

Implementation Plan

The team has developed an implementation plan with review dates of 4/22/05, 5/11/05, and 6/21/05. Although it is too soon to determine the success of each of these interventions, the team feels that the following five will have the greatest impact on the process:

• Using assistive personnel to travel to the inpatient unit to verify the paper order, locate the patient, explain the procedure, obtain the necessary consent, and schedule the procedure with unit clerk prior to VAS nurse’s arrival to place the line.
  
• Use dedicated Interventional Radiology daily slots for PICC placements.
  
• Using guidelines/algorithms to anticipate which patients would require a PICC line, based on their diagnosis or treatment plan.
  
• Faxing x-ray requisitions rather than routing via pneumatic tube.
  
• Radiology 1700s paging VAS directly for PICC adjustments

Individuals who were part of the workshop were assigned responsibility for each of the 14 parts of the implementation plan. These individuals were also assigned support to aide in the implementation. The team is to report on each of the 14 interventions during 30-, 60- and 90-day reviews with leadership, and has scheduled monthly update meetings (after the 90-day leadership review) to ensure smooth implementation.

Additionally, the team is tracking many metrics related to the project to ensure success of the interventions implemented. The following metrics are tracked monthly:

• VAS turn-around time
• Interventional Radiology turn-around time (after VAS referral)
• VAS time to refer to Interventional Radiology
• Percentage of PICC lines placed within 12 hours and within 24 hours (VAS and IR)
• The volume of orders

The following will not be tracked in an automatic way, but will be checked periodically:

• First-time quality
• Wait time
• Process time