Vascular Access Device Selection and Insertion Planning

Establishes evidence-based criteria for the selection and planning of vascular access devices across all device types and patient populations, from short peripheral catheters through central venous access devices and arterial catheters.

policies•May 2023•Vascular Access

Vascular Access Device Selection and Insertion Planning Policy

1. Policy Statement

It is the policy of this organization that vascular access device selection shall be based on a systematic, evidence-based assessment of patient-specific clinical factors, prescribed therapy requirements, and available vascular anatomy, adhering to the principle of minimal intervention by selecting the least invasive device with the smallest diameter and fewest lumens necessary to safely complete the prescribed therapy for its anticipated duration.

2. Purpose

This policy exists to:

  • Define the types and characteristics of peripheral and central vascular access devices used in this organization
  • Establish evidence-based criteria for device selection based on therapy, duration, patient anatomy, and clinical condition
  • Define infusate compatibility requirements for peripheral vein administration
  • Provide duration-based device selection guidance for peripheral and central access
  • Establish site selection principles and sites to avoid for each device type
  • Address special population considerations for lymphedema, renal dysfunction, and neurological impairment
  • Define general practice principles including use of existing devices and contraindicated practices

3. Scope

This policy applies to:

  • All licensed clinical personnel selecting, recommending, or placing vascular access devices
  • All care settings where vascular access devices are placed or managed, including acute inpatient, ambulatory, emergency, intensive care, perioperative, and home care
  • All patient populations, including adult, pediatric, and neonatal patients
  • All vascular access device types: short and long peripheral intravenous catheters, midline catheters, PICCs, tunneled and nontunneled CVCs, implanted ports, and arterial catheters

4. Policy Requirements

4.1 Vascular Access Device Definitions

4.1.1 Short Peripheral Intravenous Catheters (PIVCs) use an over-the-needle design and are typically placed in superficial veins of the upper or lower extremities. They represent the most commonly used vascular access device in clinical practice.

4.1.2 Long Peripheral Intravenous Catheters offer extended catheter length suitable for situations where standard short PIVCs cannot adequately cannulate the target vessel. These catheters may be inserted using traditional over-the-needle techniques or Seldinger/modified Seldinger approaches.

4.1.3 Midline Peripheral Catheters are inserted via the basilic, cephalic, or brachial veins of the upper arm in adult and pediatric patients, with the catheter tip terminating at the level of the axilla. In neonatal populations, midline catheters may be placed through scalp veins with the tip positioned in the jugular vein above the clavicle, or through lower extremity veins with the tip below the inguinal crease.

4.2 Principles of Vascular Access Planning

4.2.1 Collaborative Decision-Making

4.2.1.1 Vascular access planning shall involve a collaborative approach including the healthcare team, the patient, and when appropriate, caregivers. Planning shall consider diagnosis and clinical presentation, available vasculature, appropriate device selection, and a thorough analysis of the risks and benefits of alternative therapeutic routes.1

4.2.2 Device Selection Criteria

4.2.2.1 Selection of a vascular access device shall be based on the following clinical factors:

  • Prescribed therapy or treatment regimen (primary consideration)
  • Anticipated duration of treatment
  • Available vascular pathways
  • Patient age and comorbidities
  • History of previous infusion therapy and vascular access
  • Patient preference regarding device type and location
  • Assessment of overall vascular health, including history of difficult intravenous access, vessel integrity, and skin condition
  • Availability of resources for ongoing device care

4.2.3 Principle of Minimal Intervention

4.2.3.1 Clinical practice shall favor the least invasive vascular access device with the smallest outer diameter and fewest lumens necessary to complete the prescribed therapy for its anticipated duration. This principle reduces patient discomfort, minimizes infection risk, and preserves vascular integrity for future access needs.234

4.2.4 Site Selection Philosophy

4.2.4.1 Optimal site selection shall begin with thorough vessel assessment and shall incorporate vessel preservation strategies. The planned therapy, patient comfort, patient preference, and the characteristics of the selected device type shall all influence site determination.

