PICC Insertion Competency Framework: From Novice to Independent Practice

Complete PICC insertion competency framework: didactic training content, simulation requirements, proctored case minimums, competency checklist, privileges documentation, and annual competency maintenance requirements.

guide•Feb 2026•Credentialing

PICC Insertion Competency Framework: From Novice to Independent Practice

PICC insertion is a complex vascular access procedure with a defined learning curve. Establishing a structured, defensible competency framework — from initial didactic training through independent practice — protects patients, reduces institutional liability, and produces consistently safe outcomes. This guide provides a complete framework for designing or implementing a PICC insertion competency program based on INS 2021 Standards, AVAR guidance, and published evidence on PICC procedure outcomes.

Parent guide: Vascular Access Credentialing: Complete Reference

The Learning Curve

Multiple studies have documented the PICC insertion learning curve:

  • First-attempt success rate improves significantly over the first 15–25 insertions
  • Malposition rate (incorrect tip position) is highest in the first 10 insertions; stabilizes with experience
  • Time per insertion decreases through the first 25–30 insertions

A training program minimum of 10–15 proctored cases (with target ≥25 within the first 6 months of independent practice) produces clinically safe outcomes in published studies.

Program Structure Overview

Phase 1: Didactic Training (16–24 hours)

Required content modules:

Module 1: Anatomy and Physiology (2–3 hours)

  • Upper extremity venous anatomy (basilic, brachial, cephalic)
  • Axillary, subclavian, brachiocephalic anatomy
  • SVC and right heart anatomy
  • Lymphatic considerations (lymphedema, mastectomy)
  • Renal vasculature and vessel preservation for dialysis patients

Module 2: Device Selection and Indications (2 hours)

  • MAGIC appropriateness criteria
  • INS 2021 device selection principles
  • PICC vs. midline vs. CVC decision algorithm
  • Catheter types (power-injectable, valved, single/multi-lumen)
  • Catheter-to-vein ratio and vein selection

Module 3: Infection Prevention (2 hours)

  • CLABSI pathophysiology and risk factors
  • Maximal sterile barrier (MSB) requirements and technique
  • CHG antisepsis — dry time, application area
  • ANTT principles
  • Insertion bundle checklist

Module 4: Ultrasound for PICC Insertion (4 hours)

  • Basic US physics and probe selection
  • Transverse and longitudinal views
  • In-plane vs. out-of-plane technique
  • Vein identification and compressibility test
  • Vein assessment (diameter, depth, thrombus)
  • Guidewire US confirmation
  • Pitfalls and troubleshooting

Module 5: PICC Insertion Procedure (4 hours)

  • Pre-insertion measurement
  • Sterile technique and MSB setup
  • Modified Seldinger technique step-by-step
  • Guidewire advancement and troubleshooting
  • Peel-away sheath technique
  • Catheter trimming and hub assembly

Module 6: Tip Confirmation (2 hours)

  • Cavoatrial junction standard (CEVAD)
  • ECG guidance: P-wave interpretation, systems, technique
  • CXR interpretation: landmarks, acceptable vs. unacceptable positions
  • Malposition types: recognition and management

Module 7: Complications (2 hours)

  • PICC-associated DVT: risk factors, prevention, treatment
  • Catheter occlusion: types, alteplase protocol
  • Air embolism: prevention during insertion and removal
  • Arterial cannulation recognition and management
  • Nerve injury prevention (needle path planning)
  • MARSI and CLABSI prevention

Module 8: Documentation and Compliance (1 hour)

  • INS 2021 documentation requirements
  • Insertion note mandatory elements
  • TJC bundle documentation

Assessment: Written test; minimum 80% pass to proceed to simulation.

Phase 2: Simulation Training (minimum 4 sessions)

Session 1: Probe handling, vessel identification, compressibility testing on vascular phantom.

Session 2: US-guided venipuncture and guidewire placement in phantom.

Session 3: Full simulated PICC insertion on phantom (MSB setup through catheter placement).

Session 4: Repeat full insertion; troubleshooting scenarios (guidewire resistance, no blood return, catheter won’t advance).

Simulation competency sign-off before proceeding to clinical proctoring.

