ORIGINAL RESEARCH

Factors that influence the use of peripherally inserted central catheter in adult patients

Letícia Machado da Costa^I; Eliane Raquel Rieth Benetti^II; Daiane Dal Pai^III; Silviamar Camponogara ^IV

^I Assistance nurse. Master in Nursing, Federal University of Santa Maria. Rio Grande do Sul, Brazil. E-mail: leticiamachadocosta@gmail.com
^II Assistance nurse. Master in Nursing, Federal University of Santa Maria. Rio Grande do Sul, Brazil. Email: elianeraquelr@yahoo.com.br
^III Nurse. PhD in Nursing. Professor at the Federal University of Rio Grande do Sul. Porto Alegre, Rio Grande do Sul, Brazil. Email: daiadalpai@yahoo.com.br
^IV Nurse. PhD in Nursing. Professor at the Federal University of Santa Maria.Rio Grande do Sul, Brazil. Email: silviaufsm@yahoo.com.br

DOI: http://dx.doi.org/10.12957/reuerj.2017.20976

ABSTRACT

Objective: to identify factors that, from the trained nurse's point of view, facilitate and complicate use of peripherally inserted central catheter in adult patients. Methodology: in this qualitative, descriptive, exploratory study of 18 nurses at a teaching hospital, data was collected from May to August 2015 by semi-structured interview and treated by thematic analysis. Results: the results showed facilitator factors to be: institutional encouragement, catheter availability, and support from medical and nursing staffs. Complicating factors were institutional resources (lack of nurses, training deficit in nursing staff, knowledge shortfall in medical and nursing staff; staff shortage and overwork; ultrasound machine unavailable; clinical aspects (difficult venous access); and individual aspects (lack of patient perspective). Conclusion: knowing these factors may favor the establishment of conduct to improve use of this catheter.

Keywords: Nursing; central venous catheter; peripheral catheter; adult.

INTRODUCTION

The use of intravenous therapy is a daily nursing practice during care in the treatment of diseases or health problems¹. Preventive measures and maintenance of the venous access are necessary in order to allow continuous safe venous infusions in patients, ensuring the establishment and recovery of health and avoiding complications related to venous punctures².

Over the years, intravenous therapy has advanced and gained innovative intravenous devices. Currently, peripheral catheters used in intravenous therapy can be needle catheters, short-term peripheral catheters, and peripherally inserted central catheters (PICCs)³. The latter are considered more reliable because they are inserted in the central vein, remaining for a longer time, with a less traumatic insertion, and reduced risk of complications⁴.

In this perspective, peripherally inserted central catheters, also known by the English abbreviation PICCs, are centrally intravenous devices with peripheral insertion^5,6. PICCs were created in the 1970s in the United States of America. They were initially used in intensive care units (ICUs) only⁷. In Brazil, since 1990, PICCs have been used in neonatology, and since 1995 in adult patients ^6,8. The Federal Nursing Council (COFEN), through the use of its legal and regimental attributions, established through Resolution nº 258/2001 that nurses can insert PICCs provided they have professional training and/or qualification⁹. Thus, over the years, more nurses have been trained to insert this type of catheter¹⁰.

However, studies have shown that the use of PICCs in adult patients is not yet a common practice^4,11, while it is more common in neonatology and pediatrics^1-3,7. This fact has raised questions about the reasons for the low use of PICCs in adults, especially considering the benefits related to safety and quality of patient care.

In this sense, the present study presents the following guiding question: which factors facilitate or hinder the use of PICCs by nurses in adult patients? Considering the importance of nurses as the main responsible professionals for the indication, insertion, maintenance and removal of peripherally inserted central catheters, this study aimed to identify the facilitating and hindering factors for the use of PICCs in adult patients from the perspective of trained nurses.

LITERATURE REVIEW

Throughout the evolution of intravenous therapy, PICCs have gained prominence due to their characteristics and benefits for patients. In the 1990s, these catheters began to be made of more biocompatible, less thrombogenic materials, made of polyurethane or silicone elastomers, offering greater advantages and benefits to patients and lower risks of complications¹².

