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Nurse led PICC line service: the Hawkes Bay Hospital experience.

A PICC line is a peripherally inserted central catheter. The catheter is inserted in a peripheral vein, usually the upper arm and advanced until the tip is positioned in the distal superior vena cava (SVC). In 2005 the Medical Imaging Nurses at Hawkes Bay District Health Board (HBDHB) began inserting PICC lines using ultrasound and fluoroscopy guidance. Prior to this, a limited bedside service was provided by house surgeons. Lines were placed in a palpable vein, generally the ante cubital fossa. The patient would require a chest x-ray to check tip placement. Some patients would be referred to the interventional radiologist for PICC insertion after several unsuccessful attempts.

PICC lines are increasingly becoming the long term intravenous line of choice. This is due to its relative safety and less invasive insertion compared to hickman lines, femoral or jugular lines (Nichols & Humphrey, 2008). PICC lines are a safe and effective access device for intravenous antibiotics, chemotherapy, total parenteral nutrition and other vesicant infusions. They reduce peripheral vein irritation whilst delivering the medication into an area of haemodilution in the SVC. They are often inserted into patients with poor venous access who require frequent blood sampling, thus preventing damage to the peripheral vessels due to multiple, unsuccessful attempts at venepuncture (Nichols & Humphrey, 2008).

Service Development

Initially, the Medical Imaging Nurse-led service developed slowly, with two nurses accepting the challenge to learn this new skill. The radiologists fully supported this nursing role development and provided expert mentorship during training. Radiologists continue to support the nurse-led service and are readily available for advice or assistance for challenging PICC line insertions. In 2006 a portable ultrasound machine was purchased enabling the service to expand. Referral volumes increased and the two nurse inserters became experts providing in-house training to other Medical Imaging Nurses, until critical mass was achieved.

The service grew from an average of 12 line insertions per month in 2007 to the current 2013 average of 40 lines per month. The annual volume of radiology nurse-led PICC line insertion volumes is shown in Figure 1. The nurse insertion team expanded in line with the service growth to provide a timely service.


At HBDHB, nurse-led PICC line insertion is a credentialed skill. The credentialing processes provide public protection, regulatory requirements and mechanisms for providing evidence of quality practice (HBDHB, 2011). This process supports novice practitioners' transition to expert practitioners and ensures their competency is maintained. In order to be eligible for credentialing, the HBDHB nurse must demonstrate advanced nursing knowledge and skills by obtaining a Level 3 or 4 Professional Development and Recognition Programme (PDRP) portfolio and hold a Level 6 advanced life support certificate.

Experienced Medical Imaging Nurses have core knowledge in patient assessment, radiation safety, infection control and are expert intravenous cannulators. By working in fluoroscopy settings they are familiar with real time imaging and have experience in assisting radiologists with central line insertions. Inserting PICC lines builds on the core specialty nursing skills of the medical imaging nurse.

Training is provided in basic ultrasound physics and knobology, as well as anatomy and physiology, potential complications and troubleshooting strategies. The novice practitioner has access to expert mentorship from radiologists, sonographers, medical radiation technologists and senior nursing colleagues. Training is provided on-the-job as well as through the completion of a specialised course. The nurses have been funded to attend the Australian Institute of Ultrasound vascular access three day workshop in Queensland. The experience of the Christchurch nurse-led PICC team, established in 1997 has also been valuable. (See page 13).

The credentialing system requires the novice practitioner to observe a minimum of five PICC insertions, scrub in for five procedures with an expert practitioner and perform a minimum of 20 insertions under the guidance of a supervising preceptor. The novice will be deemed competent when the preceptor and the nurse intimates competency with supervision continuing until this time. A minimum of 20 PICC insertions per year are required to maintain competency (HBDHB, 2013).

Medical Imaging Nurses provide a non-rotational, non-transient workforce which facilitates proficiency in this skill. In order to ensure a timely service, all six Hawkes Bay Hospital imaging nurses insert ultrasound and fluoroscopy guided PICC lines. This has resulted in a prompt, often same day service.

