Q: The standards state that a new VAD should be used with each attempt. My question is what defines a second attempt when inserting a PICC. For example if you have a sterile field set up and you have tried to insert the catheter at one site and you move to a more proximal site on the same arm within the field is this considered a second attempt. Thank you for your help with this.

A:  There is no definition of “second attempt” for any vascular access device (VAD) placement ( also called VAD insertion) that I can find in published literature, so I will do my best to answer your question.

In the medical dictionary, an IV insertion or placement is a nursing intervention defined as insertion of a needle into a peripheral vein for the purpose of intravenous infusion of fluids, blood, or medications. The word “attempt” according to Merrian-Webster, means an effort to accomplish something. I would deduce that “second attempt” is an effort to accomplish something the second time. As it applies to PICC placement/ insertion or any VAD insertion/placement, second attempt means an effort to accomplish catheter placement/insertion a second time – obviously the first time was not successful in establishing access for whatever reason. Attempt often is used with IV placement or insertion. One IV placement or insertion = one IV attempt or one cathetization attempt, whether the goal of establishing a vascular access was successful or not.

Now to answer this:

For example if you have a sterile field set up and you have tried to insert the catheter at one site and you move to a more proximal site on the same arm within the field is this considered a second attempt.

In your example above, using a more proximal site in the same arm for insertion, and if it is still within the sterile field, assuming the sterility of the field was maintained (not blood soaked or contaminated) – is considered a second attempt at placement/insertion. Therefore, a new PICC catheter (VAD device) and micro-introducer or MST kit should be used for this second attempt as you stated the standards says. If the sterile field is compromised, arm prep and draping should be repeated like you did the first time(start all over) before this second attempt at placement/insertion. If you only used the micro introducer or MST kit and was not successful in insertion, but the PICC catheter itself has not been used and kept sterile, then for the second attempt you need a new micro introducer needle to gain vein access. The same PICC catheter can be used, again, as long as it wasn’t used in the first attempt and kept sterile during your second attempt.

It will still be called “second attempt” if you used a vein in the patient’s opposite arm. A new sterile prep, setup , new PICC catheter and micro introducer, etc…should be used.

The applicable 2016 Infusion Therapy Standards:

Infusion Therapy Standard 33.1 – A new, sterile vascular access device (VAD) is used for each catheterization attempt.

• Practice Criteria 1F: Make no more than 2 attempts at short peripheral intravenous access per clinician, and limit total attempts to no more than 4. Multiple unsuccessful attempts cause patient pain, delay treatment, limit future vascular access, increase cost, and increase risk for complications. Patient with difficult vascular access require careful assessment  of VAD needs and collaboration with the health care team to discuss appropraite options.

Thank you for your question.