PICCs are inserted into a peripheral vein and reach the superior or inferior vena cava, acquiring a central location^4-6. The device has one, two or three lumens, is flexible and is made of polyurethane, silicone or polyethylene⁸. It has an open or valved tip and in the presence of some characteristics, such as hemocompatibility, biocompatibility, radiopacity and biostability, is mandatory in its fabrication¹³.

PICCs are indicated when intravenous therapy will be needed for five days to several months; for long-term administration of antibiotics (from two-three weeks to several months); for infusion of antineoplastic agents, irritant or vesicant drugs, or drugs with extremes of pH and osmolarity, and for infusion of blood products^14,15. An important care measure that should be considered is that the indication of PICC use be made before the venous network is damaged by multiple punctures¹⁶.

The main advantages of this type of catheter are: it is introduced at the bedside; it can be inserted by qualified nurses; it causes minimal pain at the moment of insertion; it has a low rate of complications from insertion until removal¹¹. It eliminates potential complications such as pneumothorax and hemothorax, because the insertion is peripheral; it is also of lower cost (compared to surgically inserted central catheters); it allows a longer permanence time than common peripheral devices; it has a lower risk of contamination; it promotes the preservation of the peripheral venous system; and it is indicated for home therapy¹⁷.

PICCs represent a new venous access option for intravenous infusions in patients because they are safe and very favorable¹¹. They are already widely used in the neonatal area and the application in adult patients is on the rise.

METHODOLOGY

This was an exploratory and descriptive study with a qualitative approach. The period of data collection was May to August of the year 2015. The research scenario was the University Hospital of Santa Maria (HUSM), a health reference institution for the central region of the State of Rio Grande do Sul. As a teaching hospital, it is intended for teaching, research and health care¹⁸. The management of this hospital is carried out by the Brazilian Company of Hospital Services (Ebserh) since December 17, 2013¹⁹. Currently, the HUSM has a total capacity of 384 beds¹⁹.

This research was developed in the hospitalization units that provide care for adult patients. Eighteen nurses trained to handle PICCs, out of a universe of 60 nurses trained and active in the HUSM, participated in the study. The inclusion criteria were: to have attended a Training Course on Use, Insertion, Maintenance and Care of PICCs (for at least one year) and also to be working with adult patients for at least one year in the work sector. Nurses who were on leave during the period of data collection were excluded from the survey. After applying the inclusion and exclusion criteria, 20 nurses could participate in the study, but two nurses refused the invitation. Thus, 18 participants remained in the study, once the data exhaustion criterion was applied, in which the closure of the sample considers all eligible participants²⁰.

Data were collected through a semistructured interview with questions related to the object of study, which was audio recorded and later transcribed. The interviews were previously scheduled and carried out in the workplace. The participants were asked about their experience with the use of PICCs, as well as their opinion regarding factors that interfere with their use.

The content of the interviews was analyzed according to Minayo²¹, using the thematic analysis technique, that is, a modality of content analysis that "consists in discovering the nuclei of meaning that make up a communication whose presence or frequency means something to the analytic object"^21:316. Once the corpus of analysis was defined, the data were thoroughly read in order to seek the nuclei of meaning, originating the categories of analysis, which were interpreted in the light of the scientific literature of the area. Two thematic categories emerged from this process, namely: facilitating factors and hindering factors.

During the semistructured interviews, nurses were identified with the letter N and a cardinal sequential number was added, according to the order of realization of the interviews. The project was submitted to all the necessary procedures for its execution, respecting the ethical and moral precepts, as recommended in Resolution nº 466 of December 2012, of the National Health Council²², being approved under CAAE nº 40675915.1.0000.5346. Next, the aspects that interfere with the use of PICCs in adult patients according to the nurses will be presented.

RESULTS AND DISCUSSION

After analyzing the statements, the themes identified were grouped into two categories, one related to the facilitating factors and another to the factors that made it difficult to use PICCs in adult patients, according to the nurses' perspective.

