research
Nurse-led PICC insertion: is it cost effective? Graham Walker and Alistair Todd
© 2013 MA Healthcare Ltd
R
epeated attempts to cannulate small veins can cause considerable distress for patients and substantial staff time expenditure (Todd and Hammond, 2004; Kelly et al, 2013). For longer term venous access, a peripherally inserted central catheter (PICC) may be used instead of a peripheral cannula (Todd and Hammond, 2004). Previous studies indicate that insertion of a PICC costs three times more than a cannula but the lifespan is substantially longer (Periard et al, 2008). Three groups of staff commonly insert PICCs: registered nurses working either on general-ward duties or in vascular access teams, medical staff, who may or may not have received formal training, and senior medical staff such as anaesthetists and radiologists. Insertion of these devices by inexperienced staff has been found to result in higher first-attempt failure rates and reduced overall insertion success with increased cannula wastage (Pratt et al, 2007). Teams of competent nurses are employed by many organisations to provide this service and are capable of high success rates (Todd and Hammond, 2004), inserting all but the most complicated PICCs. In many hospitals, nurses will insert the majority of devices but if complications occur, they can seek advice from a supervising physician. Based on evidence from a recent trial, nurses can be trained to insert CVCs both at the bedside and via fluoroscopic guidance in a 3-month period. Although they may experience a degree of stress, these nurses experience greater job satisfaction and feel that their roles have a positive impact on the patients in their care (Kelly et al, 2013). Nurse insertions can free up clinical resources in a safe and effective manner at a time of increasing pressure within the NHS (Boland et al, 2003).
Aims: Repeated attempts to cannulate small veins can cause considerable distress for patients and expend substantial staff time. For longer term venous access, a peripherally inserted central catheter (PICC) may be used instead of a peripheral cannula. Previous studies indicate that insertion of a PICC costs three times more than a cannula but the lifespan is substantially longer. This study aimed to compare insertion cost, patient satisfaction, and infection rates of PICCs for the two main staff groups (trained nurses and radiologists) inserting these devices in a district general hospital. Materials and Methods: The study took place over 4 months in 2012–13. A questionnaire was attached to all identified PICCs in stock at Raigmore Hospital to collect details of the date of insertion, patient involved, time taken, attendant staff grade and experience level, consumables used and insertion success. The lead author’s personal observation of PICC insertion by different staff groups allowed estimation of staff time, costs and success rates. Patient experience and satisfaction was assessed before and after insertion using a patient questionnaire. PICC longevity, infection rates and failures were assessed by review of patient notes. Results: The radiologist group had a statistically significant (p< 0.01) increased cost (42%) over the nurse group. Patient satisfaction regarding explanation of treatment before insertion was higher in the nurse group. Insertion success and infection rates were higher in the radiologist group. Conclusion: The authors conclude that the majority of PICCs can be safely performed without x-ray screening in a ward-based environment. This is likely to be the most cost-effective solution for large volume services.
Nurse vs doctor insertion
Nurse-led vascular access teams
The results of Stokowski et al’s (2009) comparative study undertaken in a Canadian community hospital showed that registered nurses inserted more PICCs than radiologists. When incidence rates of thrombosis between registered nurses and radiologists were compared, no statistical difference was discovered. Nichols and Humphrey (2008) conducted a quantitative research study comparing PICC placement success rates for nurses against physicians. Using ultrasound, success rates for nurses were found to be 91%–95% in comparison to success rates by physicians in interventional radiology suites of 97%–100%. The difference is probably a result of the ability to inject contrast to define vascular anatomy and the availability of guidewires to direct the catheter tip under fluoroscopic guidance.
