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There is a lack of standard minimal requirements for the training of insertion techniques and maintenance of central venous access devices (CVADs). An international evidence-based consensus task force was established through the World Congress of Vascular Access (WoCoVA) to provide definitions and recommendations for training and insertion of CVADs. Medical literature published from February 1971 to April 2012 regarding 'central vascular access', 'training', 'competency', 'simulation', and 'ultrasound' was reviewed on Pubmed, BioMed Central, ScienceDirect, and Scopus databases. The GRADE and the GRADE-RAND methods were utilized to develop recommendations. Out of 156 papers initially identified, 83 papers described training for central vascular access placement. Sixteen recommendations are proposed by this task force, each with an evidence level, degree of consensus, and recommendation grade. These recommendations suggest central venous access education include didactic or web-based teaching with insertion procedure, infection prevention, complications, care, and maintenance of devices, along with laboratory models and tools for simulation practice incorporating ultrasound. Clinical competence should be determined by observation during clinical practice using a global rating scale rather than by the number of procedures performed. Ensuring safe insertion and management of central venous devices requires standardized education, simulation practice, and supervised insertions.

The consequences of random PICC practice can be serious and manifest as deep vein thrombosis, pulmonary embolism, catheter related bloodstream infection, and post thrombotic syndrome. Risk factors related to site selection have been well established for other central venous access devices, but not for ultrasound guided PICC insertion in the upper arm. The author presents observations of upper arm PICC insertion designated by color zones to highlight the variability of PICC practice. The author also details site risk factors associated with each color zone and proposes an ideal insertion location for upper arm ultrasound guided PICC procedures. The PICC Zone Insertion Method (ZIM) is a proposed system design for patient safety related to PICC insertions; performed by optimizing and organizing the clinical approach. It aids in identifying the Ideal Zone for upper arm needle insertion with ultrasound guidance. The significance of a systematic approach is that it is reproducible, measurable, and as a result will reduce variation in PICC insertion practice. The ZIM combines known mechanisms for vascular access insertion site complications with a systematic measuring and ultrasound scanning process, to reduce the impact of site risk factors. The impact of thrombosis cannot be underestimated, as it will likely limit the future use of veins for life saving vascular access. This issue should not be ignored by hospitals or clinicians, in fact, systematic solutions like PICC Zone Insertion Method, should be explored and supported as part of a comprehensive approach to vascular access care.T he PICC Zone Insertion Method (ZIM) is a systematic approach to PICC insertion for the purpose of optimization of results and reduction in patient risk. It aids in identifying the Ideal Zone (IZ) for upper arm needle insertion with ultrasound guidance. The ZIM looks beyond common PICC site selection practice; it reveals a specific pattern of zones that offer various risks and benefits for PICC insertion and management. The ZIM utilizes musculoskeletal, skin, and vessel characteristics that can be separated into red, green and yellow zones. Like the traffic light system, the color of the zone indicates whether or not a zone should be entered.Observations of practice are presented to describe the benefits of the ZIM and the Ideal Zone for PICC insertion. This is a discussion of practice and a proposed methodology for selection of PICC insertion sites in the upper arm. Clinical practice from the author is reviewed as well as observations from other facilities related to PICC insertion locations in the upper arm. Permission was received to photograph and observe PICC insertion sites. The prevalence of upper arm PICC insertion by zone color is presented to highlight the variability of PICC practice. This is a proposed system design for patient safety related to PICC insertions; ZIM is a tool designed for the entire continuum of PICC practice to include: assessment, planning, intervention and evaluation. Significance of ZIMThe PICC Zone Insert...

The insertion of central venous catheters through the femoral veins is not uncommon and is potentially associated with the risk of immediate puncture-related complications and severe late complications as infection and thrombosis. As for other central venous access devices, the use of a standardized protocol of insertion and the correct application of evidence-based strategies are beneficial in reducing the risk of complications. We proposed a standardized protocol (S.I.F.: Safe Insertion of Femorally Inserted Central Catheters) consisting of seven strategies that should be part of vascular cannulation and should be adopted during the insertion of femoral venous catheters, aiming to minimize immediate, early and late insertion-related complications. These strategies include: preprocedural evaluation of the patient history and of the veins, appropriate aseptic technique, ultrasound guided puncture and cannulation of the vein, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and appropriate coverage of the exit site.