4.2.4.2 When multiple appropriate sites exist, selection shall begin at the most distal clinically suitable location.

4.3 Peripheral Infusion Therapy Considerations

4.3.1 Infusate Compatibility

4.3.1.1 Healthcare providers shall utilize all available resources — including evidence-based drug monographs, precaution statements, toxicology data, and interprofessional consultation — to determine which medications are appropriate for peripheral vein administration. Peripheral infusion therapy ideally involves solutions that are isotonic and maintain physiological pH values.

4.3.1.2 When isotonic or physiologically pH-balanced solutions cannot be achieved, clinicians shall minimize peripheral intravenous infusion of substances with extreme pH or osmolarity values to reduce vascular endothelial damage. No universally accepted pH or osmolarity threshold has been established in clinical literature.

4.3.1.3 The following factors shall be assessed when evaluating infusate compatibility for peripheral administration:

  • Final osmolarity of the infusion as influenced by the chosen diluent
  • pH of the infusate
  • Method of administration (continuous, intermittent, or manual IV push)
  • Infusion rate and pressure considerations (particularly for power injections)
  • Number of concurrent infusion therapies
  • Pharmacological effect of medications on venous tissue (including vasodilation and vasoconstriction effects)

4.3.2 Duration-Based Device Selection

4.3.2.1 Short-Term Therapy (four days or less): A peripheral intravenous catheter is appropriate when all infusate characteristics indicate peripheral compatibility.

4.3.2.2 Intermediate-Duration Therapy (five to fourteen days): A midline catheter shall be the preferred option for hospitalized adult patients when infusate characteristics support peripheral compatibility. A long PIVC may remain appropriate when the patient’s vasculature, stated preference, and institutional outcome data support this practice.

4.3.2.3 Extended-Duration Therapy (greater than fifteen days): A peripherally inserted central catheter (PICC) shall warrant consideration. Midline catheters or PIVCs may remain appropriate when infusate characteristics indicate peripheral compatibility and when the patient’s vasculature, preference, and institutional outcomes support this approach.

4.4 Short Peripheral Intravenous Catheter Guidelines

4.4.1 Site Selection

4.4.1.1 Forearm veins shall be the preferred insertion location when feasible, as they are associated with prolonged dwell time, reduced pain, and lower overall device failure rates. Appropriate veins include the metacarpal, cephalic, basilic, and median veins on both dorsal and ventral surfaces.

4.4.1.2 Hand veins may be considered for short-term therapy, typically defined as less than 24 hours in duration.

4.4.1.3 The antecubital fossa shall be avoided when possible due to higher failure rates over time for PIVCs inserted in areas of joint flexion.

4.4.1.4 Jugular vein access using the external or internal jugular vein may be considered in acute care settings and emergency situations when peripheral extremity veins cannot be accessed. Clinical teams shall collaborate to establish an alternative vascular access site as soon as the patient’s condition permits.

4.4.2 Sites to Avoid

4.4.2.1 The following anatomical locations shall be avoided due to increased risk of nerve injury:

  • The cephalic vein at the radial wrist (risk to superficial radial nerve)
  • The volar (inner) aspect of the wrist (risk to median nerve)
  • At or above the antecubital fossa (risk to median nerve, anterior interosseous nerve, and lateral and medial antebrachial nerves)

4.4.2.2 Additional sites requiring avoidance include:

  • Areas of joint flexion
  • Sites with pain on palpation
  • Areas of compromised skin and locations distal to such areas
  • Extremities with active infection
  • Extremities with planned surgical procedures
  • Veins showing compromise from previous cannulation, bruising, erythema, streaking, infiltration, sclerosis, cord formation, or engorgement
  • Visible veins of the chest, breast, abdomen, or other trunk locations
  • Lower extremity veins in adult patients, except in emergency situations

4.4.3 Technology Utilization

4.4.3.1 Vascular visualization technology, including near-infrared devices and ultrasound, shall be employed to increase insertion success rates in patients with difficult intravenous access (DIVA).56

4.4.4 Infusate Restrictions for Short PIVCs

4.4.4.1 Short PIVCs shall not be used for continuous infusion of medications with irritant or vesicant properties.

4.4.4.2 For time-critical infusions such as vasopressors, clinicians shall consider the medication type, dose, and mechanism of action. When appropriate, therapy may be initiated through a PIVC, but the device shall be replaced with a central venous access device as early as clinically feasible.