The first nurse-led vascular access team was established in the USA. The availability of a knowledgeable and experienced PICC team may result in fewer complications, improved success rates, and overall better patient satisfaction (Ryder, 1995; Robinson et al, 2005). A recent study (Robinson et al, 2005) found that introduction of a dedicated PICC team resulted in a 33% reduction in CVC placement as inappropriate patients were identified and CVCs not
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
Abstract
Key words: PICC
■
Cost
■
Nurse
■
Radiology
■
Vascular
■
Insertion
Graham Walker is Medical Student, University of Aberdeen and Alistair Todd is Consultant Radiologist, Raigmore Hospital, Inverness and Programme Mentor, University of Aberdeen, Aberdeen, Scotland. Accepted for publication: October 2013
S9
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on February 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
Current situation at Raigmore Hospital Raigmore Hospital in Inverness is the largest hospital in the Highlands. It receives patients from the Western Isles and Morayshire. It has 577 beds and serves a vast variety of patients. The hospital is typical among many other hospitals in the UK in that the vascular access service is divided across a number of different departments: PICCs are inserted by oncology and outpatient parenteral antibiotic therapy (OPAT) nurses, as well as senior medical staff such as anaesthetists and radiologists. The absence of a coherent strategy is illustrated by the experience of six ward nurse practitioners who underwent basic training but did not have an adequate period of supervised practise so were not confident enough to undertake PICC placement. At one time, the only ultrasound machine available to these nurses was on loan and eventually removed by the catheter supplier. As a result, there was an absence of strategic and
S10
operational planning and documentation was poor. Audit and standard setting was deficient, hindering outcome improvement for patients. To the best of the authors’ knowledge, a detailed comparison of insertion cost, longevity and complication rates for each staff group had not previously been assessed and this was one of the main purposes of this study. Originally, it was also intended to look at junior doctors inserting PICCs, however, during the course of this study no CVCs were placed by junior doctors, probably because of a lack of training. All staff nurses and radiologists are fully trained in PICC insertion techniques including the use of ultrasound and micropuncture kits. Device position was confirmed by chest radiography shortly after insertion by a nurse and by fluoroscopy at the time of insertion by a radiologist.
Study aim This study was carried out following suggestions that organisation of PICC insertion at Raigmore Hospital was not as cost effective as it could be. There was disagreement between senior members of staff over the best method of proceeding in this area. The authors aimed to analyse this idea in further detail by estimating the resource use and cost of the different groups involved in PICC insertion.
Methods The lead author conducted a prospective cohort analysis of cannula insertion, maintenance, complication rates and patency for hospital inpatients undergoing PICC insertion according to the staff group performing the insertion. Ethical approval for the project was obtained from the National Research Ethics Service (NRES) using the Integrated Research Application System (IRAS). The study took place over 4 months in 2012–13. A questionnaire was attached to all identified PICCs in stock at Raigmore Hospital to collect details of the date of insertion, patient involved, time taken, attendant staff grade and experience level, consumables used and insertion success. The lead author’s personal observation of PICC insertion by different staff groups allowed estimation of staff time, costs and success rates. Patient experience including pain score, and satisfaction was assessed before and after insertion using a patient questionnaire. PICC longevity, infection rates and failures were assessed through a review of patient notes.
Calculating overall cost of insertion A micro-costing was carried out. Prices are given in pound sterling (£) in 2012 prices. Costing has been carried out purely from an NHS perspective and personal costs to the patient have not been considered. Insertion by each different member of staff was observed to confirm the inventory lists used for costing were correct.
Equipment costs An inventory list of equipment used by each staff member was drawn up while under the lead author’s personal observation. Each team member’s inventory was similar but they had a few minor variations. The overall cost was worked out by consulting a number of sources, including
© 2013 MA Healthcare Ltd
inserted. There was an 80% decrease in average patient wait time for PICC insertion, facilitating more timely discharge from hospital. Placement costs were reduced by 9% 6 months after initiation of the service and by 24% after ultrasound became available. The study concluded that a dedicated PICC service should become the standard of care for all hospitals with high-volume PICC use. Implementation of a successful team will lead to improved patient safety; experts always carrying out procedures, improved device aftercare and up-to-date knowledge on vascular access changes, as well as increased patient involvement in making choices about their own device. Another recent case study undertaken by the University Hospitals of Leicester (UHL) NHS Trust (2011) looked at the implementation of a centralised, nurse-led, vascular access team. Three nurses within the Radiology Department at Leicester Royal Infirmary were trained to insert and remove all vascular access devices using ultrasound and fluoroscopy guidance as standard. Sessions in a dedicated room were reserved for them to carry out this work and the new service was heavily publicised across the Trust. The new service helped to improve device choice and increase cost savings in the form of reduced bed stays, reduced infection rates and reduced repetition of work. The service is still developing but savings are currently a mixture of reduction in expenditure and productivity improvements. It was calculated that £25 000 was directly saved and approximately £730 000 indirectly saved. Savings were £72 600 per 100 000 population covering Leicester, Leicestershire and Rutland areas. For every outpatient central venous access device (CVAD) insertion, there is potential to save up to four bed days, with fewer repeat cannulations, as staff are now taking time to consider long-term vascular access needs.There were additional savings as a result of fewer patient infections, pneumothoraces or arterial punctures and time savings with medical and support staff now performing fewer procedures. Capital investment was required to set up the service, refurbish existing estate and purchase dedicated imaging equipment. Revenue costs of £225 000 and capital costs of £110 000 were required to implement this proposal
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on February 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
research the manager of supplies and individual staff on the wards who were responsible for ordering their own stock. The online stock catalogue was consulted and individual prices for each item checked via the equipment reference number. VAT was added at a rate of 20%. Delivery, postage and packaging cost was added at a uniform rate of 1% as suggested by the procurement office. For this project, a whole new costing was carried out but an audit sheet for PICC insertion equipment from July 2012 was referred to to ensure everything was accounted for. Although prices had increased slightly during this period, all equipment appeared to be included.
