Donna Dowling, PhD, RN ❍ Section Editor

Original Research

Neonatal Peripherally Inserted Central

Catheter Practices and Providers
Results From the Neonatal PICC1 Survey
Elizabeth Sharpe, DNP, APRN, NNP-BC, VA-BC; Latoya Kuhn, MPH; David Ratz, MS; Sarah L. Krein, PhD;
Vineet Chopra, MD, MSc

ABSTRACT
Background: Neonatal intensive care units (NICUs) commonly utilize peripherally inserted central catheters (PICCs) to
provide nutrition and long-term medications to premature and full-term infants. However, little is known about PICC
practices in these settings.
Purpose: To assess PICC practices, policies, and providers in NICUs.
Methods: The Neonatal PICC1 Survey was conducted through the use of the electronic mailing list of a national neona-
tal professional organization’s electronic membership community. Questions addressed PICC-related policies, monitor-
ing, practices, and providers. Descriptive statistics were used to assess results.
Results: Of the 156 respondents accessing the survey, 115 (73.7%) indicated that they placed PICCs as part of their
daily occupation. Of these, 110 responded to at least one question (70.5%) and were included in the study. Reported use
of evidence-based practices by NICU providers varied. For example, routine use of maximum sterile barriers was reported
by 90.4% of respondents; however, the use of chlorhexidine gluconate for skin disinfection was reported only by 49.4%
of respondents. A majority of respondents indicated that trained PICC nurses were largely responsible for routine PICC
dressing changes (61.0%). Normal saline was reported as the most frequently used flushing solution (46.3%). The most
common PICC-related complications in neonates were catheter migration and occlusion.
Implications for Practice: Variable practices, including the use of chlorhexidine-based solutions for skin disinfection and
inconsistent flushing, exist. There is a need for development of consistent monitoring to improve patient outcomes.
Implications for Research: Future research should include exploration of specific PICC practices, associated conditions,
and outcomes.
Key Words: catheter migration, central venous catheter, flushing, neonate, NICU, peripherally inserted central catheter,
PICC, team

BACKGROUND AND SIGNIFICANCE neonatal providers performing this function.3 More

Neonatal intensive care units (NICUs) routinely uti-
lize peripherally inserted central catheters (PICCs) to
provide nutrition and long-term medications to pre-
mature and full-term infants. While there has been
much growth in understanding PICC practices and
outcomes in adults, less has been learned in pediatric
and neonatal populations.1,2 This leaves knowledge
gaps regarding practice for those who are the small-
est and most vulnerable. Trained vascular access
clinicians are most responsible for PICC insertion in
the adult population, yet little is known about
Author Affiliations: The School of Nursing, University of Alabama at
Birmingham (Dr Sharpe); The Division of General Medicine, University
of Michigan Health System, Ann Arbor (Drs Krein and Chopra); and
Center for Clinical Management Research and Patient Safety
Enhancement Program, VA Ann Arbor Healthcare System, Ann Arbor,
Michigan (Ms Kuhn, Mr Ratz, and Drs Krein and Chopra).
Elizabeth Sharpe is a speaker for Argon Medical Devices and Salveo
Healthcare, has consulted for C. R. Bard, and is on the Advisory Board
for IV Watch. No conflicts of interest are declared for all coauthors.
Correspondence: Elizabeth Sharpe, DNP, APRN, NNP-BC, VA-BC,
University of Alabama at Birmingham School of Nursing, NB406, 1720
2nd Ave South, Birmingham, AL 35294 (elsharpe@uab.edu).
Copyright © 2017 by The National Association of Neonatal Nurses
DOI: 10.1097/ANC.0000000000000376
needs to be learned about PICC practices and those
inserting and caring for PICCs in neonates. A better
understanding of their background and challenges
can identify key areas for quality improvement and
for optimizing outcomes for this special
population.
Literature Review
There is ongoing interest surrounding the domain of
neonatal PICCs. Given challenges of performing
clinical trials in neonates, surveys provide invaluable
information about the state of practice. A number of
surveys have resulted from interest in this specialized
area of neonatal vascular access.4-6 An early national
survey of nurses focused on common maintenance
practices and catheter-related sepsis criteria found
that the use of barrier precautions varied consider-
ably and povidone–iodine was the most common
agent used for skin preparation.4 Similarly, a survey
of neonatologists in Japan examined acceptable
catheter tip locations for PICC use, complications,
and informed consent, and reported that acceptable
catheter tip locations varied greatly, pericardial effu-
sion was rare, and most did not obtain informed

