When Should a Provider Order a PICC Line vs a Midline Catheter?

Selecting the right vascular access device (VAD) is one of the fastest ways to reduce IV delays, prevent extravasation/phlebitis, and lower complication risk—especially in skilled nursing facilities (SNFs), LTACs, rehab, and hospital step-down units.

The Infusion Nurses Society (INS) Standards emphasize choosing the least invasive device that meets the therapy needs, based on duration of therapy, infusate characteristics, patient factors, and ability/resources to care for the device. 

This guide translates those standards into simple “order” decision points that providers can use when deciding between midline vs PICC.

Clinical note: This post supports clinical decision-making and does not replace your facility policies, pharmacy guidance, or provider judgment.

The INS “Golden Rules” for Device Selection

INS recommends that VAD selection be based on the prescribed regimen and patient factors (duration, vascular characteristics, comorbidities, prior infusion history, preferences, and resources). 

INS also states the selected device should be the least invasive option with the smallest outer diameter and fewest lumens needed to complete therapy. 

Quick Definitions

Midline catheter

A peripheral catheter typically placed in the upper arm with the tip remaining in the peripheral circulation. It is often used for therapies that are well tolerated by peripheral veins. 

PICC (Peripherally Inserted Central Catheter)

A central venous access device (CVAD) used when therapy requires a central route or when clinical complexity and access needs justify central access. INS provides an evidence-based list of CVAD indications (examples below). 

When to Order a Midline Catheter

Order a MIDLINE when ALL of the following are true:

1) The infusate is appropriate for peripheral tolerance

INS: Choose a midline after assessing infusate characteristics and planned duration for peripheral tolerability. 

INS specifically supports midlines for antimicrobials, fluid replacement, and analgesics that are well tolerated by peripheral veins. 

2) You are NOT giving continuous vesicants, PN, or extreme pH/osmolarity solutions

INS explicitly says: Do not use midlines for continuous vesicant therapy, parenteral nutrition (PN), or infusates with extremes of pH or osmolarity. 

3) The patient is a good midline candidate

INS advises avoiding a midline when there is a history of thrombosis/hypercoagulability, decreased venous flow to extremities, or end-stage renal disease requiring vein preservation. 

Common “Order Midline” scenarios (provider-facing)

• Short-to-intermediate IV antibiotics that are peripherally tolerated (e.g., many standard antimicrobials) 

• Hydration, maintenance fluids, and symptom control IV meds (peripheral-tolerated analgesics, etc.) 

• Difficult peripheral access where you need longer dwell than a short PIV—and the medication profile fits peripheral tolerance (consider ultrasound-guided access per facility capability)

When to Order a PICC Line (Central Access)

INS recommends selecting a CVAD when the benefit outweighs risk and provides a practical list of indications for CVAD use. 

Order a PICC (or other CVAD) when ONE OR MORE apply:

1) The infusion is not appropriate for peripheral administration

INS includes this as a CVAD indication: continuous infusion therapy inappropriate for peripheral infusion, including examples such as vesicants, PN, electrolytes, and other medications. 

2) Long-term or complex infusion needs

INS includes CVAD indications such as:

• Clinical instability and/or complex infusion regimen (multiple infusates) 

• Long-term intermittent infusion therapy, including anti-infectives for known/suspected infection or IV therapy for chronic disease 

• History of failed/difficult peripheral access after ultrasound-guided attempts fail 

3) You need central-line capabilities (monitoring/therapy requirements)

INS includes invasive hemodynamic monitoring as a CVAD indication. 

PICC risk reminders (important for ordering)

INS notes CVAD risks, including venous thrombosis and increased risk for CLABSI in some hospitalized patients, and recommends using the fewest lumens and appropriate catheter size to reduce complications. 

INS also says to avoid PICCs in chronic kidney disease (CKD) (vein preservation considerations). 

Duration Guidance (How long will IV therapy last?)

A widely used catheter guideline referenced in infection-control practice recommends:

Use a midline or PICC instead of a short peripheral catheter when IV therapy will likely exceed 6 days. 

How IDPH fits in: IDPH’s patient safety/quality “Additional Resources” page includes “Catheter and other Vascular Access Care” resources that point facilities to CDC catheter guidance and CLABSI prevention tools. 

(Meaning: while IDPH may not publish a “PICC vs midline indications chart,” they direct facilities to evidence-based catheter safety guidance used in healthcare settings.)

Practical “Order Set” Language You Can Use (Provider-Friendly)

You can adapt the following phrases directly into your facility order sets or consult notes:

Midline Order Language

“Order Midline catheter for peripheral-tolerated IV therapy (e.g., fluids/analgesics/peripherally tolerated antimicrobials) when therapy is expected to last >6 days and does not require central administration; avoid for continuous vesicants/PN/extreme pH or osmolarity.” 

PICC Order Language

“Order PICC (CVAD) when therapy requires central administration (e.g., continuous vesicant/PN or other peripheral-inappropriate infusions), when infusion regimen is complex/multiple infusates, for long-term intermittent IV therapy, or when peripheral access has failed despite ultrasound-guided attempts (consider CKD/vein preservation).” 

Frequently Asked Questions (SEO section)

Can a midline be used for vesicants?

INS advises: Do not use midlines for continuous vesicant therapy and recommends increased surveillance and careful risk-benefit evaluation for intermittent vesicants. 

When should we move beyond a short PIV?

A major catheter guideline recommends using midline or PICC (instead of a short peripheral catheter) when IV therapy will likely exceed 6 days. 

What’s the overall goal of device selection?

INS emphasizes selecting the least invasive device with the fewest lumens that can safely complete therapy, while prioritizing vessel health and preservation. 

Free Clinical Consultation Before You Order

Choosing between a PICC line and a midline catheter should never feel uncertain—especially when the wrong device can delay therapy or increase complication risk.

At Optimus Vascular, we offer free phone consultations to help providers and nursing teams determine the most appropriate vascular access device before submitting an order.

During this consultation, our experienced vascular access clinicians review:

• Ordered or anticipated medications

• Expected duration of IV therapy

• Patient history (including difficult access, thrombosis risk, CKD considerations)

• Facility capabilities and urgency of access

This collaborative approach helps ensure the selected device aligns with INS Standards of Practice, supports patient safety, and avoids unnecessary escalation to central access when a peripheral option is clinically appropriate.

Once the appropriate device is identified, our team can promptly assist with placement when the facility is ready to proceed.

Need access quickly? Call (630) 819-0367 or email contact@optimusvascular.com to confirm the appropriate line and arrange prompt placement.

Rapid Response When Access Can’t Wait

Delayed vascular access often leads to:

• Missed antibiotic doses

• Treatment interruptions

• Unnecessary emergency department transfers

Optimus Vascular is designed specifically to address these challenges.

We provide rapid-response, mobile vascular access services, allowing facilities to obtain timely PICC or midline placement without waiting days for hospital-based teams or radiology availability.

Our streamlined process allows providers to:

• Call for a quick consultation

• Confirm the appropriate device

• Receive prompt bedside placement using ultrasound guidance

This responsiveness supports continuity of care, reduces escalation of care, and helps facilities maintain treatment timelines—especially in skilled nursing, rehab, and long-term care settings.