Staff costs Staff costs were worked out using the NHS pay band system, Agenda for Change (AfC). Staff involved in PICC insertion ranged from band 1 to band 8A and an average salary was calculated for each band. The NHS pay band system applies to all staff except doctors, dentists and very senior managers. Therefore, for consultants who inserted PICCs, an average salary for senior consultants was used. On costs were considered for calculation but as these would be similar between groups, this was discounted. Some staff would work part time or overtime but the authors felt a fairly accurate picture could be included without going into this level of detail. Using these figures, wage per minute for each pay band was calculated and these figures are shown in Table 1.
© 2013 MA Healthcare Ltd
Other costs considered A cost analysis was not carried out for maintenance expenses after PICC insertion as this was beyond the scope of this current piece of research. Another cost that was not accounted for is the expense incurred when PICCs become infected. This normally includes the cost of inserting a new device as well as the expense of treating the infection, including antibiotic treatment and hospital bed space. This emphasises the importance of satisfactory device maintenance, via educating staff and the patient on the best way of minimising infection risk. If a dedicated team in the community serves the patient, the PICC should not get infected and should last until the end of treatment without replacement. As previously stated, patients who have their PICC inserted by a nurse team must have the correct placement of their device confirmed by x-ray. Time is spent completing request forms but dealing with documentation is similar for any department. The actual x-ray is carried out by one radiographer on band 4–7 and this takes an average of 10 minutes in the radiology ward. Therefore, the staff cost involved is £3.11. There is no cost for film as the x-ray image is now produced digitally. For intensive care unit (ICU) patients, the radiographer goes to the ward. As patients tend to be too sick to move around, the time taken averages 30 minutes and the staff cost is £9.33. Capital equipment costs such as initial purchase, maintenance costs and depreciation of value as well as estate costs such as heating, lighting, water and security are also costs involved with any hospital procedure, for example, running an operating theatre. On consultation with the hospital finance team and senior consultants, it was discovered that there was no costing for insertion of a PICC. Therefore, costing for
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
the similar procedure of inserting a skin-tunnelled catheter was used. Consultants and the finance team together agreed on a cost of £12.62 per minute. There was uncertainty over whether to include this theatre tariff in overall costs. PICCs are inserted at the bedside or in specific treatments rooms. If a PICC insertion is performed in these departments, it is not blocking a slot for another procedure to take place as it would do if performed in the radiology department. For this reason, the authors calculated these departments to be exempt from a theatre tariff. The angiography laboratory has capabilities far beyond those required for a PICC insertion, however, this is where devices are inserted at Raigmore Hospital. Costs have been given with, and without, a theatre tariff for clarity.