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Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
2 Sharpe et al
consent.6 The most recent national survey of neona-
tal PICC practices exploring multiple aspects of
care, including insertion, maintenance, providers,
training, assessment, and radiographic monitoring,
revealed wide variation in numerous practices.5
Ongoing dialogue in the electronic community of
myNANN frequently addresses and speaks to con-
cerns regarding PICC use and outcomes. MyNANN
is the community forum for the National Associa-
tion of Neonatal Nurses (www.nann.org), which
represents more than 7000 neonatal nurses primar-
ily in the United States and North America. Mem-
bers frequently post questions and responses sur-
rounding PICCs and PICC teams. Although required
for advancing practice, knowledge about how to
appropriately insert, care, and manage PICCs in
neonates is limited. To date, few surveys have exam-
ined practices and use of contemporary technolo-
gies, which continue to evolve, when it comes to
neonates. None have focused on experience or work
setting of providers that place PICCs in neonates. To
bridge these gaps, we conducted the neonatal PICC1
survey aiming to better understand these aspects in
this unique population.
What This Study Adds
• Catheter migration may be more common than infec-
tion as a PICC-related complication.
• Systems need to be developed to gather and produce
meaningful data related to neonatal PICCs and patient
outcomes.
• Neonatal providers are using less heparin for flushing
for increased patient safety.
METHODS
Study Setting and Participants
The Neonatal PICC1 survey was administered
through electronic invitation to neonatal nurses or
nurse practitioners who are members of the
National Association of Neonatal Nurses. Respon-
dents who opened the invitation were eligible to
participate if placing PICCs was part of their daily
occupation.
Development and Validation of the Survey
The PICC1 survey instrument was originally admin-
istered to adult vascular access specialists through
the Association for Vascular Access and the Infusion
Nursing Society.7 To gain insight into the neonatal
setting, the survey instrument was modified to incor-
porate information, evidence, and questions that
pertained to neonatal providers and practices. Mod-
ifications for neonates included substitution of
neonatal-specific terms (eg, the NICU or unit instead
of facility) and, in consultation with a neonatal
Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
practitioner, items relevant to the context of neona-
tal intensive care practice (eg, skin disinfection, neo-
natal techniques). To preserve the integrity of the
original PICC1 instrument and ensure that compari-
sons between providers could be made, extensive
alterations were not possible. However, these were
acknowledged within the study team before admin-
istering the Neonatal PICC1 survey.
Participation for the Neonatal PICC1 survey was
solicited through open invitation through the elec-
tronic mailing list of a national neonatal professional
organization’s online membership community in June
2015. An electronic link was provided for partici-
pants to complete the instrument. Reminders were
posted in the same online community at 2 weeks, 4
weeks, and 5 weeks. The survey link remained active
for 6 weeks, concluding in July 2015.
Statistical Analysis
Descriptive statistics (percentage, proportion) were
used to tabulate the results. Data were assessed and
summarized according to predefined categories,
including demographics, hospital-level characteristics,
and provider practices. Respondents were not required
to answer all questions; therefore, the response rate for
individual questions will vary on the basis of the num-
ber of respondents who answered each question.
Because some questions allowed for multiple responses
(eg, provider categorization or preferences), responses
to some questions total more than 100%. All statistical
analyses were conducted using Stata 13 MP/SE
(StataCorp, College Station, Texas).
Ethical and Regulatory Oversight
Because the PICC1 survey-based study sought to
describe existing practice and did not seek to collect
any individual or unit-specific identifiable informa-
tion, the project received a “Not Regulated” status
by the institution’s institutional review board
(HUM00088351).
RESULTS
Demographics
A total of 156 individuals responded to the survey
invitation. Of these, 115 qualified to participate
because they indicated they placed PICCs as part of
their daily practice. Of the 115 qualifying to partici-
pate, 110 responded to at least 1 question (response
rate: 70.5%) and were included in the study. Respon-
dents represented North American territories, includ-
ing 30 territories from continental United States and
Canada. Experience level among respondents was
variable: approximately 50% reported inserting
PICCs for 10 years or more, 34% reported that they
had placed 100 to 500 PICCs while 22% reported
having placed 500 or more PICCs (Table 1).
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 Neonatal Peripherally Inserted Central Catheter Practices and Providers 3

TABLE 1. General Characteristics and Perceived Relationships of Respondents

Which of the following best describes you? N (%) N = 76
Vascular access nurse (or specially trained PICC nurse) 30 (39.5%)
Mid-level provider (eg, physician assistant or advance practice nurse) 40 (52.6%)
Other 6 (7.9%)
How many vascular nurses are on your team? N (%) N = 110
<10 59 (53.6%)

≥10 35 (31.8%)
Unknown/not applicable 16 (14.5%)
How many PICCs have you placed in your career? N (%) N = 76
<500 59 (77.6%)

≥500 17 (22.4%)
How many years have you been inserting PICCs? N (%) N = 76
≤10 y 38 (50%)

>10 y 38 (50%)
Do you currently have VA-BC or CRNI vascular access qualifications? N (%) N = 76
Yes 2 (2.6%)
No 74 (97.4%)
Are you the vascular access lead nurse for your facility or organization? N (%) N = 76
Yes 18 (23.7%)
No 58 (76.3%)
How would you rank the overall support (eg, staffing, financial, and political) your vascular N = 104
access service receives from hospital leadership? N (%)
Very good or excellent 50 (48.1%)
Fair or good 48 (46.2%)
Poor 6 (5.8%)
How would you describe your relationship with physicians in your unit when it comes to N = 104
communicating recommendations or management of PICCs? N (%)
Very good 71 (68.3%)
Good 28 (26.9%)
Fair 5 (4.8%)
How would you describe your relationship with bedside nurses in your unit when it comes to N = 104
communicating recommendations or management of PICCs? N (%)
Very good 67 (64.4%)
Fair or good 36 (34.6%)
Poor 1 (1.0%)
Abbreviations: CRNI, certified registered nurse in infusion; PICC, peripherally inserted central catheter; VA-BC, vascular access-board
certified; y, years.