Facilitating factors

The encouragement of the institution, the availability of the catheter, and the support of the medical and nursing teams were aspects cited by the participants as facilitators for the use of PICCs in adult patients.

The interviewees reported that they had attended a training course on PICCs, funded by the institution itself, in partnership with a company that provides these catheters, and that this opportunity offered by the institution served as an incentive for nurses to carry out this training.

According to the Ministry of Health, continuing education means learning at work, where teaching and learning are part of the daily life of organizations and work, based on meaningful learning and the possibility of transforming professional practices²³. Permanent health education is also used as a managerial strategy to rethink and qualify the work organization²⁴. Thus, it was noticed that the Institution has invested in the improvement of nurses' knowledge and skills, offering new sets of knowledge through courses and training, so that they could use new technologies to provide better quality care to patients.

Another factor that promotes the use of PICCs, according to study participants, was the availability of the catheter at the hospital pharmacy. Respondents reported that when they need to insert a PICC, the institution always provides the necessary material.

With this, it is understood that the availability of material in the institution has an influence on the nurses' actions, and may favor the decision making on the use of PICCs. On the other hand, a study carried out in another public hospital points out that there is a general frustration among public service workers due to the lack of material. These professionals need a greater capacity of improvisation in order to perform procedures, leaving them dissatisfied with to patient care²⁵.

The other factor cited as a facilitator for the use of the PICCs was the support of the medical and nursing teams.

Teamwork is a strategy of work organization that incorporates the articulation of actions and knowledge of several professional categories in search of agreement, in order to qualify patient care²⁶. In this context, the partnership between health teams promotes the proper functioning of the service and, consequently, better care provided to patients.

However, despite these facilitating factors, nurses also pointed out several factors that hinder the use of PICCs. This data is described in the next category.

Hindering factors

The participants' statements on the factors that make it difficult to use PICCs are explored in this category, evidencing the influence of institutional resources (lack of trained nurses, lack of training of the nursing team, lack of knowledge of the medical and nursing teams, lack of staff and work overload, and unavailability of ultrasound device); clinical aspects (difficult venous network); and individual aspects (lack of discernment of the nurse to diagnose the need to insert a PICC).

The interviewees pointed out the lack of trained nurses trained for PICC insertion in adult patients as one of the difficulties for the use of this device.

I think to this work out better, in my opinion, more nurses are needed, for not leaving it in the hands of few nurses. (N1)

The testimonies point out that it is necessary to provide more qualified nurses on PICC insertion in adult patients in order to allow greater use of this device. It is important to reinforce the perception that this venous access route brings benefits and increases patient safety by standardizing and qualifying the procedure, as well as giving autonomy to nurses²⁷.

Also, according to the interviewees, another institutional aspect was the lack of training of the nursing team for the handling and use of this catheter after installed, which also interferes with its use, because there may be intercurrences.

The lack of training of the nursing team to handle PICCs may lead to early catheter loss, for which the team must be constantly trained and qualified to use this intravenous device. The use of PICCs requires knowledge, skills and mastery by the nursing team and other health professionals, to reduce the complications that compromise the permanence of this catheter ⁵.

The lack of knowledge of the medical and nursing teams on the catheter was also cited by nurses as an institutional factor that hinders their use. Although in the previous category, some of the interviewees reported that there was support from the medical and nursing teams, some professionals mentioned the lack of knowledge of both the medical team and the nursing team as a difficult aspect, generating some resistance to the use PICCs.

The lack of knowledge on the part of the doctors, or on the part of nursing, the resistance of the workers, both technical and auxiliary workers, because they are afraid to handle the device. (N9)

It is noted in the testimony that the lack of knowledge of both nursing and medical staff hinders the use of PICCs, because it generates insecurity in the handling and unpreparedness at the moment of choosing this device. As PICCs have only recently been used for venous access in adult patients, many people are unaware of its advantages and benefits, what leeds them to reject the option of using this device.

Any new procedure or technology generates discomfort, arguments, and, most of the time, resistance among professionals. One of the major difficulties for the use of PICCs is the total lack of knowledge of the team about these catheters, especially of our own nursing colleagues¹⁰.