Results Of the PICC insertions at Raigmore Hospital, 48 were inserted by radiologists, two were inserted by consultant anaesthetists in ICU, and the remaining 91 were inserted by 3 nurse-led insertion teams (OPAT, Oncology Ward 2C and Oncology Macmillan Suite staff). Although PICCs were requested from the majority of departments (Figure 2) throughout the hospital, most devices were requested for oncology patients owing to the fact that a high number of patients receive chemotherapy through a PICC. Radiology inserted the most PICCs during the course of the study. This was followed by oncology and then OPAT, who both focus on their own patient groups. Ten devices were inserted on the oncology ward 2C and finally, two were inserted in ICU. To analyse the data, SPSS (v20) was used. A power and sample size calculation was not carried out before initiating the study because all patients over the period of recruitment were entered into the study. Therefore, even if the sample size was not deemed to be large enough, nothing could be done to alter this. Questionnaires were analysed in various ways depending on what was being asked. On the Likert-scale questions, an overall percentage satisfaction was assigned to each patient by giving a score for each response; for example, a ‘very dissatisfied’ response would get a score of 0 for that subquestion and a ‘very satisfied’ response would get a score of 3. For the two questions asking about pain, the level of pain was translated into a pain score, no pain being assigned a score of 0 and severe pain a score of 3. Table 1. Staff wage per minute according to pay band Pay Band
Salary Range
Average Annual Wage per Salary hour
Wage per minute
1
£14153 - £14864
£14,508,50
£9.74
£0.162
2
£14153 - £17253
£15,703
£10.54
£0.176
3
£16110 - £19077
£17,593.50
£11.81
£0.197
4
£18652 - £21798
£20,255
£13.60
£0.227
5
£21176 - £27625
£24,400.50
£16.38
£0.273
6
£25528 - £34189
£29,858.50
£20.05
£0.334
7
£30460 - £40157
£35,308.50
£23.71
£0.395
8A
£38851 - £46621
£42,736
£28.70
£0.478
£87,475
£55.07
£0.918
Consultant £74504 - £100446
S11
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on February 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
4
70
100%
60
90%
7
1
80%
4
n Failed insertion attempt
70%
30
n Line blocked
20
60%
10
50%
n Line ‘expired’ n Line infected
n ICU n OPAT n Oncology (Macmillan Suite) n Oncology (2C) n Radiology Figure 2. Raigmore PICC insertion by requesting department
A crude analysis was also performed. Categorical data was analysed using the chi-squared test. If the assumptions of a chi-squared test (expected count
Nurse-led PICC insertion: is it cost effective? Graham Walker and Alistair Todd
© 2013 MA Healthcare Ltd
R
epeated attempts to cannulate small veins can cause considerable distress for patients and substantial staff time expenditure (Todd and Hammond, 2004; Kelly et al, 2013). For longer term venous access, a peripherally inserted central catheter (PICC) may be used instead of a peripheral cannula (Todd and Hammond, 2004). Previous studies indicate that insertion of a PICC costs three times more than a cannula but the lifespan is substantially longer (Periard et al, 2008). Three groups of staff commonly insert PICCs: registered nurses working either on general-ward duties or in vascular access teams, medical staff, who may or may not have received formal training, and senior medical staff such as anaesthetists and radiologists. Insertion of these devices by inexperienced staff has been found to result in higher first-attempt failure rates and reduced overall insertion success with increased cannula wastage (Pratt et al, 2007). Teams of competent nurses are employed by many organisations to provide this service and are capable of high success rates (Todd and Hammond, 2004), inserting all but the most complicated PICCs. In many hospitals, nurses will insert the majority of devices but if complications occur, they can seek advice from a supervising physician. Based on evidence from a recent trial, nurses can be trained to insert CVCs both at the bedside and via fluoroscopic guidance in a 3-month period. Although they may experience a degree of stress, these nurses experience greater job satisfaction and feel that their roles have a positive impact on the patients in their care (Kelly et al, 2013). Nurse insertions can free up clinical resources in a safe and effective manner at a time of increasing pressure within the NHS (Boland et al, 2003).
Aims: Repeated attempts to cannulate small veins can cause considerable distress for patients and expend substantial staff time. For longer term venous access, a peripherally inserted central catheter (PICC) may be used instead of a peripheral cannula. Previous studies indicate that insertion of a PICC costs three times more than a cannula but the lifespan is substantially longer. This study aimed to compare insertion cost, patient satisfaction, and infection rates of PICCs for the two main staff groups (trained nurses and radiologists) inserting these devices in a district general hospital. Materials and Methods: The study took place over 4 months in 2012–13. A questionnaire was attached to all identified PICCs in stock at Raigmore Hospital to collect details of the date of insertion, patient involved, time taken, attendant staff grade and experience level, consumables used and insertion success. The lead author’s personal observation of PICC insertion by different staff groups allowed estimation of staff time, costs and success rates. Patient experience and satisfaction was assessed before and after insertion using a patient questionnaire. PICC longevity, infection rates and failures were assessed by review of patient notes. Results: The radiologist group had a statistically significant (p< 0.01) increased cost (42%) over the nurse group. Patient satisfaction regarding explanation of treatment before insertion was higher in the nurse group. Insertion success and infection rates were higher in the radiologist group. Conclusion: The authors conclude that the majority of PICCs can be safely performed without x-ray screening in a ward-based environment. This is likely to be the most cost-effective solution for large volume services.