4.4.4.3 When medically necessary to administer parenteral nutrition through a peripheral device, dextrose concentration shall not exceed 10% and protein concentration shall not exceed 5%.

4.4.5 Catheter Sizing

4.4.5.1 Short PIVCs shall not be used when the target vein lies deep in subcutaneous tissue or when accessing veins classified as deep (beneath muscle tissue), as reduced catheter-to-vein ratios may predispose to device failure.

4.4.5.2 The smallest gauge catheter capable of accommodating the prescribed therapy and patient needs shall be selected.

4.4.5.3 For blood transfusion, 24- to 20-gauge PIVCs are appropriate based on vein size; larger gauges are suitable when rapid transfusion is required.

4.4.5.4 Steel-winged devices are appropriate only for single-dose administration and shall not be left in situ following use.

4.4.5.5 Larger-gauge PIVCs may be appropriate for adult and pediatric patients requiring rapid fluid replacement or for contrast-based radiographic studies using fenestrated catheters, within manufacturer-specified pressure limits.

4.5 Long Peripheral Intravenous Catheter Guidelines

4.5.1 Long PIVCs shall be used when all criteria for short PIVC use are met, but the target vessel is difficult to palpate or visualize without technological assistance. Ultrasound guidance shall be employed to improve first-time insertion success.

4.5.2 Appropriate veins include those on dorsal and ventral surfaces of the upper extremities — specifically the cephalic, basilic, and median veins. Insertion shall occur in the forearm with the catheter tip positioned below the antecubital fossa. When forearm insertion is not feasible, insertion may occur above the antecubital fossa.

4.6 Midline Peripheral Catheter Guidelines

4.6.1 Patient Assessment

4.6.1.1 All planned infusates shall be assessed for peripheral compatibility prior to midline catheter insertion. The planned duration of infusion therapy shall be evaluated for appropriateness of peripheral vein therapy.

4.6.1.2 The minimum number of lumens necessary to accommodate anticipated therapy shall be selected. Evidence demonstrates that single-therapy administration through single-lumen midline catheters is associated with fewer complications compared to multi-lumen devices.

4.6.2 Tip Positioning

4.6.2.1 The midline catheter tip shall be positioned distal to the axillary fold to minimize complications associated with catheter tip migration across joint spaces.

4.6.3 Antimicrobial Considerations

4.6.3.1 Clinical evaluation of midline catheters designed to inhibit bacterial attachment and biofilm formation may be appropriate based on patient risk factors and institutional protocols.

4.6.4 Contraindications and Precautions

4.6.4.1 Midline catheters are contraindicated for continuous infusion of vesicant therapy, parenteral nutrition, or other infusates with extreme pH or osmolarity values.

4.6.4.2 Increased catheter site surveillance is required when administering intermittent infusions of known irritants or vesicants, regardless of duration, due to elevated risk of phlebitis or extravasation.

4.6.4.3 Midline catheter use shall be avoided in patients with a history of thrombosis, hypercoagulability, decreased venous flow to the extremities, or end-stage renal disease requiring vein preservation.

4.7 Neonatal and Pediatric Considerations for Peripheral Catheters

4.7.1 Device selection criteria for neonatal and pediatric patients shall parallel those established for adult patients, with emphasis on removing PIVCs as soon as they are no longer clinically required.78910

4.7.2 Site options for pediatric patients: Foot veins may be considered in pediatric patients when the child’s activity level will not compromise catheter integrity.

4.7.3 Site options for neonatal and infant patients: Scalp veins represent a last-resort option when no alternative sites are available. The hands, fingers, and thumbs shall be avoided in this population.

4.7.4 Long PIVCs in pediatric patients may utilize forearm veins and the saphenous vein in nonambulatory patients.

4.7.5 Midline catheters in neonatal and pediatric populations shall utilize upper arm sites via the basilic, cephalic, and brachial veins. Additional site options include leg veins (saphenous, popliteal, femoral) with the tip positioned below the inguinal crease, and scalp veins with the tip in the neck above the thorax.

