OBJECTIVES:

The purpose of this study was to evaluate the feasibility of a new long peripheral catheter (LPC) program at a large academic center in an effort to reduce the use of peripherally inserted central catheters (PICCs) and their related complications.

METHODS:

The pilot participants were hospitalized children, age >2 years, with a need for noncentral intravenous access for 2 to 29 days, or laboratory blood draw >5 times per day. Patients expected to discharge with intravenous access were excluded. Included in the pilot program development were a literature review, 1-year baseline data analysis, and program design and implementation. A multidisciplinary committee developed and implemented the program from December 2018 to September 2019. LPCs were placed from August to September 2019.

RESULTS:

Regarding the baseline data, between July 2018 and June 2019, 584 PICCs were placed in 461 patients. Of these, 139 PICCs (24%) did not meet requirements necessitating central access and, potentially, could have been avoided if an LPC alternative were available at the time. For the LPC pilot program, 20 LPCs were placed in 19 patients. The median age was 11 (interquartile range of 7–15). The insertion success rate was 83%. There were no serious complications, such as venous thrombosis or catheter-related bloodstream infection. The total rate of minor complications was 35%: the rate of occlusions was 10% (n = 2), and the rate of dislodgement was 25% (n = 5). The catheter failure rate was 74 per 1000 catheter-days. The mean line duration was 6 days.

CONCLUSIONS:

There is a role for LPCs in hospitalized children requiring durable vascular access. Multispecialty designed pilot implementation of an LPC program was successful at an academic pediatric hospital.

Peripherally inserted central catheters (PICCs) are frequently used in hospitalized children for long-term, durable access. However, concerns for their inappropriate use1,2  and high rates of complications3,4  have triggered exploration of safer alternatives. Long peripheral catheters (LPCs) have been recently adopted by some institutions for durable access because of lower rates of complications compared to PICCs.58  An LPC is a 6 to 15 cm peripheral dwelling catheter inserted in the upper extremity; the catheter tip terminates distal to the axilla.9  In Table 1, we provide a summary of studies in which LPCs in pediatrics are evaluated.7,8,1015 

