Document 192792

How to structure a training course PICC: the
recommendations of the consensus WoCoVA
and GIPE
Massimo Lamperti MD
Consultant in Neuroanesthesia and Pediatric Anaesthesia, Cleveland Clinic Abu Dhabi, UAE
 Where are we now?
 Where are we going to?
 Do we perform well?
What was known (before) about
•  Lack of evidence-based medicine
•  Some position statements of Scientific Societies (RCR, ACEP, AMS)
•  More based on a consolidated habits that on standards of education
•  Total lack of objective criteria
What about clinical training?
•  Greater standardization in nurses training
•  More attention in pediatrics and neonates (where the process is properly
standardized and a final audit is considered mandatory)
Consensus and guidelines
•  WOCOVA: objective: to achieve a minimum proficiency level on central
venous access placement and care
•  GIPE: objective: specific requirements a PICC course must have to teach
insertion / management of PICCs
Differences WOCOVA/GIPE
EBM consensus with specific recommendations on minimal
skills not only on trainees but also on trainers/supervisors
•  GIPE: experts’ opinion, no-EBM based with the specific objective to create a
network of centers with qualified experts in teaching PICC line insertion
and management
Why an EBM method?
•  JCAHO and ISO certifications accept only EBM-based guidelines
•  WOCOVA used the GRADE-RAND method which is considered by the
Cochrane review as the gold standard method for writing statements after
a consensus conference
•  From level of evidence (I,Ia, IIa, IIb...) to
new different levels of evidence
(A=high,B=moderate,C=poor), levels of
recommendation (strong/weak)
and degrees of Consensus (very good/good/poor) between experts
Wording based on Degree of Consensus & Grade of recommendations
Degree of consensus
GRADE of recommendation
Perfect consensus
recommend – must/to be/ will
Very good consensus
recommend – should be/can
Good consensus
recommend – may be/may
Some consensus
Suggest- may be
No consensus
No recommendation was made regarding
Main topics to be covered in a PICC
•  Theoretical teaching
•  Ultrasound anatomy (knobology)
•  Simulators
•  Supervised training on patients
•  Final audit
Theoretical teaching
•  Basic Ultrasound anatomy
•  Physics of ultrasounds and ultrasound imaging (gain, depth, focus, freeze,
NO Doppler in the basic ultrasound knowledge)
•  Recognition of abnormalities/complications (major and minor)
•  Maintenance / care of CIC
Theoretical teaching
•  Indications to the positioning of CICs and types of CICs
•  Knobology (vascular, nervous, soft tissues)
•  Ultrasound for venipuncture and control of complications
•  Control of the tip of CIC
•  Infection control and sterility
Theoretical teaching
•  Insertion
procedure (maintaining sterility, kit preparation, ultrasound
evaluation of pre-, intra-post control, fixation, dressing)
•  Prevention, assessment and treatment of complications
•  Proficiency rating with the GRS
•  Specific aspects in the infant / child
•  Vascular anatomy, size, location, course
•  Differentiation A / V with ultrasound
•  Identification of skin changes
•  Distribution and identification of peripheral nerve structures
•  Respiratory Anatomy (not MANDATORY for the basic PICC
Ultrasound lab
•  How an US machines works
•  RACEVA protocol
•  CVR (catheter / vein) ratio
•  CUS (compressive ultrasound)
•  Choice of CICs (patient, treatment, length)
• Use of a checklist for choosing CICs
• Use of checklist for PICC insertion
• Recognition of the tip of the PICC
-Intracavitary ECG (recommended)
-chest x-ray (tip recognition/misplacements)
-CEUS (contrast enhanced ultrasound)
Checklist for the maintenance and care of PICC:
•  medication •  dressing
•  washing techniques
•  techniques for removing catheter’s clots or obstructions
How to replace a PICC in case of:
•  rupture of the catheter
•  thrombosis
•  infection
Teaching techniques
•  Experiential
learning: a model of learning, in which learning/meaning is
derived from direct experience. Experiential learning can be attained in a
reflective cycle such as Kolbs’ learning cycle.
•  Experiential
education: is a methodology where educators/mentors
purposefully engage with learners in direct experience and reflection in
order to increase knowledge, develop skills and clarify values
Simulation training
What you should teach?
Each trainee should perform a PICC insertion starting from:
•  Discussion on the clinical scenario
•  Preparation of patient and materials
•  Completion of the procedure with the greatest adherence to reality and
within the bundles for infection prevention
Simulation Training
•  Communication with team members to assist the operator performing
PICCs insertions
•  Communication must be clear, effective and
shared decision-making
Anatomical models
•  Must be able to reproduce the vascular component, soft tissues, muscles,
•  There are already 3D models available that simulate the reality of human
•  It is necessary to establish anatomic models with different characteristics
• Safety
learning curve: with a 50% reduction of major
proficiency based on a predetermined number of
procedures (4) to increase in case of failure (up to 10)
Example of a PICC course
•  6-8 hours of theoretical education
•  4 hours of practice on animal model
•  Ultrasound lab: 4 hours in healthy volunteers
•  Supervised practice until proficiency is achieved (from 4 to 10 according
GIPE- GRS3 according WOCOVA)
Audit and assessment of competence
•  Use a logbook
•  If trainees fail in a step, they have to go back to the previous step in order
to be trained again (retraining back)
•  For the theoretical part: passing score 70% of MCQs (at least 100)
Final exam and evaluation of
•  Final audit with the Global Rating Score that involves passing all the steps
•  If the steps are not fully passed, the trainee must continue in practice until it
gets full power and he/she is not recognized to perform the operation in an
autonomous way
•  Core privileges definition of PICC inserters
Proctored supervision
•  Mandatory during certified training
•  Failure of the method "see one, do one, teach one"
•  Experienced operators defined according to their proficency (not according
to the number of installations itself)
•  Core privileges definition of PICC trainers
Trainer/supervisor core privileges
•  Certified trainer
•  Trainer have to maintain a clinical proficiency continuously in order to have
a personal logbook and morbidity lower than other operators
•  Have to be members of a IV team
•  Must support and promote the culture of the IV team and IP team with
regard to the prevention of CLABSI
Training in neonates/paediatrics
•  Dedicated to those who usually works in the field of neonates / paediatrics
•  Staff already trained in the care of these patients
•  Specialist training by the trainer
•  Supervised training increased up to final GRS full autonomy
Take home points
•  Standardization of the educational programmes
•  Minimal theoretical teaching defined
•  Anatomical laboratory
•  Laboratory on inanimate model
•  Supervised practice on patients
•  Final audit and objective evaluation method (GRS)
Questions at:
[email protected]