A Conversation With Nancy Moureau: In 2020, So Little Time and So Many Battles to PICC From

As 2019 comes to a close, Nancy Moureau, RN, PhD, CRNI, CPUI, VA-BS, takes a look at what to expect for peripherally inserted central catheter (PICC) programs in 2020. Among the many points she makes, Moureau touches on training, guidelines (or the lack thereof) and reinforcing the standardization process. At the other end, she hopes manufacturers will rise to the occasion (as they seem to have done with duodenoscopes) to make disposable healthcare devices more available and at prices that won’t burden budgets.

Infection Control Today:What changes to PICC programs do you see taking place as we move into the new year?

Moureau: Facilitating and managing the infusion needs of patients is an ever-changing dynamic process. So many patients are now considered difficult access that specialists are needed to carefully select and proficiently insert the best device for the patient and treatment. Gone are the days of the PICC nurse. Now every hospital needs someone, or a team of clinicians, trained and proficient with placement of all types of ultrasound-guided peripheral, midline, and central catheters including PICCs. Two of my recent publications, Steere, Moureau PIV5RIGHTS, and the open-access book Vessel Health and Preservationemphasize the value of the specialist for efficiency, safety and economic success of the healthcare facility. 

ICT: You mentioned in your ICT article in October that there is wide variation regarding how the sterilization process should go for ultrasound-guided peripheral intravenous (UGPIV) insertions. What would it take to create procedural guidelines that everyone can agree upon? 

Moureau: There are multiple groups and associations addressing the issues associated with ultrasound use in conjunction with UGPIV placement. In my opinion not enough emphasis and training is given to the foundational elements needed for standardization, such as skin prepping, sterile gel, reducing contamination, separation of gel from the insertion site in addition to transducer/probe disinfection before and after insertion. The research we have on probe cover failure is 20 years old. I am encouraging companies to test products now to gain a better understanding of effective function. One product I’ve been researching facilitates a sterile insertion site while separating the probe and gel. This approach, if the research proves no failures from needle puncture, would allow low level disinfection before and after the procedure since the probe does not ever contact skin or body fluids. These are all issues that need evidence prior to establishing guidelines that jump to high level and more expensive disinfection with these procedures.

ICT: You also mentioned in our October issue that there is a lack of standardization with procedures for disinfection policies for reusable medical devices. Any movement on this front? Do you see hospitals and manufacturers (at the prodding of CDC, CMS, and FDA) turning more to disposable devices? 

Moureau: I am hoping manufacturers will rise to the occasion and provide the evidence to avoid the more expensive wave. Rather than jumping on the bandwagon, that clinicians would demand evidence before applying these expensive measures of disinfection. I am currently involved with multiple hospitals providing webinars and training on standardization of UGPIV insertions. As I said, I believe education and training is key to promoting safety rather than throwing money where it may not be needed. The proof is just not solid yet.

ICT: Globally, the lack of standardization seems to be the main problem here, as you suggested in your article. Who needs to get on board to make this happen?

Moureau: I believe a step-by-step approach to training all staff involved with UGPIV insertions is needed. Providing education on the aseptic no-touch technique is the first step teaching about skin disinfection, how contamination occurs and working with clinicians to finetune the procedure will go a long way to ensuring safety. Using a securement barrier dressing for gel and probe separation makes the whole process that much easier and safer for the patient. As an inserting clinician, I no longer can tolerate having gel on the skin around the needle puncture site. The smearing of gel, the probe needle insertion, and the clean-up of the skin following insertion all provide opportunities for contamination and poor technique.