PICC Inserter Characteristics of specially trained PICC nurses in individual units

Providers inserting PICCs included vascular access
nurses (53.6%), neonatal hospitalists, neonatal
nurse practitioners or physician’s assistants (63.6%),
and interventional radiologists (14.5%). In addition,
some respondents specifically identified as neonatal
nurse practitioners (14.5%). While the total number
varied, the majority reported that there were fewer
than 10 such nurses (53.6%) in their unit. The
majority of respondents described themselves as
advanced practice nurses (52.6%) or specially
trained NICU PICC nurses (39.5%). Nearly a quar-
ter (23.7%) of respondents identified as being the

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4 Sharpe et al
vascular access lead nurse (eg, PICC team leader) for
their unit. Only 2 respondents (2.6%) reported
holding current vascular access certification by the
Vascular Access Certification Corporation (eg,
Vascular Access–Board Certified, VA-BC) or Infu-
sion Nurses Society (eg, certified registered nurse in
infusion) (Table 1).
Hospital/Facility Characteristics
Respondents reported working in not-for-profit hospi-
tals (59.2%), academic medical centers (32.9%), and
for-profit hospitals (7.9%). The majority of respon-
dents (59%) reported working in facilities that had at
least 250 hospital beds and fewer than 40 NICU beds
(58.7%). Facility characteristics varied among those
surveyed: 105 (95.5%) reported having hospitalists in
their facility and 58 and 56 (52.7% and 50.9%)
reported an affiliation with a medical school or nurs-
ing school, respectively. Most reported that their facili-
ties tracked both numbers of PICCs placed (82.7%)
and catheter dwell times (88.2%). The electronic med-
ical record system was most often utilized to perform
these functions (47.8%), followed by user-maintained
documents (42.4%). The majority of respondents esti-
mated the number of PICCs placed monthly in their
units as fewer than 25 (79.8%) (Table 2).
PICC Indications and Insertion Practices
The 2 most commonly reported indications for neo-
nates to receive PICCs were total parenteral nutri-
tion and difficult peripheral venous access. During
insertion, 90.4% of respondents reported the use of
all 5 maximum sterile barrier precautions including
sterile gloves, gown, cap, mask, and full body drapes.
A total of 83.3% of PICC inserters reported rou-
tinely receiving assistance from a vascular access
nurse when placing the PICC. Only 41 (49.4%)
respondents stated that they used chlorhexidine-
containing solutions for skin disinfection prior to
PICC insertion. Similarly, only 2 respondents (2.4%)
stated that they used ultrasound to locate a suitable
vein for PICC insertion. Most (82.9%) reported rou-
tinely trimming PICCs to length prior to insertion
with more than half (52.9%) utilizing a specialized
trimming device for this purpose (Table 3).
PICC Policies and Monitoring Schema
The majority of those surveyed reported that written
policies for PICC insertion (89.4%) and PICC care
and maintenance (97.1%) existed in their units.
Most respondents (81.3%) also reported having a
written process for daily review of PICC necessity.
Of those with written processes, this included a mul-
tidisciplinary review (53.8%) or a physician-driven
review (50.8%). Only 17.7% reported that vascular
access nurses were empowered to discontinue PICCs
that were not in use without physician authorization
(Table 2).
Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
Maintenance and Management of PICC
Complications
Dressing changes were reported as being under the
purview of specially trained NICU PICC nurses by
61.0% of respondents. Similarly, 67.1% stated that
they did not use securement devices (eg, Statlock
[Bard Medical, Covington, GA], Grip-Lok [Zefon
International, Inc., Ocala, FL]). The most commonly
reported needleless connector used was a neutral
valve connector (32.5%) or positive displacement
connector (30.0%). Frequency of needleless connec-
tor change varied, but was most commonly reported
as being exchanged either every 72 hours (27.5%) or
every 24 hours (23.8%) (Table 3).
The majority of PICC inserters (85.4%) reported
that bedside nurses were primarily responsible for
adherence to a flushing protocol. Most (48.8%)
described targeted flushing practices (flushing
lumens that were not being actively used or only
used for blood draws) with a slow flushing tech-
nique. The most commonly reported volume of flush
was no more than 2 to 3 mL (92.7%). Normal saline
was most often used as the flushing solution (46.3%).
The reported interval between flushing ranged from
every 8 hours to once every 24 hours, with no single
interval being most prevalent (Table 3; Figure 1).
When catheter occlusion was suspected, the
majority (59.5%) reported the use of tissue plasmin-
ogen activator. Although responses were low,
respondents were more inclined to remove the device
and consider replacement at a new site when cathe-
ter migration more than 2 cm was encountered
(8.9%). A third of respondents (32.9%) indicated
that they would discontinue the PICC for any sign of
phlebitis; 27.8% reported that they would also pro-
vide supportive measures such as warm compresses
and analgesics (Table 4).
With respect to complications, respondents indi-
cated that catheter migration was the most com-
monly encountered PICC complication (47.2%),
followed by catheter occlusion (13.9%), coiling/
kinking after insertion (12.5%), phlebitis (9.7%),
and central line–associated bloodstream infection
(CLABSI) (9.7%) (Table 4; Figure 2).
Neonatal PICC Inserter Views Regarding
PICC Use
With respect to the appropriateness of PICC place-
ment, the majority of those surveyed (92.1%) stated
that less than 5% of PICCs placed in neonates were,
in their opinion, inappropriate or avoidable (Table 4).
Nearly half of all respondents (48.1%) described
support from hospital leadership as very good or
excellent; however, a small number reported this as
poor (5.8%). Relationships between physicians and
bedside nurses when communicating recommenda-
tions regarding PICCs were most often described as
being very good (68.3% and 64.4%, respectively).
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 Neonatal Peripherally Inserted Central Catheter Practices and Providers 5