It was also pointed out by some interviewees that the lack of knowledge on the part of the medical team caused the catheter to be withdrawn too early, because of suspicion of catheter-related infection.

According to ANVISA, primary bloodstream infections (PBI) are among the most common health care-related infections²⁸. A rigorous evaluation by the medical and nursing team that provides assistance to patients with PICCs is necessary to check the real need to remove the catheter, as well as more contribution from professional experience, scientific evidence and the evaluation of each clinical case so that the removal of the PICC may not be reqeusted too early, before the end of the proposed therapy^15,29. Several criteria for catheter removal should be analyzed and considered in a joint decision between the medical and nursing teams^15,29.

Lack of staff and, consequently, work overload were also cited as institutional aspects that make it difficult to use PICCs.

Lack of staff considerably influences the use of PICCs because the procedure requires time and organization of material for insertion. The need for professional training and the time spent to perform the procedure, which takes around 45 minutes to 1 hour, are disadvantages for the use of PICCs³⁰.

Still, the participants cited as another institutional factor that hinders the use of PICCs the unavailability of the ultrasound device to visualize the most difficult veins.

As it turns out, the ultrasound device as a technological resource to aid the insertion would facilitate the use of PICCs. The use of ultrasound ensures the accurate visualization of the target and the direct visualization of needle and guidewire progression, decreases the number of puncture attempts, improves insertion success rates, decreases insertion time, and minimizes complications, especially in patients with difficult vascular access^15,29,31.

Regarding the clinical aspects, the interviewees mentioned the difficult venous network of inpatients.

These reports made it clear that the difficulty of finding a visible and palpable venous access for the insertion of a PICC in some patients interferes with the insertion of this device, and that this occurs due to the delay to choose for this type catheter. Regarding the above, it is important to note that the selection of PICCs should occur as soon as the patient arrives, that is, when the venous network still allows the insertion of a PICC.

Thus, characterization of superficial peripheral vessels is fundamental to prevent and/or reduce vascular damage and also to plan nursing care³².

Individual characteristics of the nurses were also mentioned by the interviewees as factors that compromise the choice for using PICCs, as can be seen in the statements below:

Sometimes this clinical discernment is lacking in the nurses, when it comes to making a decision about the patient's need for long-term venous access, which would lead to considering PICCs as the first option and not as the last choice.

To that end, considering the use of Systematization of Nursing Care (SNC) and a protocol could help to improve this care, as it would promote the standardization and uniformization of the use of PICCs in the institution. A protocol to guide the use of this type of catheter and the continuous training of the nursing team to handle PICCs are essential¹⁰.

Thus, the obstacles to the use of PICCs in adult patients at the hospital were evidenced. Knowledge about these aspects represents an important strategy to overcome the restricted use of the indicated technology to benefit the care provided to the adult patients under intravenous therapy.

CONCLUSION

The results of this research made it possible to identify the factors that facilitate and hinder the use of PICCs in adult patients from the perspective of trained nurses.

Respondents considered the following factors as facilitators of the use of PICCs: incentive of the institution, availability of the catheter, and support from the medical and nursing teams.

On the other hand, factors that make it difficult to use PICCs include those related to the institution, such as lack of trained nurses; lack of training of the nursing team; lack of knowledge of the medical and nursing teams; lack of staff and work overload; lack of ultrasonic device. Furthermore, there are clinical aspects, particularly the difficult venous network, and individual aspects such as those related to the nurses' lack of discernment about the possibility of using PICCs.

Knowledge about these factors and a process of continuing education in service constitute possibilities for expanding the use of IPCCs, resulting in the qualification of the health care process, as well as in better nursing care practices.

As a limitation of the study, we mention the fact that the study was carried out as a local investigation. However, we expect that this research may contribute to the construction of knowledge in the area and improvement of adult patient care, as well as of the safe nursing care practices and, consequently, to soften of suffering and stress caused by repeated punctures and complications related to short-term peripheral devices.

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