Nurse vs doctor insertion
Nurse-led vascular access teams
The results of Stokowski et al’s (2009) comparative study undertaken in a Canadian community hospital showed that registered nurses inserted more PICCs than radiologists. When incidence rates of thrombosis between registered nurses and radiologists were compared, no statistical difference was discovered. Nichols and Humphrey (2008) conducted a quantitative research study comparing PICC placement success rates for nurses against physicians. Using ultrasound, success rates for nurses were found to be 91%–95% in comparison to success rates by physicians in interventional radiology suites of 97%–100%. The difference is probably a result of the ability to inject contrast to define vascular anatomy and the availability of guidewires to direct the catheter tip under fluoroscopic guidance.
The first nurse-led vascular access team was established in the USA. The availability of a knowledgeable and experienced PICC team may result in fewer complications, improved success rates, and overall better patient satisfaction (Ryder, 1995; Robinson et al, 2005). A recent study (Robinson et al, 2005) found that introduction of a dedicated PICC team resulted in a 33% reduction in CVC placement as inappropriate patients were identified and CVCs not
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
Abstract
Key words: PICC
■
Cost
■
Nurse
■
Radiology
■
Vascular
■
Insertion
Graham Walker is Medical Student, University of Aberdeen and Alistair Todd is Consultant Radiologist, Raigmore Hospital, Inverness and Programme Mentor, University of Aberdeen, Aberdeen, Scotland. Accepted for publication: October 2013
S9
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on February 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
Current situation at Raigmore Hospital Raigmore Hospital in Inverness is the largest hospital in the Highlands. It receives patients from the Western Isles and Morayshire. It has 577 beds and serves a vast variety of patients. The hospital is typical among many other hospitals in the UK in that the vascular access service is divided across a number of different departments: PICCs are inserted by oncology and outpatient parenteral antibiotic therapy (OPAT) nurses, as well as senior medical staff such as anaesthetists and radiologists. The absence of a coherent strategy is illustrated by the experience of six ward nurse practitioners who underwent basic training but did not have an adequate period of supervised practise so were not confident enough to undertake PICC placement. At one time, the only ultrasound machine available to these nurses was on loan and eventually removed by the catheter supplier. As a result, there was an absence of strategic and
S10
operational planning and documentation was poor. Audit and standard setting was deficient, hindering outcome improvement for patients. To the best of the authors’ knowledge, a detailed comparison of insertion cost, longevity and complication rates for each staff group had not previously been assessed and this was one of the main purposes of this study. Originally, it was also intended to look at junior doctors inserting PICCs, however, during the course of this study no CVCs were placed by junior doctors, probably because of a lack of training. All staff nurses and radiologists are fully trained in PICC insertion techniques including the use of ultrasound and micropuncture kits. Device position was confirmed by chest radiography shortly after insertion by a nurse and by fluoroscopy at the time of insertion by a radiologist.
Study aim This study was carried out following suggestions that organisation of PICC insertion at Raigmore Hospital was not as cost effective as it could be. There was disagreement between senior members of staff over the best method of proceeding in this area. The authors aimed to analyse this idea in further detail by estimating the resource use and cost of the different groups involved in PICC insertion.
Methods The lead author conducted a prospective cohort analysis of cannula insertion, maintenance, complication rates and patency for hospital inpatients undergoing PICC insertion according to the staff group performing the insertion. Ethical approval for the project was obtained from the National Research Ethics Service (NRES) using the Integrated Research Application System (IRAS). The study took place over 4 months in 2012–13. A questionnaire was attached to all identified PICCs in stock at Raigmore Hospital to collect details of the date of insertion, patient involved, time taken, attendant staff grade and experience level, consumables used and insertion success. The lead author’s personal observation of PICC insertion by different staff groups allowed estimation of staff time, costs and success rates. Patient experience including pain score, and satisfaction was assessed before and after insertion using a patient questionnaire. PICC longevity, infection rates and failures were assessed through a review of patient notes.