TABLE 1

Summary of the Pediatric Literature Evaluating LPCs and Midline Catheters

StudyNo. Patients and CathetersCatheter TypeTechniqueSuccess Rate, %Successful Cannulation on First Attempt, %Remained in Until Completion of Therapy, %Indwell Time in dComplicationsComments
Millar-Jones et al10  36 and NR Neonatal line and landmark catheter Sterile condition and local anesthesia NR NR NR Neonatal line: mean ± SD = 11 ± 6; landmark: mean ± SD = 12.6 ± 2.3 Neonatal line: total complications: 35%; phlebitis: 7%; positive culture results: 9%a; occlusion: 9%; dislodgement: 1%. Landmark: total complications: 45%; phlebitis: 36%; positive blood culture results: 0%; occlusion: 9%; dislodgment: 0% Patients with cystic fibrosis 
Wyckoff et al11  NR and 135 24 gauge 8-cm and 19-cm and 20 gauge 8-cm L-Cath polyurethane catheter Sterile technique NR NR 49 10 Dislodgement and clotting: 9%; leakage or mild edema: 17% NICU; <30 d old; GA 25–46 wk 
Turner et al12  19 and 34 19 gauge 30-cm Vygon catheter Sterile line advanced to 20 cm NR 68 97 NR NR Patients with cystic fibrosis 
Qian et al13  20 and 40 22 gauge 8-cm polyurethane LPC (LeaderFlex) Sterile Seldinger 100 85 48 10.08 Local inflammation and/or infection: 33%; local pain: 33% Patients with cystic fibrosis; used general anesthesia in the younger age 
Anderson et al7  NR and 122 22 gauge and 26 gauge, both 6 cm and 8 cm Sterile technique 86 NR NR Mean ± SD = 8.9 ± 5.9 Complications during placement: 8%; complications during use: 44% (leaking: 13%, dislodgement: 12%, infiltrate: 6%, occlusion: 5%, and thrombophlebitis: 5%) Compared to PICCs 
Paladini et al14  20 and 20 20 gauge 8-cm polyurethane catheter Direct Seldinger 100 100 75 Mean ± SD = 9.2 ± 6 Complications (dislodgement and/or infiltration, occlusion, and/or thrombosis): 25%; no VTE or infections ED; age >10 y 
Pacilli et al15  18 22 gauge 8-cm polyurethane LPC (LeaderFlex) Sterile Seldinger 94 94 76 Mean ± SD = 6.4 ± 5.1 Occlusion: 17%; thrombophlebitis: 6% Patients undergoing surgery; most placed under sedation 
Chenoweth et al8  432 1.9F 6-cm and 8-cm silicone-based catheter (Neo Medical) NR NR NR 71.7 Mean ± SD = 4.0 ± 2.3 Leaking: 9%, infiltration: 7%, palpable venous cord: 4%, clotting: 4%, and dislodgement: 3%; no life-threatening complications NICU
GA ≥32 wk 
StudyNo. Patients and CathetersCatheter TypeTechniqueSuccess Rate, %Successful Cannulation on First Attempt, %Remained in Until Completion of Therapy, %Indwell Time in dComplicationsComments
Millar-Jones et al10  36 and NR Neonatal line and landmark catheter Sterile condition and local anesthesia NR NR NR Neonatal line: mean ± SD = 11 ± 6; landmark: mean ± SD = 12.6 ± 2.3 Neonatal line: total complications: 35%; phlebitis: 7%; positive culture results: 9%a; occlusion: 9%; dislodgement: 1%. Landmark: total complications: 45%; phlebitis: 36%; positive blood culture results: 0%; occlusion: 9%; dislodgment: 0% Patients with cystic fibrosis 
Wyckoff et al11  NR and 135 24 gauge 8-cm and 19-cm and 20 gauge 8-cm L-Cath polyurethane catheter Sterile technique NR NR 49 10 Dislodgement and clotting: 9%; leakage or mild edema: 17% NICU; <30 d old; GA 25–46 wk 
Turner et al12  19 and 34 19 gauge 30-cm Vygon catheter Sterile line advanced to 20 cm NR 68 97 NR NR Patients with cystic fibrosis 
Qian et al13  20 and 40 22 gauge 8-cm polyurethane LPC (LeaderFlex) Sterile Seldinger 100 85 48 10.08 Local inflammation and/or infection: 33%; local pain: 33% Patients with cystic fibrosis; used general anesthesia in the younger age 
Anderson et al7  NR and 122 22 gauge and 26 gauge, both 6 cm and 8 cm Sterile technique 86 NR NR Mean ± SD = 8.9 ± 5.9 Complications during placement: 8%; complications during use: 44% (leaking: 13%, dislodgement: 12%, infiltrate: 6%, occlusion: 5%, and thrombophlebitis: 5%) Compared to PICCs 
Paladini et al14  20 and 20 20 gauge 8-cm polyurethane catheter Direct Seldinger 100 100 75 Mean ± SD = 9.2 ± 6 Complications (dislodgement and/or infiltration, occlusion, and/or thrombosis): 25%; no VTE or infections ED; age >10 y 
Pacilli et al15  18 22 gauge 8-cm polyurethane LPC (LeaderFlex) Sterile Seldinger 94 94 76 Mean ± SD = 6.4 ± 5.1 Occlusion: 17%; thrombophlebitis: 6% Patients undergoing surgery; most placed under sedation 
Chenoweth et al8  432 1.9F 6-cm and 8-cm silicone-based catheter (Neo Medical) NR NR NR 71.7 Mean ± SD = 4.0 ± 2.3 Leaking: 9%, infiltration: 7%, palpable venous cord: 4%, clotting: 4%, and dislodgement: 3%; no life-threatening complications NICU
GA ≥32 wk 

Arranged in chronological order. A midline catheter is a 15- to 25-cm peripheral dwelling catheter; its tip typically extends into the axilla or the infra-supraclavicular region.9  ED, emergency department; GA, gestational age; NR, not reported; VTE, venous thromboembolism.

a

Cultured line tip at time of removal.

In this pilot study, we evaluated the feasibility of a new LPC program at a large academic pediatric center in an effort to reduce inappropriate use of PICCs and their related complications.

After a comprehensive literature review and consensus from our local committee, 3 common indications for LPC were identified (difficult vascular access, durable vascular access, and frequent blood draws), which guided a review of baseline data.

A retrospective review of the electronic health records (EHRs) was conducted. Patients <18 years old hospitalized from July 2018 to June 2019 who received a peripheral intravenous (PIV) catheter or PICC were included. Patients admitted to the NICU and those with lines placed before admission were excluded.