4.8 Special Population Considerations

4.8.1 Lymphedema

4.8.1.1 Venipuncture of the ipsilateral upper extremities shall be avoided in patients with lymphedema and those at increased risk, including patients who have undergone axillary surgical dissection or radiation therapy. This reflects concerns regarding decreased perfusion, impaired immune function, and elevated infection risk secondary to compromised axillary drainage.

4.8.1.2 Early referral to vascular access specialists is appropriate for patients with lymphedema. In emergent situations requiring vascular access, the most readily accessible vein may be used, followed by establishment of a plan for ongoing vascular access needs.

4.8.2 Renal Dysfunction

4.8.2.1 For patients with planned or existing arteriovenous fistula (AVF) or arteriovenous graft (AVG), vein preservation strategies are required. The dorsum of the hand shall be the preferred PIVC insertion site. The cephalic vein shall be avoided regardless of arm dominance. Forearm and upper arm veins shall not be used for peripheral catheter insertion. Midline and PICC insertion shall be avoided when possible due to increased thrombosis risk.

4.8.2.2 Collaborative discussion between the patient and nephrology providers regarding the risks and benefits of vein use in affected extremities shall occur when vascular access is required.

4.8.3 Paralysis or Hemiparesis

4.8.3.1 Venipuncture on affected extremities (such as those compromised by traumatic injury or cerebrovascular accident) shall be avoided when possible due to alterations in normal blood flow and decreased sensation.

4.9 Central Venous Access Device Guidelines

4.9.1 Indications for Central Venous Access

4.9.1.1 Evidence-based indications for CVAD insertion shall be implemented to minimize unnecessary central line placement.1112 Appropriate indications include:

  • Clinical instability (altered vital signs, oxygen saturation)
  • Infusion therapy inappropriate for peripheral administration (vesicants, non-peripherally compatible parenteral nutrition, concentrated electrolytes)
  • Physical incompatibility or complexity of infusion regimens (multiple concurrent infusates)
  • Insufficient peripheral venous access for planned treatment
  • Invasive hemodynamic monitoring requirements
  • Long-term intermittent infusion therapy for chronic disease management
  • History of failed or difficult peripheral IV access when ultrasound-guided attempts have been unsuccessful

4.9.2 Risk Considerations

4.9.2.1 CVADs with the minimum number of required lumens shall be selected to reduce risks of thrombosis, infection, and occlusion.

4.9.2.2 The need for power-injectable capability shall be evaluated with understanding of pressure limits and device limitations.

4.9.2.3 Anti-infective CVADs shall be considered in patients with elevated infection risk.

4.9.2.4 For patients with chronic kidney disease, PICCs and other intravenous devices that might compromise future fistula sites shall be avoided, with proactive planning for permanent dialysis access.

4.9.3 PICC-Specific Guidelines

4.9.3.1 The basilic, brachial, or cephalic vein above the antecubital fossa shall be selected for PICC insertion, with the basilic vein generally preferred. A catheter-to-vessel ratio of 45% or less shall be maintained.

4.9.3.2 Subcutaneous skin tunneling shall be considered when the optimal vein is at its largest diameter in the upper third of the upper arm near the axilla.

4.9.4 Nontunneled Central Venous Catheters

4.9.4.1 Ultrasound shall be used in adult and pediatric patients for vein identification, assessment, and insertion at all sites to decrease risks of cannulation failure, arterial puncture, hematoma, pneumothorax, and hemothorax.1314

4.9.4.2 Jugular approach: Associated with greater first-time insertion success, fewer needle punctures, and lower mechanical complications during insertion. Low internal jugular vein or brachiocephalic approach may improve first-time success and patient comfort.

4.9.4.3 Femoral approach: Associated with higher infection risk but provides easy ultrasound-guided access in emergent or short-term situations when other sites are exhausted.

4.9.4.4 Axillo-subclavian approach: Associated with lower infection risk and lower symptomatic deep vein thrombosis risk, but may carry increased mechanical complications during insertion. The subclavian vein shall be avoided for CVAD placement in patients with chronic kidney disease.

4.9.5 Tunneled Cuffed CVADs and Implanted Ports

4.9.5.1 The internal jugular vein is preferred over subclavian and femoral veins for tunneled cuffed CVADs and implanted ports. Ultrasound shall be used for thorough assessment.