Calculating overall cost of insertion A micro-costing was carried out. Prices are given in pound sterling (£) in 2012 prices. Costing has been carried out purely from an NHS perspective and personal costs to the patient have not been considered. Insertion by each different member of staff was observed to confirm the inventory lists used for costing were correct.
Equipment costs An inventory list of equipment used by each staff member was drawn up while under the lead author’s personal observation. Each team member’s inventory was similar but they had a few minor variations. The overall cost was worked out by consulting a number of sources, including
© 2013 MA Healthcare Ltd
inserted. There was an 80% decrease in average patient wait time for PICC insertion, facilitating more timely discharge from hospital. Placement costs were reduced by 9% 6 months after initiation of the service and by 24% after ultrasound became available. The study concluded that a dedicated PICC service should become the standard of care for all hospitals with high-volume PICC use. Implementation of a successful team will lead to improved patient safety; experts always carrying out procedures, improved device aftercare and up-to-date knowledge on vascular access changes, as well as increased patient involvement in making choices about their own device. Another recent case study undertaken by the University Hospitals of Leicester (UHL) NHS Trust (2011) looked at the implementation of a centralised, nurse-led, vascular access team. Three nurses within the Radiology Department at Leicester Royal Infirmary were trained to insert and remove all vascular access devices using ultrasound and fluoroscopy guidance as standard. Sessions in a dedicated room were reserved for them to carry out this work and the new service was heavily publicised across the Trust. The new service helped to improve device choice and increase cost savings in the form of reduced bed stays, reduced infection rates and reduced repetition of work. The service is still developing but savings are currently a mixture of reduction in expenditure and productivity improvements. It was calculated that £25 000 was directly saved and approximately £730 000 indirectly saved. Savings were £72 600 per 100 000 population covering Leicester, Leicestershire and Rutland areas. For every outpatient central venous access device (CVAD) insertion, there is potential to save up to four bed days, with fewer repeat cannulations, as staff are now taking time to consider long-term vascular access needs.There were additional savings as a result of fewer patient infections, pneumothoraces or arterial punctures and time savings with medical and support staff now performing fewer procedures. Capital investment was required to set up the service, refurbish existing estate and purchase dedicated imaging equipment. Revenue costs of £225 000 and capital costs of £110 000 were required to implement this proposal
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on February 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
research the manager of supplies and individual staff on the wards who were responsible for ordering their own stock. The online stock catalogue was consulted and individual prices for each item checked via the equipment reference number. VAT was added at a rate of 20%. Delivery, postage and packaging cost was added at a uniform rate of 1% as suggested by the procurement office. For this project, a whole new costing was carried out but an audit sheet for PICC insertion equipment from July 2012 was referred to to ensure everything was accounted for. Although prices had increased slightly during this period, all equipment appeared to be included.
Staff costs Staff costs were worked out using the NHS pay band system, Agenda for Change (AfC). Staff involved in PICC insertion ranged from band 1 to band 8A and an average salary was calculated for each band. The NHS pay band system applies to all staff except doctors, dentists and very senior managers. Therefore, for consultants who inserted PICCs, an average salary for senior consultants was used. On costs were considered for calculation but as these would be similar between groups, this was discounted. Some staff would work part time or overtime but the authors felt a fairly accurate picture could be included without going into this level of detail. Using these figures, wage per minute for each pay band was calculated and these figures are shown in Table 1.