Paediatric PICCs

Our service has extended to incorporate a paediatric PICC line service. Inserting paediatric PICC lines can be challenging due to the smaller lumen size and tendency for the vein to spasm. Before embarking on paediatric PICC insertions a medical imaging nurse has typically inserted over 100 PICC lines in adult patients. Paediatric PICCs for very young children are usually inserted in theatre under general anaesthetic. However, for children over six-years-old, we successfully insert the PICC line in the fluoroscopy room with just local anaesthesia. The child remains comfortable when accompanied by their parents and a play therapist for distraction. In the last year we have inserted 18 paediatric PICC lines.

Clinical Auditing

Clinical auditing is essential for monitoring the safety, timeliness and efficacy of nursing services. A PICC line database was developed to capture patient demographics, the reason for the insertion, the vessel accessed, the inserter details and insertion difficulties and finally the dwell time and reason for removal. The database is accessed by intravenous nurse specialists, district nurses and the infection control team for ongoing maintenance and data collection.

The Medical Imaging Nurse insertion group uses the database as an audit tool to reflect on their practice. Database entries from 2009 to 2013, show Medical Imaging Nurses are highly proficient in PICC line insertion. The success rate is greater than 99 per cent (2129/2132). The database also assists with clinical decision making, particularly regarding patients with multiple previous lines or difficult access.

Central Line Anti Bacteremia (CLAB)

HBDHB has introduced a hospital wide Central Line Insertion Bundle Checklist and Procedure Note, in line with the Health Quality and Safety Commission New Zealand national guidelines for CLAB. (Health Quality and Safety Commission [HQSC], 2012). All central line insertions have documentation which reflects the new standards. It requires both the proceduralist and an observer to check off a list of essential steps in order to minimise the incidence of central line infections. The list includes hand hygiene, patient skin preparation and sterile draping. The proceduralist must wear a hat, mask, sterile gown and gloves. (HBDHB, 2012; HQSC, 2012).

Benefits of Nurse led PICC service

Medical Imaging Nurses are based in radiology departments and utilise ultrasound and fluoroscopy imaging during PICC line insertion. There is substantial international literature supporting ultrasound guidance as best practice for PICC line insertions, supported by the Society of Interventional Radiology (2004). Ultrasound increases the success rate of first attempt placement (Parkinson, Gandhi, Harper & Archibald, 1998), decreases the incidence of mechanical phlebitis and thrombosis (Simcock, 2008) and reduces trauma for the patient caused by failed attempts (Velindre Cancer Centre, 2013).

The nurses have immediate expert advice and support from consultant radiologists. This is particularly helpful for patients with aberrant vascular anatomy. A venogram or injection of intravenous dye into the vein can be performed and reviewed by the radiologist instantly. Figure 2 shows a venogram of a basilic vein spasm and thrombus. The nurse was unable to advance the PICC line further up the arm and an alternative vessel was used for the PICC insertion. The venogram images are electronically archived and are available for future reference if another PICC is required.

Fluoroscopic guidance during PICC insertions has many benefits. It provides the ability to visualise the tip placement at the time of insertion. As stated by Thompson (2004, p.1) 'There's no better way to view the exact tip of a catheter location than real-time fluoroscopy, where you can actually watch the catheter moving with the heartbeat'. The location of a central line tip on a chest X-ray can be falsely proximal and the true tip may be further down (Thompson, 2004). Fluoroscopy guidance of tip placement ensures that the PICC line is in the correct location and is immediately available for use. It minimises any patient delays waiting for a chest X-ray to be reported.

Medical imaging PICC nurse inserters using ultrasound and fluoroscopy guidance, with the support of consultant radiologists when required, provide a seamless patient service. We have encountered a small number of PICC insertions where placement has proved difficult and wire manipulation under fluoroscopy has been required. Only 4.7 per cent (47/1000) of PICC insertions required wire manipulation.

However, there have also been a number of cases where manipulation of the catheter required either patient positional changes or slight withdrawal and reinsertion of the PICC line. The PICC line follows the path of least resistance and the line may travel towards the neck or coil back on itself. Figure 3 shows a PICC line travelling into the jugular vein towards the head. This is easily visualised and corrected under fluoroscopy. Fricke, Racadio, Duckworth, Donnelly, Tamer and Johnson (2005) recommend inserting PICC lines in an interventional radiology suite for this very reason. Fricke et al., (2005) conducted a study of 843 paediatric PICC insertions under fluoroscopy guidance. All catheters were threaded blindly to a previously estimated length and tip placement was checked by spot fluoroscopy. The majority of PICC catheters (723/843; 85.8 per cent) required manipulation with fluoroscopy guidance to achieve a final position in the distal SVC.