Difficult Vascular Access and Frequent Blood Draws

The number of PIV catheters per admission, number of insertion attempts per PIV catheter, and number of patients with PIV catheter and frequent blood draw, defined as >5 draws per day, were extracted. If the EHR insertion attempt field was empty, the insertion was considered 1 attempt.

Durable Vascular Access

PICC duration in our study population was classified as <7, 7 to 14, and >14 days. The 14-day cutoff was based on the Michigan Appropriateness Guide for Intravenous Catheter guidelines recommending PICCs for intravenous (IV) infusions >14 days.16  Data collected included the following: patient demographics, attempts, dwell time, infused “red” medications (medications requiring central administration: Supplemental Table 4), and patients discharged with line.

A multidisciplinary team of hospitalist and critical care providers, clinical nurse specialists, bedside and central access team nurses, and critical care transport nurse clinicians collaborated in the LPC pilot program. The goal was the placement of 20 LPCs on 1 pilot acute care floor and the medical and surgical ICU.

The PowerGlide Pro Midline Catheter (Bard Access Systems, Salt Lake City, UT) was selected for the pilot in 2 sizes: 20 g × 8 cm and 22 g × 8 cm. Hands-on training was provided by the vendor for 5 nurse practitioners and transport nurse clinicians with previous ultrasound experience. At our institution, transport nurse clinicians are consulted for difficult PIV catheter placement. Catheter placement used ultrasound guidance according to manufacturer-recommended technique.17  An adhesive securement device was used for all LPC placements. No sedation was used.

All PIV catheter requests from the pilot units were screened for appropriateness of LPC placement. The inclusion criteria were age >2 years, IV duration of 2 to 29 days or laboratory blood draw expected >5 times per day, no need for red infusates, and line removal before discharge. Catheters placed during training days were included in the data analysis. A bedside tool was developed and given to the bedside nurses caring for the patient (Supplemental Fig 1). Data collected included the following: patient demographics, attempts, placement site, catheter size, dwell time, and complications.

Difficult Vascular Access and Frequent Blood Draws

Over the 1-year baseline period, 9481 PIV catheters were placed in 5570 patients: 23% (n = 1306) required 2 PIV catheters, and 10% (n = 559) required >3 PIV catheters per hospitalization. Forty-one percent of the PIV catheters were placed after ≥2 attempts, and 279 patients had >5 attempts per admission when accounting for all PIV catheters inserted. Additionally, 59 patients with a PIV catheter had >5 blood draws per day.

Durable Vascular Access

Over the 1-year baseline period, 584 PICCs were placed in 461 patients (Table 2). Forty-nine percent of PICCs had a duration ≤14 days; 23% had a duration of 8 to 14 days, and 26% had a duration ≤7 days. Forty-one percent of PICCs were without red infusates. A total of 139 PICCs (24%) met no requirements necessitating central access.

TABLE 2

Characteristics of PICCs Placed in Hospitalized Children Between July 2018 and June 2019

Characteristics of PICCs
PICCs, n 584 
Patients, n 461 
Age, y, median (IQR) 5 (0.6–14) 
Admitting service, n (%)  
 Critical care 126 (22) 
 Medical 262 (45) 
 Oncologic 72 (12) 
 Surgical 119 (20) 
No. attemptsa, n (%)  
 1 attempt 311 (53) 
 2 attempts 20 (3) 
 3 attempts 4 (1) 
 4 attempts 2 (<1) 
Duration, d, median (IQR) 12 (6–27) 
Discharged with PICC, n (%) 171 (37) 
Red medications givenb, n (%) 343 (59) 
Complications, n (% per catheter)  
Venous thromboembolism, n (%) 34 (5.8) 
Central line–associated bloodstream infections, n (%) 17 (2.9) 
Characteristics of PICCs
PICCs, n 584 
Patients, n 461 
Age, y, median (IQR) 5 (0.6–14) 
Admitting service, n (%)  
 Critical care 126 (22) 
 Medical 262 (45) 
 Oncologic 72 (12) 
 Surgical 119 (20) 
No. attemptsa, n (%)  
 1 attempt 311 (53) 
 2 attempts 20 (3) 
 3 attempts 4 (1) 
 4 attempts 2 (<1) 
Duration, d, median (IQR) 12 (6–27) 
Discharged with PICC, n (%) 171 (37) 
Red medications givenb, n (%) 343 (59) 
Complications, n (% per catheter)  
Venous thromboembolism, n (%) 34 (5.8) 
Central line–associated bloodstream infections, n (%) 17 (2.9) 

IQR, interquartile range.

a

Missing data: n = 247.

b

Red medication is a hyperosmolar or other medication requiring central administration (Supplemental Table 4).