4.9.5.2 Tunneled cuffed CVADs are appropriate for continuous long-term infusion therapy such as antineoplastic agents or parenteral nutrition.

4.9.5.3 Implanted vascular access ports are appropriate for patients requiring infrequent or intermittent vascular access.1516

4.10 Arterial Catheter Guidelines

4.10.1 Arterial catheter insertion is indicated for hemodynamic monitoring, blood sampling, and blood gas analysis in critically ill patients.

4.10.2 The smallest gauge catheter possible shall be used for radial arterial access to minimize complication risk.

4.10.3 Ultrasound guidance shall be employed for arterial catheter insertion.17

4.10.4 Circulation to the hand shall be assessed prior to radial artery puncture through physical examination including assessment of radial and ulnar pulses using the Allen test, pulse oximetry, or Doppler flow study.

4.10.5 For adult patients: The radial artery shall be the most appropriate access site for percutaneous cannulation.

4.10.6 For pediatric patients: The radial, posterior tibial, and dorsalis pedis arteries are appropriate. The brachial artery shall not be used in pediatric patients due to absence of collateral blood flow.

4.11 General Practice Requirements

4.11.1 Healthcare providers shall discuss preferred PIVC insertion sites with patients and caregivers, including recommendations to utilize sites on the nondominant side when clinically appropriate.

4.11.2 When intravenous access is required, a patient’s existing implanted vascular access port shall be accessed in preference to inserting an additional VAD, unless the existing device is contraindicated due to complications.

4.11.3 Insertion of PIVCs or midline catheters solely as a CLABSI prevention strategy when central venous access is clinically indicated is an inappropriate practice and shall not occur.

5. Compliance

5.1 Key Performance Indicators

  • Rate of compliance with duration-based device selection guidelines, documented at time of insertion order
  • Rate of PIVC placement in clinically indicated settings versus avoidance of unnecessary central access
  • Rate of compliance with site selection standards (avoidance of antecubital fossa, lower extremity in adults, contraindicated sites)
  • Rate of catheter-to-vein ratio documentation for PICCs (target ≤45%)
  • Rate of midline use for 5–14 day therapy in adult patients when infusate-compatible (target: tracked)
  • Rate of vascular preservation plan documentation for patients with renal dysfunction

5.2 Enforcement

Non-compliance with this policy shall be addressed through standard performance improvement and professional accountability processes, including documentation audits, peer review, targeted education, and escalation to unit leadership or the Vascular Access Governance Committee as appropriate.

6. Exceptions

Exceptions to this policy may arise in emergency or life-threatening situations where adherence to standard device selection criteria is not feasible. Any deviation shall be documented in the patient health record with clinical justification, and a plan for transitioning to appropriate vascular access shall be established at the earliest opportunity. Exceptions shall not become routine practice without formal policy revision.

  • Vascular Access Device Insertion Policy
  • Vascular Access Site Preparation and Skin Antisepsis Policy
  • Central Vascular Access Device Tip Location Policy
  • Vascular Visualization Technology Policy
  • Implanted Vascular Access Ports Policy
  • Vascular Access for Hemodialysis Policy
  • Evidence-Based Selection and Clinical Monitoring Policy
  • Informed Consent for Vascular Access Policy
  • Foundations of Clinical Practice and Specialized Population Management Policy

8. Revision History

VersionDateAuthorDescription
1.02023-05-15Vascular Access Governance CommitteeInitial policy release
1.12025-09-01Vascular Access Governance CommitteeAnnual review; renal dysfunction and neonatal site guidance updated

References

  1. Krein SL, Harrod M, Weston LE, et al. Vascular access specialist teams and catheter-related bloodstream infection prevention: a multisite qualitative study. BMJ Qual Saf. 2021;30(8):628-638. doi:10.1136/bmjqs-2020-011806 ↩︎

  2. Moureau NL, Carr PJ. Vessel Health and Preservation: the right approach for vascular access. Br J Nurs. 2018;27(8):S28-S35. doi:10.12968/bjon.2018.27.8.S28 ↩︎

