Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: results of a national survey

Improving Appropriate Use of Peripherally Inserted Central Catheters Through a Statewide Collaborative Hospital Initiative: A Cost-Effectiveness Analysis

BACKGROUND

Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use.

METHODS

The authors used an economic evaluation from a health care sector perspective. Implementation costs included incentive payments to hospitals and costs for data abstractors and the coordinating center. Effectiveness was calculated from propensity score-matched observations across two time periods for complications (venous thromboembolism [VTE], central line-associated bloodstream infection [CLABSI], and catheter occlusion): preintervention period (January 2015 through December 2016) and intervention period (January 2017 through December 2021). Cost-effectiveness was presented as the cost-offset per averted complication, reflecting the health care costs avoided due to having lower complication rates.

RESULTS

Across 35 hospitals, this study sampled 17,418 PICCs placed preintervention and 26,004 placed during the intervention period. PICC complications decreased significantly following the intervention. CLABSIs decreased from 2.1% to 1.5%, VTEs from 3.2% to 2.3%, and catheter occlusions from 10.8% to 7.0% (all p < 0.01). Estimated number of complications prevented included 871 CLABSIs, 2,535 VTEs, and 8,743 catheter occlusions. Project implementation costs were $31.8 million, and the cost-offset related to avoided complications was $64.4 million. Each participating hospital averaged $932,073 in cost-offset over seven years, and the average cost-offset per complication averted was $2,614 (95% CI [confidence interval] $2,314-$3,003).

CONCLUSION

A large-scale, multihospital QI initiative to improve appropriate PICC use yielded substantial return on investment from cost-offset of prevented complications.

Content validity of an instrument for analysing nurses' knowledge of peripherally inserted central catheters

Peripherally inserted central catheters (PICCs) ensure safe and long-lasting venous access. Using validated instruments to assess nurses' knowledge of PICC use will allow educational measures to improve this area of care to be developed.

OBJECTIVE

This study aimed to build an instrument for analysing nurses' knowledge about PICCs and assess its content validity.

METHODS

A psychometric study was used with the construction of a knowledge analysis instrument. This was developed in two stages: instrument construction; and content validation by expert judges using the content validity ratio.

RESULTS

The panel of experts comprised nine nurses. Nineteen changes related to content and semantics were suggested for the instrument.

CONCLUSION

The research allowed for the construction and validation of a tool for knowledge analysis; this is relevant to practice as no such knowledge instrument exists. It is proposed to use this assessment instrument to identify gaps in knowledge and implement focused training interventions.

Promoting appropriate midline catheter and PICC placement through implementation of an EHR-based clinical decision support tool: An interrupted time-series analysis

BACKGROUND

Inappropriate use of peripherally inserted central catheters (PICCs), including multilumen PICCs, may increase the risk of patient complications.

OBJECTIVE

Implement computerized decision support to: (a) increase the use of midline catheters over PICCs when appropriate and (b) decrease PICC lumens when a PICC is necessary.

DESIGNS

Quasi-experimental, interrupted time series.

SETTING

Single tertiary academic medical center.

PATIENTS

Hospitalized adults who received a midline or PICC during clinical care.

INTERVENTION

Decision support on appropriate vascular access device choice via a set of electronic orders embedded within the electronic health record.

MEASUREMENTS

Proportion of midline catheter and single-lumen PICCs placed between January 2, 2017 and November 19, 2017 (preintervention) versus November 20, 2017 to December 1, 2019 (postintervention).

RESULTS

A total of 8758 midline and PICCs were inserted during the study period. A statistically significant increase in the insertion of midline catheters was observed during the intervention (p = .006). In parallel, single-lumen PICC insertion as a proportion of all PICCs also increased after the intervention (p = .035). Results were consistent across multiple disciplines, including internal medicine, surgery, and intensive care. After considering the hospital census, total PICC and midline utilization rates and rates of complications did not change over time. However, an increase in catheter exchanges from less to more invasive devices occurred.

CONCLUSIONS

In this single-center study, the implementation of electronic decision support to inform appropriate catheter use led to a more appropriate midline catheter and single-lumen PICC insertion. Dissemination of this single, effective intervention to examine efficacy in other hospital settings would be welcomed.