Of the 30 patients screened from August to September 2019, 17 patients met criteria for LPC evaluation. Additionally, 6 patients were selected during training days.

LPC Pilot Outcomes

A total of 24 LPC placements were attempted in 23 patients; 4 LPC placements were unsuccessful because of difficulty cannulating or threading the vein. Twenty catheters were successfully placed (success rate of 20 of 24; 83%) in 19 patients; 47% were <10 years of age (Table 3). Nineteen catheters were inserted on the first attempt, and 1 catheter was inserted on the second attempt. The mean line duration was 6 days, with a median of 5.5 days (range of 1–16). Eleven of 20 catheters (55%) remained in until completion of therapy, with a catheter failure rate of 74 per 1000 catheter-days (95% confidence interval 40–139).

TABLE 3

Characteristics of LPCs Placed in Hospitalized Children During the Pilot Period

Characteristics of LPCs
LPCs inserted, n 20 
Patients, n 19 
Age, y, median (IQR) 11 (7–15) 
Male, n (%) 9 (45) 
Location, n (%)  
 Acute care unit 9 (45) 
 ICU 11 (55) 
Service, n (%)  
 Critical care 7 (35) 
 Gastroenterology 6 (30) 
 Hospital medicine 4 (20) 
 Oncology 3 (15) 
Anatomic site, n (%)  
 Cephalic vein 7 (35) 
 Basilic vein 12 (60) 
 Brachial vein 1 (5) 
No. insertion attempts, n (%)  
 1 attempt 19 (95) 
 2 attempts 1 (5) 
Catheter size, n (%)  
 22 gauge 10 (50) 
 20 gauge 10 (50) 
PIV catheter insertion attempts before LPC,an (%)  
 0 attempts 12 (60) 
 1 attempt 4 (20) 
 2 attempts 3 (15) 
 3 attempts 1 (5) 
LPC duration, d, median (IQR) 5.5 (1–9) 
Remained until therapy completion, n (%) 11 (55) 
Complications, n (%)  
 Occlusion 2 (10) 
 Dislodgement 5 (25) 
 Phlebitis 0 (0) 
 Venous thromboembolism 0 (0) 
 Central line–associated bloodstream infections 0 (0) 
Characteristics of LPCs
LPCs inserted, n 20 
Patients, n 19 
Age, y, median (IQR) 11 (7–15) 
Male, n (%) 9 (45) 
Location, n (%)  
 Acute care unit 9 (45) 
 ICU 11 (55) 
Service, n (%)  
 Critical care 7 (35) 
 Gastroenterology 6 (30) 
 Hospital medicine 4 (20) 
 Oncology 3 (15) 
Anatomic site, n (%)  
 Cephalic vein 7 (35) 
 Basilic vein 12 (60) 
 Brachial vein 1 (5) 
No. insertion attempts, n (%)  
 1 attempt 19 (95) 
 2 attempts 1 (5) 
Catheter size, n (%)  
 22 gauge 10 (50) 
 20 gauge 10 (50) 
PIV catheter insertion attempts before LPC,an (%)  
 0 attempts 12 (60) 
 1 attempt 4 (20) 
 2 attempts 3 (15) 
 3 attempts 1 (5) 
LPC duration, d, median (IQR) 5.5 (1–9) 
Remained until therapy completion, n (%) 11 (55) 
Complications, n (%)  
 Occlusion 2 (10) 
 Dislodgement 5 (25) 
 Phlebitis 0 (0) 
 Venous thromboembolism 0 (0) 
 Central line–associated bloodstream infections 0 (0) 

IQR, interquartile range.

a

Includes number of nonfunctioning and displaced PIV catheters placed in the previous 24 h.

Complications

No symptomatic venous thrombosis was identified. One ICU patient had a positive blood culture result before the LPC was placed; otherwise, there were no reports of catheter-related bloodstream infection. The total rate of minor complications was 35%: the rate of occlusions was 10% (n = 2), and the rate of dislodgement was 25% (n = 5).