  3. Fiorini J, Venturini G, Cicolini G, et al. Vascular access device selection and vessel health preservation in a group of hospitalised patients: an observational study. J Clin Nurs. 2019;28(7-8):1039-1049. doi:10.1111/jocn.14728 ↩︎

  4. Hallam C, Denton A, Weston V, et al. UK Vessel Health and Preservation (VHP) Framework: a commentary on the updated VHP 2020. J Infect Prevent. 2021;22(4):147-155. doi:10.1177/1757177420976806 ↩︎

  5. Carr PJ, Higgins NS, Cooke ML, Rippey JC, Rickard CM. Tools, clinical prediction rules, and algorithms for the insertion of peripheral intravenous catheters in adult hospital patients: a systematic review and meta-analyses. Cochrane Database Syst Rev. 2018;3(3):CD011429. doi:10.1002/14651858.CD011429.pub2 ↩︎

  6. Paterson RS, Schults JA, Slaughter E, et al. Peripheral intravenous catheter insertion in adult patients with difficult intravenous access: a systematic review. Emerg Med Australas. 2022;34(6):862-870. doi:10.1111/1742-6723.14069 ↩︎

  7. Ullman A, Kleidon T. Developmental Stages and Clinical Conditions for Vascular Access in Pediatrics. In: Moureau NL, ed. Vessel Health and Preservation: The Right Approach for Vascular Access. Springer International Publishing; 2019:171-179. ↩︎

  8. Ullman AJ, Bernstein SJ, Brown E, et al. The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC. Pediatrics. 2020;145(Suppl 3):S269-S284. doi:10.1542/peds.2019-3474I ↩︎

  9. Aiyagari R, Cooper DS, Jacobs JP. Vascular access in children with congenital heart defects. Pediatrics. 2020;145:S285-S286. doi:10.1542/peds.2019-3474N ↩︎

  10. Legemaat MM, Carr PJ, van Rens RM, van Dijk M, Poslawsky IE, van den Hoogen A. Peripheral intravenous cannulation: complication rates in the neonatal population: a multicenter observational study. Int J Nurs Stud. 2015;52(5):1003-1010. doi:10.1016/j.ijnurstu.2015.02.009 ↩︎

  11. Bechdel BA, Bardman KJ, Machemer C. Developing a nurse-driven vascular access device order set using the electronic medical record. J Infus Nurs. 2022;45(1):20-26. doi:10.1097/nan.0000000000000450 ↩︎

  12. Xiong Z, Chen H. Interventions to reduce unnecessary central venous catheter use to prevent central-line-associated bloodstream infections in adults: a systematic review. Infect Control Hosp Epidemiol. 2018;39(12):1442-1448. doi:10.1017/ice.2018.250 ↩︎

  13. Spencer TR, Bardin-Spencer A. Ultrasound guidance for vascular access procedures by qualified vascular access specialists or other applicable healthcare clinicians. J Assoc Vasc Access. 2019;25(1):18-22. doi:10.2309/j.java.2019.004.002 ↩︎

  14. Spencer TR, Bardin-Spencer A. Central venous access device insertion by qualified vascular access specialists or other applicable healthcare clinicians. J Assoc Vasc Access. 2020;25(1):52-55. doi:10.2309/j.java.2020.01.001 ↩︎

  15. Wu S, Li W, Zhang Q, Li S, Wang L. Comparison of complications between peripheral arm ports and central chest ports: a meta-analysis. J Adv Nurs. 2018;74(11):2484-2496. doi:10.1111/jan.13766 ↩︎

  16. Wang K, Zhou Y, Huang N, Lu Z, Zhang X. Peripherally inserted central catheter versus totally implanted venous port for delivering medium- to long-term chemotherapy: a cost-effectiveness analysis based on propensity score matching. J Vasc Access. 2022;23(3):365-374. doi:10.1177/1129729821991360 ↩︎

  17. Bardin-Spencer A, Spencer TR. Ultrasound-guided peripheral arterial catheter insertion by qualified vascular access specialists or other applicable health care clinicians. J Assoc Vasc Access. 2019;25(1):48-50. doi:10.2309/j.java.2019.003.008 ↩︎

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