In Hawke's Bay the nurses have not been gathering data on manipulation under fluoroscopy guidance. To address this gap, the database has recently been amended and now collects this information. This will provide supporting evidence on the true numbers requiring both wire assisted and non wire assisted catheter manipulation.


The imaging nurse-led PICC service at Hawke's Bay District Health Board is safe, timely and highly regarded. The PICC lines are normally inserted as a same day service and the failure rate is less than one percent. Approximately 40 PICC lines are inserted each month using ultrasound and fluoroscopy guidance. The CLAB checklist ensures that PICC insertions meet infection control national standards. There are gaps in the HBDHB PICC database on the prevalence of catheter manipulation techniques. This has been amended and will allow for further auditing and evaluation of the benefits of fluoroscopy guidance.


Fricke, B.L., Racadio, J.M., Duckworth, T., Donnelly, L.F., Tamer, R.M., & Johnson, N.D. (2005). Placement of peripherally inserted central catheters without fluoroscopy in children: Initial catheter tip position. Radiology, 234, 887-892.

Hawke's Bay District Health Board. (2011). Nurse credentialing [policy]. Operational policy manual HBDHB/OPM/061. Hastings: Author.

Hawke's Bay District Health Board. (2012). Central venous line insertion [guideline]. IV & Therapeutic Guideline HBDHB/IVTG/217. Hastings: Author.

Hawke's Bay District Health Board. (2013). Application to register for advanced credentialing activity/skill: Radiology nurse-led ultrasound guided PICC. Hastings: Author.

Health Quality and Safety Commission New Zealand. (2012). Target CLAB zero national collaborative to prevent central line associated bacteraemia: Annual report September 2011 to August 2012. Wellington: Author.

Mermel, L,A. (2000) Prevention of intravascular catheter related infection. Aunintern Med. 132(5) March 7. 391-402

Nichols, I., & Humphrey, J.P. (2008). The efficacy of upper arm placement of peripherally inserted central catheters using bedside ultrasound and microintroducer technique. Journal of Infusion Nursing, 37(3), 165-176.

Parkinson, R., Gandhi, M., Harper, J., & Archibald, C. (1998). Establishing an ultrasound guided peripherally inserted central catheter (PICC) insertion service. Clin Radiol, 53(1), 33-36.

Simcock L. (2008). No going back: advantages of ultrasound guided upper arm PICC placement. JAVA, 13(4), 191-197.

Society of Interventional Radiology. (2004). Interventional radiology grand rounds: Central venous access. Retrieved, 15 June 2013 from

Velindre Cancer Centre. (2013). Guidelines for the placement of peripherally inserted central catheters using ultrasound guidance. Retrieved 15 June 2013 from

By Tania Berkett RN and Andrea Walford RN

Andrea Walford has been a Registered Nurse for 24 years having trained at Hawke's Bay Polytechnic. Andrea has worked in a variety of settings from Kaitaia to Sydney specializing in ENT and orthopedic nursing. Andrea's first experience in medical imaging was in Auckland before returning to the Hawkes Bay Radiology Department in 2003. She has been one of the foundational members for developing the Hawke's' Bay DHB's PICC service.

Tania Berkett completed her Bachelor of Nursing at Manawatu Polytechnic in 1998 and gained postgraduate experience at Tauranga Hospital. Her overseas experience found her working in Sydney prior to leaving for the more distant shores of the United Kingdom. Tania was based in Edinburgh, Scotland for eight years where she began her career in Medical Imaging Nursing taking on senior roles at Edinburgh Royal Infirmary. On returning to her roots of Hawke's Bay in 2008, Tania joined the Hawke's Bay District Health Board, becoming a member of the Medical Imaging Nursing team.
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Title Annotation:professional
Author:Berkett, Tania; Walford, Andrea
Publication:The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation
Date:Sep 1, 2013
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