Quantified versus willful handgrip exercises for the prevention of PICC-related thrombosis: A meta-analysis and systematic review

BACKGROUND

Thrombosis is a common yet serious complication in patients with peripherally inserted central venous catheter (PICC), the prevention of thrombosis is very important to the prognosis of PICC patients. We aimed to evaluate the effects of quantified versus willful grip exercises for the prevention of PICC-related thrombosis, to provide evidence to the clinical nursing care of PICC patients.

METHODS

Two authors searched PubMed et al databases for randomized controlled trials (RCTs) comparing the effects of quantified versus willful grip exercises in PICC patients up to August 31, 2022. Quality assessment and data extraction were independently performed by 2 researchers, and meta-analysis was performed using RevMan 5.3 software.

RESULTS

15 RCTs involving 1741 PICC patients were finally included in this meta-analysis. Synthesized outcomes indicated that compared with willful grip exercises, quantified grip exercises reduced the incidence of PICC-related thrombosis (odds ratio = 0.19, 95% confidence interval [CI]: 0.12-0.31) and infection (odds ratio = 0.30, 95% CI: 0.15-0.60) in PICC patients, increased the maximum venous velocity (mean difference = 3.02, 95% CI: 1.87-4.17) and mean blood flow (mean difference = 3.10, 95%CI: 1.57-4.62) in PICC patients (all P < .05). There were no publication biases amongst the synthesized outcomes (all P > .05).

CONCLUSION

Quantified grip exercises can effectively reduce the occurrence of PICC-related thrombosis and infection, improve the venous hemodynamics. Limited by study population and regions, large-sample, and high-quality RCTs are still needed in the future to further evaluate the effects and safety of quantified grip exercises in PICC patients.

Effect of exercise therapy on PICC-associated venous thromboembolism: A meta-analysis

BACKGROUND

Peripherally inserted central catheter (PICC) is widely used in clinical practice because of its long retention time and easy maintenance. However, PICC-associated venous thromboembolism (VTE) is the most serious complication of PICC. Guidelines recommend exercise therapy to prevent PICC-associated VTE. However, inconsistent findings have been reported across the literature. This study conducted a meta-analysis to further evaluate the effect of exercise therapy on PICC-associated VTE.

METHODS

We searched CNKI, Wanfang database, Chinese Science and Technology Journal Full Text Database, PubMed, Embase, Web of Science and Cochrane Library databases and included all randomized controlled trials (RCTs) of exercise therapy for the prevention of PICC-associated VTE. Two investigators independently screened the literature, extracted information, and evaluated the risk of bias for eligible RCTs. Meta-analysis was conducted by RevMan5.4 software.

RESULTS

Eleven RCTs were included, including 1919 patients. Meta-analysis showed that the incidence of PICC-associated VTE was lower in the exercise therapy group than in the usual care group (RR = 0.30, 95% CI: 0.22-0.41, p < 0.00001).Exercise therapy increased the axillary vein maximum velocity (SMD = 0.93, 95% CI: 0.58-1.28, p < 0.00001) and the axillary vein time-mean flow velocity (SMD = 0.86, 95% CI: 0.53-1.20, p < 0.00001). Subgroup analysis showed statistically significant differences for the incidence of PICC-associated VTE for intervention times<4 weeks (RR = 0.26, 95% CI: 0.17-0.40, p < 0.00001) and intervention times≥4 weeks (RR = 0.35, 95% CI: 0.22-0.54, p < 0.00001). For axillary vein maximum velocity, the difference was statistically significant for both intervention time <4 weeks (SMD = 0.73, 95% CI: 0.55-0.91, p < 0.00001) and intervention time ≥4 weeks (SMD = 1.18, 95% CI: 0.18-2.19, p = 0.02). For axillary vein time-mean flow velocity, the intervention time <4 weeks (SMD = 0.75, 95% CI: 0.46-1.04, p < 0.00001), and the difference was statistically significant; while ≥4 weeks, the difference was not statistically significant (SMD = 1.14, 95% CI: -0.07 to 2.35, p = 0.06).

CONCLUSIONS

Exercise therapy improved venous blood flow velocity and effectively reduced the incidence of PICC-associated VTE. However, RCTs with large samples and high quality are needed to further evaluate the effectiveness of exercise therapy in PICC patients.