Phase 3: Proctored Clinical Insertions (minimum 10–15 cases)

Proctor requirements:

  • Credentialed PICC inserter with ≥12 months independent experience
  • Proctor is present at the bedside for the entire procedure (not available by phone)
  • Proctor completes standardized competency checklist for each case

Trainee requirements:

  • Performs all steps independently under observation (proctor does not take over except for patient safety)
  • Debriefing session after each procedure

Success criteria:

  • Minimum 90% checklist compliance averaged over all proctored cases
  • Demonstrated safe technique throughout
  • No pattern of repeated errors despite feedback

Phase 4: Independent Practice Initiation

After completing the minimum proctored cases with satisfactory performance:

  • Submit competency documentation to hospital privileging office
  • Privileges granted for independent PICC insertion
  • New independent inserter performs first 10–15 independent insertions with a credentialed inserter available for consultation (not necessarily at the bedside)

PICC Insertion Competency Checklist

Pre-Insertion

  • Verified PICC indication meets MAGIC/INS criteria; documented in chart
  • Reviewed contraindications (ESRD, DVT, AV fistula, ESRD vessels)
  • Obtained and documented informed consent
  • Performed bilateral US vein survey; documented findings
  • Calculated catheter-to-vein ratio; selected appropriate device
  • Measured pre-insertion catheter length accurately

Insertion Bundle Elements

  • Performed hand hygiene immediately before gloving
  • Applied maximal sterile barrier (full-body drape, sterile gown, sterile gloves, surgical mask, cap)
  • Applied CHG/IPA antisepsis to adequate area; confirmed complete dry time
  • Documented clinical indication for central access

Sterile Technique Maintenance

  • Maintained sterile field throughout procedure (no breaks identified)
  • Managed any break in technique appropriately (acknowledged, corrected)

Ultrasound-Guided Insertion

  • Applied sterile probe cover correctly; no contamination of sterile field
  • Identified target vein in transverse and/or long-axis view
  • Confirmed compressibility; identified adjacent artery
  • Applied tourniquet; identified optimal insertion site
  • Visualized needle tip entering vein; confirmed blood return before advancing guidewire
  • Confirmed guidewire in vein by US before removing needle

Catheter Placement

  • Nicked skin at guidewire entry site appropriately
  • Advanced dilator/sheath without resistance
  • Peeled sheath without advancing catheter simultaneously
  • Advanced catheter to pre-measured length
  • External length matches pre-measured target

Post-Insertion Verification

  • Aspirated blood return from all lumens
  • Flushed all lumens; no resistance, no swelling
  • Applied CHG gel patch and TSM dressing correctly
  • Applied securement device correctly
  • Ordered/initiated tip confirmation (ECG guidance documentation or CXR order)
  • Labeled dressing with date, length, gauge, inserter initials

Documentation

  • Completed insertion note with all required elements
  • Documented MSB compliance
  • Documented CHG antisepsis and dry time confirmation
  • Documented tip confirmation method and result

Overall assessment: ☐ Meets Standard ☐ Does Not Meet Standard

Proctor signature: _________________ Date: _________________

Annual Competency Maintenance

To maintain PICC insertion privileges, clinicians must demonstrate ongoing competency:

Volume requirement: Minimum 12 PICC insertions per year. Clinicians inserting fewer than 12 PICCs per year should discuss with program leadership whether PICC insertion is still an appropriate scope for them; additional proctoring may be required.

Annual assessment options:

  1. Simulation laboratory performance with competency sign-off
  2. Observed clinical insertion with competency checklist
  3. Chart audit of recent insertion documentation for compliance

Outcome review: Annual review of individual outcome data:

  • First-attempt success rate (target: ≥85% for credentialed inserters)
  • Insertion-related complication rate (arterial puncture, nerve injury, malposition)
  • Bundle compliance documentation rate

Clinicians with outcome metrics below benchmark should receive individualized feedback, retraining, and increased supervision.

Related guides:

Related policies:

References

  1. Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice (Standards 13, 26). J Infus Nurs, 44(Suppl 1).
  2. Sharp R, et al. (2014). The PICC5 Randomised Controlled Trial — PICC vs midline catheter. BMC Nurs, 13(1):1.
  3. Chopra V, et al. (2015). MAGIC criteria for PICC appropriateness. Ann Intern Med, 163(6 Suppl):S1–S40.
  4. Moureau NL, et al. (2013). Evidence-based consensus on CVAD insertion. Br J Nurs, 22(Sup8):S4–S10.