We report a systematic implementation of a pilot LPC program at a large pediatric academic center including a literature review, baseline data collection, pilot program design, roll-out, and outcomes. In this program, patients appropriate for LPC were successfully identified, with an acceptable 83% success rate of insertion with ultrasound guidance. The promising results of the pilot study in screening, placement, and outcomes of LPCs have led us to initiate a hospital-wide LPC program.

We found that 24% of PICCs placed during the baseline period had a dwell time of ≤14 days, without red infusates and removed before discharge so possibly could have been avoided if a better alternative existed. Using LPCs for durable access when central access is not needed could reduce the rate of central line–associated complications.

Children with difficult vascular access requiring multiple PIV catheters and/or multiple attempts to successfully obtain access may benefit from LPCs as well. One-third of the children hospitalized during the baseline period required ≥2 PIV catheters during their stay, most with >1 attempt per PIV catheter placement, resulting in multiple pokes per patient per hospital stay. The first attempt success in our PIV catheter placement is 59%, an overestimate as the EHR documentation of attempts is underused. If attempts were not documented, we assumed the insertion was the first attempt. For LPC placement, our first attempt success rate was 79%, and our overall success rate was 83%. The trend toward improved first insertion success with LPCs will need to be confirmed with a larger study; however, the use of an ultrasound-guided technique may also contribute to the difference in success rate.

The mean LPC duration in this study was 6 days, shorter than the mean of 9.2 days reported by Paladini et al14  but similar to the mean duration of 6.4 days reported by Pacilli et al.15  In our study, we included children ≥2 years old, with 47% <10 years. Young children may have higher rates of dislodgement, resulting in shorter dwell time compared with older children and adults, on the basis of developmental behaviors. In our pilot, we included LPCs placed as part of training with no requirement for anticipated duration of IV access. Because several were removed <24 hours, the results of catheter duration may be skewed.

Only 55% of the LPCs remained in place until completion of therapy, with a higher dislodgement rate (25%) than the 0% to 12% reported in the pediatric literature (Table 1). We used an adhesive securement device instead of sutures to avoid the need for pain medication or sedation with placement. Further investigation into the specific circumstances surrounding dislodgement, including more frequent assessment of securement device integrity, may improve this dislodgement rate.

For the pilot study, we defined the appropriate LPC candidate as a patient >2 years old, with need for durable access and not requiring infusates necessitating central administration. Two 3-year-old patients screened as LPC candidates were found to be too small and the catheter tip would extend proximal to the axilla. Three years old is probably a more appropriate cutoff for routine LPC screening for placement in the upper extremity (when using a PowerGlide catheter). For the pilot, we screened patients with IV access needs anticipated >2 days. This will be extended to ≥6 days for the ongoing LPC program to be consistent with the Michigan Appropriateness Guide for Intravenous Catheter and other guidelines.16,18 

We are undertaking additional steps for implementation of a hospital-wide LPC program.

  • 1. Provider insertion training will use a standardized training module incorporating mannequin simulation. Providers with existing ultrasound skills will be eligible for this training.

  • 2. Nursing champions have been identified to standardize LPC care. A just-in-time education sheet has been developed. Drawing blood tests from the LPC will be consistent with existing hospital policy.

  • 3. A new lines, drains, and airway type has been added to our EHR titled LPC. We will analyze comparative quarterly reports on the placement and outcomes of LPC, PIV catheters, and PICCs. Trends in infection, thrombosis, PICC use, and other outcomes will be tracked.

There is a role for LPCs in hospitalized children requiring durable vascular access. Multispecialty designed pilot implementation of an LPC program was successful at an academic pediatric hospital.

We recognize that the success of this pilot program was dependent on the expertise of multiple individuals and thank them for their important efforts: Alyse Bailey, Anna Kaufman, Ashley Stelter, Jaime Fox, Kathleen Jopke, Michele Yenter, Prakad Rajapreyar, Rachel Grycan, and Tanya Walenta. We thank Glen Bushee for assistance with data acquisition.

Drs Burek and Hanson conceptualized and designed the study, interpreted and summarized data, drafted the initial manuscript, and reviewed and revised the manuscript; Mr Bentzien, Mr Parker, and Ms Talbert participated in study design, piloted data collection, drafted the manuscript, and reviewed and revised the manuscript; Ms Havas participated in baseline data acquisition and critically reviewed the manuscript; and all authors approved the final manuscript as submitted.

FUNDING: Dr Hanson received internal funding from Medical College of Wisconsin Department of Pediatrics for this study.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data