Cost-effectiveness Analysis of Peripherally Inserted Central Catheters Versus Central Venous Catheters for in-Hospital Parenteral Nutrition

OBJECTIVE

Our objective was to evaluate the cost-effectiveness of the use of peripherally inserted central venous catheters (PICCs) by a vascular access team (VAT) versus central venous catheters (CVCs) for in-hospital total parenteral nutrition (TPN).

METHODS

The study used a cost-effectiveness analysis based on observational data retrospectively obtained from electronic medical records from 2018 to 2019 in a teaching hospital. We included all interventional procedures requiring PICCs or CVCs with the indication of TPN. We recorded the costs of insertion, maintenance, removal, and complications. The main outcome measure was the incidence rate of catheter-associated bacteremia per 1000 catheter days. Cost-effectiveness analysis was performed from the hospital perspective within the context of the publicly funded Spanish health system. Confidence intervals for costs and effectiveness differences were calculated using bootstrap methods.

RESULTS

We analyzed 233 CVCs and 292 PICCs from patients receiving TPN. Average duration was longer for PICC (13 versus 9.4 days, P < 0.001). The main reason for complications in both groups was suspected infection (9.77% CVC versus 5.18% PICC). Complication rates due to bacteremia were 2.44% for CVC and 1.15% for PICC. The difference in the incidence of bacteremia per 1000 catheter days was 1.29 (95% confidence interval, -0.89 to 3.90). Overall, costs were lower for PICCs than for CVCs: the difference in mean overall costs was -€559.9 (95% confidence interval, -€919.9 to -€225.4). Uncertainty analysis showed 86.37% of results with lower costs and higher effectiveness for PICC versus CVC.

CONCLUSIONS

Placement of PICC by VAT compared with CVC for TPN reduces costs and may decrease the rate of bacteremia.

Awareness of Peripheral Intravenous Catheters Among Nurses, Physicians, and Students

OBJECTIVES

Peripheral intravenous catheters (PIVCs) are frequently used to meet patients' short-term health care needs. However, many PIVCs are not promptly removed at the completion of treatment, placing patients at risk of avoidable harm from serious complications including local and systemic infection. This study aims to report the proportion and accuracy of health care staff/students awareness of the presence of their patient's PIVC.

METHODS

We asked staff/students to recall the presence or absence of a PIVC in a patient under their care, as well as details of the date of insertion and PIVC location. We recorded concordance of responses with direct observations. To achieve this, face-to-face interviews were conducted with clinical staff/students at 2 adult hospitals.

RESULTS

Overall, 90% (n = 216) of staff responses (94% of nurses, 100% of nursing students, 76% of medical staff) correctly identified the presence/absence of a PIVC. Clinicians correctly identified the PIVC location 55% (n = 71) of the time.

CONCLUSIONS

Health care services must recognize the implications of this lack of awareness and implement and evaluate tailored quality improvement efforts to address this.

Five-year outcome of peripherally inserted central catheters in adults: a separated infectious and thrombotic complications analysis

OBJECTIVE

To assess infectious and thrombotic complications of peripherally inserted central catheters (PICCs) in adults.

DESIGN

A 5-year prospective cohort study.

SETTING

Tertiary-care teaching hospital in Seville, Spain.

PATIENTS

Adult patients undergoing PICC insertion.

METHODS

Catheter-associated bloodstream infection (CABSI) including catheter-related bloodstream infection (CRBSI), primary bacteremia (PB), and upper extremity deep vein thrombosis (UEDVT) were recorded. Independent predictors of complications were assessed by multivariate analysis.

RESULTS

In total, 1,142 PICCs were inserted, with 153,191 catheter days (median, 79). Complications included 66 cases of CABSI (5.78%; 0.43‰ catheter days), 38 cases of CRBSI (3.33%; 0.25‰ catheter days), 28 cases of PB (2.45%; 0.18‰ catheter days), and 23 cases of UEDVT (2.01%; 0.15‰ catheter days). The median times to infection were 24, 41, and 60 days for CRBSI, PB, and UEDVT, respectively. Parenteral nutrition (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.77-6.52) and admission to the hematology ward (OR, 4.90; 95% CI, 2.25-10.71) were independently associated with CRBSI and PB, respectively. Admission to the hematology ward (OR, 12.46; 95% CI, 2.49-62.50) or to the oncology ward (OR, 7.89; 95% CI, 1.77-35.16) was independently associated with UEDVT. The crude mortality rate was 24.8%. Only 2 patients died of complications.