TABLE 2. Facility Characteristics

Which of the following best describes your primary work location? N (%) N = 76
Academic medical center 25 (32.9%)
For-profit community-based hospital 6 (7.9%)
Not-for-profit community-based hospital 45 (59.2%)
Number of hospital beds in your primary work location N (%) N = 78
<250 32 (41.0%)

≥250 46 (59.0%)
Number of neonatal intensive care unit beds in your primary work location N (%) N = 109
<40 64 (58.7%)

≥40 45 (41.3%)
Does your facility have hospitalists? N (%) N = 110
Yes 105 (95.5%)
No 3 (2.7%)
Unknown/not applicable 2 (1.8%)
Is your facility affiliated with a medical school? N (%) N = 110
Yes 58 (52.7%)
No 51 (46.4%)
Unknown/not applicable 1 (0.9%)
Is your facility affiliated with a nursing school? N (%) N = 110
Yes 56 (50.9%)
No 49 (44.5%)
Unknown/not applicable 5 (4.5%)
Does your facility track the number of PICCs placed each month? N (%) N = 110
Yes 91 (82.7%)
No 10 (9.1%)
Unknown 9 (8.2%)
How many PICCs do you think your unit inserts each month? N (%) N = 104
<25 83 (79.8%)
25-49 18 (17.3%)
50-100 1 (1.0%)
>100 2 (1.9%)
Does your facility track the duration or dwell time of PICCs (number of days)? N (%) N = 110
Yes 97 (88.2%)
No 7 (6.4%)
Unknown 6 (5.4%)
How does your unit track the duration of PICCs? N (%) N = 92
Through the electronic medical record system 44 (47.8%)
Manually through user-maintained documents (eg, excel spreadsheets) 39 (42.4%)
Through a module outside the electronic medical record system (eg, billing data) 2 (2.2%)
Unknown/other 7 (7.6%)
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6 Sharpe et al

TABLE 2. Facility Characteristics, Continued

Does your unit have a written policy regarding standard PICC insertion practices? N (%) N = 104
Yes 93 (89.4%)
No 9 (8.7%)
Unknown 2 (1.9%)
Does your unit have a written policy regarding standard PICC care and maintenance? N (%) N = 104
Yes 101 (97.1%)
No 3 (2.9%)
Does your unit have a written medical or nursing process to review the necessity of N = 80
PICCs on a daily basis? N (%)
Yes 65 (81.3%)
No 12 (15.0%)
Unknown 3 (3.8%)
Which of the following best describes this written medical or nursing process (select all N = 65
that apply)? N (%)
Daily multidisciplinary review 35 (53.8%)
Daily physician review 33 (50.8%)
Daily bedside nurse review 21 (32.3%)
Daily vascular access nursing review 9 (13.8%)
Automated electronic systems to review 6 (9.2%)
Daily infectious diseases or infection preventionist review 4 (6.2%)
Daily pharmacist review 3 (4.6%)
Other 1 (1.5%)
Are vascular access nurses empowered to remove PICCs that are idle or clinically N = 79
unnecessary without physician authorization? N (%)
Yes 14 (17.7%)
No 65 (82.3%)
Abbreviation: PICC, peripherally inserted central catheter.