© 2013 MA Healthcare Ltd
Other costs considered A cost analysis was not carried out for maintenance expenses after PICC insertion as this was beyond the scope of this current piece of research. Another cost that was not accounted for is the expense incurred when PICCs become infected. This normally includes the cost of inserting a new device as well as the expense of treating the infection, including antibiotic treatment and hospital bed space. This emphasises the importance of satisfactory device maintenance, via educating staff and the patient on the best way of minimising infection risk. If a dedicated team in the community serves the patient, the PICC should not get infected and should last until the end of treatment without replacement. As previously stated, patients who have their PICC inserted by a nurse team must have the correct placement of their device confirmed by x-ray. Time is spent completing request forms but dealing with documentation is similar for any department. The actual x-ray is carried out by one radiographer on band 4–7 and this takes an average of 10 minutes in the radiology ward. Therefore, the staff cost involved is £3.11. There is no cost for film as the x-ray image is now produced digitally. For intensive care unit (ICU) patients, the radiographer goes to the ward. As patients tend to be too sick to move around, the time taken averages 30 minutes and the staff cost is £9.33. Capital equipment costs such as initial purchase, maintenance costs and depreciation of value as well as estate costs such as heating, lighting, water and security are also costs involved with any hospital procedure, for example, running an operating theatre. On consultation with the hospital finance team and senior consultants, it was discovered that there was no costing for insertion of a PICC. Therefore, costing for
British Journal of Nursing, 2013 (IV Therapy Supplement), Vol 22, No 19
the similar procedure of inserting a skin-tunnelled catheter was used. Consultants and the finance team together agreed on a cost of £12.62 per minute. There was uncertainty over whether to include this theatre tariff in overall costs. PICCs are inserted at the bedside or in specific treatments rooms. If a PICC insertion is performed in these departments, it is not blocking a slot for another procedure to take place as it would do if performed in the radiology department. For this reason, the authors calculated these departments to be exempt from a theatre tariff. The angiography laboratory has capabilities far beyond those required for a PICC insertion, however, this is where devices are inserted at Raigmore Hospital. Costs have been given with, and without, a theatre tariff for clarity.
Results Of the PICC insertions at Raigmore Hospital, 48 were inserted by radiologists, two were inserted by consultant anaesthetists in ICU, and the remaining 91 were inserted by 3 nurse-led insertion teams (OPAT, Oncology Ward 2C and Oncology Macmillan Suite staff). Although PICCs were requested from the majority of departments (Figure 2) throughout the hospital, most devices were requested for oncology patients owing to the fact that a high number of patients receive chemotherapy through a PICC. Radiology inserted the most PICCs during the course of the study. This was followed by oncology and then OPAT, who both focus on their own patient groups. Ten devices were inserted on the oncology ward 2C and finally, two were inserted in ICU. To analyse the data, SPSS (v20) was used. A power and sample size calculation was not carried out before initiating the study because all patients over the period of recruitment were entered into the study. Therefore, even if the sample size was not deemed to be large enough, nothing could be done to alter this. Questionnaires were analysed in various ways depending on what was being asked. On the Likert-scale questions, an overall percentage satisfaction was assigned to each patient by giving a score for each response; for example, a ‘very dissatisfied’ response would get a score of 0 for that subquestion and a ‘very satisfied’ response would get a score of 3. For the two questions asking about pain, the level of pain was translated into a pain score, no pain being assigned a score of 0 and severe pain a score of 3. Table 1. Staff wage per minute according to pay band Pay Band
Salary Range
Average Annual Wage per Salary hour
Wage per minute
1
£14153 - £14864
£14,508,50
£9.74
£0.162
2
£14153 - £17253
£15,703
£10.54
£0.176
3
£16110 - £19077
£17,593.50
£11.81
£0.197
4
£18652 - £21798
£20,255
£13.60
£0.227
5
£21176 - £27625
£24,400.50
£16.38
£0.273
6
£25528 - £34189
£29,858.50
£20.05
£0.334
7
£30460 - £40157
£35,308.50
£23.71
£0.395
8A
£38851 - £46621
£42,736
£28.70
£0.478
£87,475
£55.07
£0.918
Consultant £74504 - £100446
S11
British Journal of Nursing.Downloaded from magonlinelibrary.com by 193.061.135.080 on February 18, 2015. For personal use only. No other uses without permission. . All rights reserved.
4
70
100%
60
90%
7
1
80%
4
n Failed insertion attempt
70%
30
n Line blocked
20
60%
10
50%
n Line ‘expired’ n Line infected
n ICU n OPAT n Oncology (Macmillan Suite) n Oncology (2C) n Radiology Figure 2. Raigmore PICC insertion by requesting department
A crude analysis was also performed. Categorical data was analysed using the chi-squared test. If the assumptions of a chi-squared test (expected count