DISCUSSION In addition, we found that catheter migration was

This study is the latest to examine neonatal PICC
practices in the United States and the first to view the
environment of care by exploring policies and pro-
viders’ perceptions surrounding organizational sup-
port. We found that certain evidence-based practices
have gained traction. For instance, the use of maxi-
mal sterile barriers when inserting PICCs in neonates
as a CLABSI-preventive strategy appears common.
Similarly, the use of normal saline rather than hepa-
rin to maintain PICCs is common. However, we also
found that some evidence-recommended practices
are lacking. For instance, the use of chlorhexidine
for skin antisepsis was reported as low despite evi-
dence of benefit. Similarly, there was little use of
ultrasound despite recommendations for its use as a
standard of care in adult and pediatric populations.8
These data suggest improvement in practices that
might be important in enhancing patient safety.
reported as the most common PICC-related
complication—trumping infectious causes, occlu-
sion, and other mechanical issues. This finding is
important as it suggests enhanced focus on training
and securement for neonates and infants is impor-
tant. Catheter migration internally or externally can
create treacherous conditions imperiling the small
baby. That mechanical complications have come to
the forefront in this study suggests that with effec-
tively implemented infection preventive strategies in
place, other complications are receiving greater cog-
nizance. Noteworthy is that most did not utilize a
securement device. This could be due to the non-
availability of an engineered stabilization device spe-
cific for each PICC, and the challenge of achieving
adequate contact area on the small baby’s limited
and fragile skin surface. Alternatively, catheter
migration may have been previously overlooked or
underrecognized as a complication.9 Evaluation

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 Neonatal Peripherally Inserted Central Catheter Practices and Providers 7

TABLE 3. Reported Practices of Respondents

Routinely uses all five sterile barriers when placing a PICC (sterile gloves, gown, cap, mask, and N = 83
full-body drapes), N (%)
Yes 75 (90.4%)
No 8 (9.6%)
Do other vascular access nurses routinely assist you when you insert a PICC? N (%) N = 84
Yes 70 (83.3%)
No 14 (16.7%)
Which of the following products do you routinely use to disinfect the patients skin prior to PICC N = 83
insertion? N (%)
Chlorhexidine gluconate with or without alcohol 41 (49.4%)
Other 42 (50.6%)
Do you use ultrasound to find a suitable vein prior to PICC insertion? N (%) N = 83
Yes 2 (2.4%)
No 81 (97.6%)
Do you routinely trim the PICC to length? N (%) N = 82
Yes 68 (82.9%)
No 14 (17.1%)
What instrument do you use to trim the PICC? N (%) N = 68
Specialized trimming tool 36 (52.9%)
Scissors 32 (47.1%)
Who is primarily responsible for administering and adhering to a flushing protocol at your N = 82
facility? N (%)
Bedside nurses 70 (85.4%)
Vascular access nurses (or specially trained PICC nurses) 4 (4.9%)
Other 8 (9.8%)
Which of the following best describes your recommended PICC flushing protocol? N (%) N = 82
Nontargeted flushing (flush all lumens daily, irrespective of use) 9 (11.0%)
Targeted flushing (flush lumens based on use or nonuse) 40 (48.8%)
Other 33 (40.2%)
Which of the following best describes your flushing technique? N (%) N = 82
Slow flushes 40 (48.8%)
Pulsatile (stop and go) flushing 32 (39%)
Rapid push flushes 1 (1.2%)
Other
How many mL’s do you typically use when you flush each lumen of a PICC? N (%) N = 82
No more than 2-3 mL 76 (92.7%)
More than 3 but less than 5 mL 4 (4.9%)
At least 5-10 mL 1 (1.2%)
More than 10 mL 1 (1.2%)
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8 Sharpe et al

TABLE 3. Reported Practices of Respondents, Continued

Which of the following best describes the frequency at which you recommend flushes of the N = 82
PICC? N (%)
Before and after each use of the PICC 18 (22.0%)
Daily 2 (2.4%)
Every 12 h 11 (13.4%)
Every 8 h 16 (19.5%)
Other/unknown 35 (42.7%)
Which of the following agents are most often used for flushing PICCs at your facility? N (%) N = 82
Normal-saline only 38 (46.3%)
Heparin only 16 (19.5%)
Both heparin and normal saline flushes (based on device or patient characteristics) 23 (28.0%)
Other 5 (6.1%)
Who is most responsible for performing dressing changes for PICCs? N (%) N = 82
Vascular access nurses (or specially trained PICC nurse) 50 (61.0%)
Bedside nurses 11 (13.4%)
Other 21 (25.6%)
Does your facility use a securement device to prevent PICC migration? N (%) N = 82
Yes 27 (32.9%)
No 55 (67.1%)
Which of the following securement devices does your facility use? N (%) N = 80
Neutral valve connectors 26 (32.5%)
Positive displacement connectors 24 (30.0%)
Negative displacement connectors 11 (13.8%)
Split septum connectors 8 (10.0%)
Other 11 (13.8%)
How often are needleless connectors typically changed in your unit? N (%) N = 80
Every 24 h 19 (23.8%)
Every 48 h 2 (2.5%)
Every 7 d 8 (10.0%)
Every 72 h 22 (27.5%)
Every 96 h 13 (16.2%)
Other 16 (20.0%)
Abbreviations: d, days; h, hours; PICC, peripherally inserted central catheter.

revealing distal displacement of a PICC could also
have been an accepted prerequisite to premature dis-
continuation. Thus, accurate data collection demon-
strating the full scale of this problem may not be
available. Consistent definitions and documentation
of catheter migration and other complications are
needed in determining relevant targets for quality
improvement. As has been demonstrated, data col-
lection and reporting have impacted CLABSI reduc-
tion.10,11 More needs to be learned about the nature,
timing, and direction of catheter migration to design
strategies such as consistent training in securement
techniques or awareness of current guidelines for
best practice recommendations.12
With catheter migration, a serious consequence to
be feared, trimming is critical as its omission enables
excess external catheter length, which can poten-
tially migrate inward with potentially fatal compli-
cations.13 Trimming practices appeared largely
unchanged from earlier findings with a small increase
in the use of specialized trimming devices.5
In addition, we observed that providers report
overall positive perceptions of organizational sup-
port and teamwork from leadership, physicians, and

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 Neonatal Peripherally Inserted Central Catheter Practices and Providers
FIGURE 1
Reported flushing frequency (n = 82).
nurses. This is in contrast to adults where studies
suggest that these ties are more variable and subop-
timal.7 Finally, CLABSI-prevention bundles have
evolved into distinct written policies for insertion
and care and maintenance. Processes for daily review
of PICC necessity are now the norm in the NICU, in
contrast with earlier reports where less than 10% of
units conducted this type of monitoring.5,14 Neona-
tal providers appear to be judicious in considering
the intended therapy’s duration, and well in com-
mand of appropriate PICC utilization, in contrast to
what has been found with adult populations.3 These
data advance the science of PICC practice in this spe-
cial population in new and important ways.
Chlorhexidine gluconate adoption for PICC inser-
tion was lower than in an earlier study (52.9%),
which was surprising considering the benefits in
CLABSI reduction and liberalization of the package
labeling.5 This may be due to the small sample size
of this study. In contrast, more recent work demon-
strates a dramatic increase in use of chlorhexidine
gluconate for disinfection (86%) for multiple proce-
dures in the NICU.15
The diversity of flushing practices was notewor-
thy; however, the majority reporting normal saline
as the flushing solution demonstrates a shift from an
earlier survey where neonatal PICCs were seldom
locked and heparin amounts varied.5 This may rep-
resent adoption of emerging findings describing suc-
cess with solely normal saline in peripheral intrave-
nous devices, guiding limiting heparin use.16 A recent
systematic review failed to conclude superiority of
normal saline or heparin in flushing central venous
catheters in infants and the risk of heparin-induced
thrombocytopenia bears consideration.17-19
We were surprised by the wide variation in flush-
ing frequency intervals considering the availability
of published flushing protocols.20 Lack of consis-
tency in flushing protocols can be attributed to neo-
natal PICCs primarily being used for continuous
infusion, and with less prevalent need to lock, or
Advances in Neonatal Care • Vol. 00, No. 00
Copyright © 2017 National Association of Neonatal Nurses. Unauthorized reproduction of this article is prohibited.
9
that neonatal providers may be unaware of the exis-
tence of a flushing protocol. In addition, daily review
of line necessity prompting catheter removal as soon
as no longer needed may obviate the need to lock the
device.
The need for outcomes data related to PICC prac-
tices either exceeds the current functionality of elec-
tronic medical record systems or has not yet been
effectively addressed and incorporated. The conduct
of randomized controlled trials in our population
remains challenging, though they may yield valuable
information regarding optimal complications-
prevention strategies. Practitioners report efforts to
utilize other manual strategies to collect data points
to construct big data. With less than half of respon-
dents tracking PICC data and duration through the
electronic medical record system, a need to develop
systems, add functionality to existing systems, or
train users to track these data is needed. The fact
that some respondents track NICU’s duration and
volume of PICCs manually through user-maintained
documents (electronic spreadsheets or databases)
illustrates the need for consistent approaches to col-
lecting data in an era driving toward standardization
for enhanced patient safety. Our work identifying
this gap is a critical first step in addressing this need.
Providers and infection preventionists will need
these capabilities and resources to guide the develop-
ment and monitoring of new evidence-based initia-
tives to support future quality improvement work.
There was little use of ultrasound reported in this
study. However, ultrasound is the standard of care in
adults and pediatric patients, not in neonates. Find-
ings related to limited ultrasound use are consistent
with previously reported data, though as capabilities
of newer technology evolve, this may shift.5 Addi-
tional barriers to NICU adoption of ultrasound,
such as capital equipment expense, training, height-
ened skill required, and maintaining proficiency
once acquired, also exist. Although there are bene-
fits of ultrasound beyond vessel location, this tech-
nology has yet to be fully embraced by neonatal pro-
viders and more research is needed to realize this
possibility.21
That respondents reported specially trained PICC
teams assume the responsibility for a critically impor-
tant procedure such as PICC dressing change demon-
strates alignment with recognition of teams effec-
tively reducing mistakes to support patient safety.22 A
significant number of respondents indicated that they
were specially trained NICU PICC nurses working in
a team. This area targeting vascular access presents a
ripe opportunity for formalization as an entity for
recognition both within and external to the institu-
tion. NICU-based providers (specially trained nurses,
nurse practitioners, and physicians) dominated PICC
insertion in neonates and seldom ventured beyond
this population. Defining which of these core
10 Sharpe et al

TABLE 4. Reported Approach to Complications and Views Regarding PICC Practice

Most commonly encountered PICC-related complication N = 72
Catheter migration 34 (47.2%)
Catheter occlusion 10 (13.9%)
Coiling or kinking after insertion 9 (12.5%)
Phlebitis over insertion site 7 (9.7%)
Central line–associated bloodstream infection 7 (9.7%)
DVT 4 (5.6%)
Catheter fracture or embolization 1 (1.4%)
What is your preferred approach to treating catheter occlusion? N (%) N = 79
Use a tissue plasminogen activator product 47 (59.5%)
Other 32 (40.5%)
What is your preferred approach to treating a PICC that has migrated out <2 cm? N (%) N = 79
Obtain a chest x-ray film to verify tip position 72 (91.1%)
Remove device and consider replacement at a new site 3 (3.8%)
Perform a complete catheter exchange over a guide-wire if possible 2 (2.5%)
Advance device back into vein 1 (1.3%)
Other 1 (1.3%)
What is your preferred approach to treating a PICC that has migrated out >2 cm? N (%) N = 79
Obtain a chest x-ray film to verify tip position 63 (79.7%)
Remove device and consider replacement at a new site 7 (8.9%)
Perform a catheter exchange over a guide wire if possible 5 (6.3%)
Advance device back into vein after cleaning with alcohol or chlorhexidine 1 (1.3%)
Other 3 (3.8%)
What is your preferred approach when you suspect a patient has PICC-associated phlebitis? N (%) N = 79
Supportive measures 22 (27.8%)
Discuss physician 28 (35.4%)
Discuss nurse 1 (1.3%)
Remove PICC 26 (32.9%)
Other 2 (2.5%)
What is your preferred approach when you suspect a patient has a PICC-related DVT? N (%) N = 79
Notify all caregivers (eg, physician, bedside nurse, resident, or student) 13 (16.5%)
Notify bedside nurse and physician-in-charge 45 (57.0%)
Other 21 (26.6%)
Reports suggest that PICCs are unnecessarily removed when a patient develops a fever. In N = 76
your experience, what percentage of PICCs may have been removed in this manner? N (%)
<10% 10 (13.2%)

≥10% 66 (86.8%)
Reports suggest that PICCs are sometimes placed for inappropriate reasons and could be N = 76
avoided. In your experience, what percentage of PICCs are inappropriate or could have been
avoided? N (%)
<5% 70 (92.1%)
5%-9% 6 (7.9%)
Abbreviations: DVT, deep vein thrombosis; PICC, peripherally inserted central catheter.

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 Neonatal Peripherally Inserted Central Catheter Practices and Providers
FIGURE 2
Most commonly reported PICC-related complications (n = 72). DVT indicates
deep vein thrombosis; PICC, peripherally inserted central catheter.
personnel comprise a team will be important in pro-
ducing meaningful outcomes-related data. Dedicated
teams providing advanced knowledge have been rec-
ognized as key in preventing complications, have
been demonstrated to be beneficial in the NICU, and
are recommended to enhance patient safety in health-
care.8,23,24 Respondents reported variable amounts of
experience and this is interpreted as an advantage in
developing the succession plan for a team. Although
few providers reported holding certification in vascu-
lar access, this finding was not unexpected consider-
ing most NICU nurses who pursue certification
choose a recommended comprehensive credential
such as neonatal intensive care nursing or critical care
nursing certification.25
Limitations
The target population was members of a national
organization who elected to participate in an elec-
tronic mailing list online community. Although the
overwhelming majority of the membership joins the
electronic community, this subset resulted in a
smaller than desired sample size. It is difficult to
quantify the subset population of members whose
duties and interests comprise or include PICC inser-
tion. While the results may not be fully representa-
tive of the overall membership, those who were
motivated to participate represented their own prac-
tices and opinions. Voluntary self-selection may
have elevated expression of certain practices accord-
ing to participants’ biases. The length of the survey
may have contributed to premature terminal fatigue
as completion required stamina and commitment
without interruption. Movement to exit the survey
was noted particularly at a question about fever,
which is uncommon in neonates. The electronic
method of administration may have eliminated par-
ticipants who may have preferred to complete the
survey in more traditional paper-based format.
Advances in Neonatal Care • Vol. 00, No. 00
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11
Considering the short term of activation, this survey
yielded robust state representation (30 states) com-
pared with a previous national survey administered
over a longer period (43 states; raw unpublished
data, Sharpe, 2013).
Strengths
The Neonatal PICC1 survey assessed the practices
and perceptions of neonatal nurses who place PICCs,
and is the first to be successfully conducted entirely
within an electronic community framework of neona-
tal providers in the United States. This study provides
valuable insight into the current state of PICC prac-
tices in neonates and demonstrates the power of utiliz-
ing current electronic technology to capture a dynamic
snapshot. This study is also among the first to identify
catheter migration as the most common PICC-related
complication in neonates, suggesting that there is a
need for improved strategies for catheter securement
and consistent training. Another key finding was that
data collection for PICC duration is being accom-
plished through multiple modalities. This highlights
the need for either more user-friendly functionality in
existing systems or the development of new systems.
The heterogeneity of providers’ backgrounds can pro-
vide a strong foundation for future collaborative care.
Positive perceptions of organizational support are
encouraging moving forward in the current complex
landscape of healthcare as leadership support is asso-
ciated with patient safety climates with decreased risk
of hospital-acquired harm.26
The results highlighted key differences in the
approach to vascular access between the neonatal
and adult populations. The use of both ultrasound
and chlorhexidine gluconate is universally accepted
in the adult population. Neonatal providers deemed
PICC utilization overwhelmingly appropriate for
patient needs in contrast to adult providers (92.1%
vs 36.4%). Neonatal providers came from more
12 Sharpe et al

Summary of Recommendations for Practice and Research

What We Know
What needs to be studied
What we can do today
• A collaborative team approach to infusion therapy has been recognized as inte-
gral to successful delivery of care.
• Provision of vascular access for neonates has traditionally been performed by
dedicated NICU-based providers from various backgrounds, including neonatolo-
gists, nurse practitioners, and specially trained nurses.
• Diversity in practice has been the norm for neonatal PICCs.
• More needs to be learned about how best to prepare, support, and elevate
NICU-based PICC teams to produce positive outcomes and prevent PICC-related
complications.
• There is a need for refinement of best practices for flushing, related to the use of
normal saline or heparin, as no one solution or interval has yet been identified as
optimal in neonates.
• There is an identified need for comprehensive systems to capture and produce
outcomes-based data.
• Formalize implementation, training, and ongoing support of collaborative inter-
professional NICU-based PICC teams.
• Develop systems to monitor patient outcomes data related to PICC teams in the
NICU.
• Collaboratively develop and implement comprehensive evidence-based bundles
directed at minimizing PICC-related complications: catheter migration, occlusion,
phlebitis, and central line–associated bloodstream infection in neonates.

heterogeneous backgrounds than adult providers.
There were higher reports of using only heparin
flushes in the more-at-risk neonatal population
(19.5% vs 2.1%, adults).7
CONCLUSIONS
The Neonatal PICC1 survey provides important
information that reiterates diversity in practice but
also new areas for practice improvement, such as
team formalization, refinement of flushing proce-
dures, minimizing the risk for catheter migration,
and accurate data reporting. While the primary
focus of the original PICC1 survey was not directed
at capturing neonatal data, neonatal-specific modi-
fications achieved unique data. Future iterations of
this instrument have the potential to capture more
meaningful neonatal practice and outcomes infor-
mation not only in the United States but globally.
The decision to utilize a PICC is not without risk.1
The continued variability in PICC practices suggests
a need for:
• Development of systems or additional func-
tionality for systems to monitor PICCs and
associated complications with outcomes data
reporting capability.
• Formalization in definition, education, training,
and functions of specially trained PICC teams.
• Collaborative approaches to preventing cathe-
ter migration and other complications includ-
ing administrative institutional support.
Healthcare providers develop, inform, and enact
their practices based on evidence, rationale (scien-
tific or personal), and common practices in the
community. Our survey results provide foundational
insight about contemporary PICC practices and pro-
viders’ perspectives in our national neonatal com-
munity. Essential to progress is the need for effective
data management platforms to identify and guide
the next generation of strategies for improvement.
There is a compelling need to generate evidence that
demonstrates the superiority of a unified workforce
in implementing best practices. With the dearth of
evidence in this population, our results can inform
the development of future research on which to build
a community of best practice for our tiny patients.
Acknowledgments
This project was funded by an Investigator Initiated
Research Grant from the Blue Cross Blue Shield of Mich-
igan Foundation (Grant Number 2140.II, principal
investigator: Dr Chopra). The funding source played no
role in study design, data acquisition, analysis, or deci-
sion to report these data. Dr Chopra is supported by a
career development award from the Agency of Health-
care Research and Quality. This work was also sup-
ported by the Department of Veterans Affairs, Health
Services Research and Development Service, and
National Center for Patient Safety. Dr. Krein is supported
by a VA Health Services Research and Development
Research Career Scientist Award (RCS 11-222). The
views expressed in this article are those of the authors
and do not necessarily reflect the position or policy of the
Department of Veterans Affairs or the US government.
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