CONCLUSIONS

PICCs showed a low rate of thrombotic and infectious complications. Compared to PB, CRBSI showed significantly different risk factors, a higher incidence density per catheter days, and a shorter median time to infection. Separate analyses of CRBSI and PB are more specific and clinically useful when analyzing infectious complications.

Peripherally inserted central catheters inserted with current best practices have low deep vein thrombosis and central line–associated bloodstream infection risk compared with centrally inserted central catheters: A contemporary meta-analysis

Background:

Peripherally inserted central catheters and centrally inserted central catheters have numerous benefits but can be associated with risks. This meta-analysis compared central catheters for relevant clinical outcomes using recent studies more likely to coincide with practice guidelines.

Methods:

Several databases, Ovid MEDLINE, Embase, and EBM Reviews were searched for articles (2006–2018) that compared central catheters. Analyses were limited to peer-reviewed studies comparing peripherally inserted central catheters to centrally inserted central catheters for deep vein thrombosis and/or central line–associated bloodstream infections. Subgroup, sensitivity analyses, and patient-reported measures were included. Risk ratios, incidence rate ratios, and weighted event risks were reported. Study quality assessment was conducted using Newcastle–Ottawa and Cochrane Risk of Bias scales.

Results:

Of 4609 screened abstracts, 31 studies were included in these meta-analyses. Across studies, peripherally inserted central catheters were protective for central line–associated bloodstream infection (incidence rate ratio = 0.52, 95% confidence interval: 0.30–0.92), with consistent results across subgroups. Peripherally inserted central catheters were associated with an increased risk of deep vein thrombosis (risk ratio = 2.08, 95% confidence interval: 1.47–2.94); however, smaller diameter and single-lumen peripherally inserted central catheters were no longer associated with increased risk. The absolute risk of deep vein thrombosis was calculated to 2.3% and 3.9% for smaller diameter peripherally inserted central catheters and centrally inserted central catheters, respectively. On average, peripherally inserted central catheter patients had 11.6 more catheter days than centrally inserted central catheter patients ( p = 0.064). Patient outcomes favored peripherally inserted central catheters.

Conclusion:

When adhering to best practices, this study demonstrated that concerns related to peripherally inserted central catheters and deep vein thrombosis risk are minimized. Dramatic changes to clinical practice over the last 10 years have helped to address past issues with central catheters and complication risk. Given the lower rate of complications when following current guidelines, clinicians should prioritize central line choice based on patient therapeutic needs, rather than fear of complications. Future research should continue to consider contemporary literature over antiquated data, such that it recognizes the implications of best practices in modern central catheterization.

The clinical features and related factors of PICC-related upper extremity asymptomatic venous thrombosis in cancer patients: A prospective study

Peripherally inserted central venous catheter (PICC) is the main venous access for cancer patients when they receive chemotherapy and nutritional support, but PICC-related venous thrombosis has become one of the most common and serious complications. It is very important to further explore the relationship among these features, so that prevent and treat the PICC-related thrombosis.To investigate the clinical features and the related factors of PICC-related upper extremity asymptomatic venous thrombosis in cancer patients, and to provide theoretical basis for the prevention of venous thrombosis.A total of 127 tumor patients with PICC catheterization were selected. Thrombus was detected by color Doppler ultrasound at different times: before catheterization and 24 hours after catheterization, and every week. The study was terminated at the time of thrombosis, and patients who did not develop thrombus were terminated after 6 weeks of follow-up. The clinical characteristics and influencing factors of asymptomatic thrombosis such as vessel diameter, blood flow velocity, thrombosis time, location, and the thrombosis stages were recorded.The incidence of PICC-related upper limbs asymptomatic thrombosis was 48.82% (62/127), and the median time was 3 days. The incidence within 24-hour was 37.1% and within 1 week was 85.49%. A total of 81 venous thrombosis were found in 62 patients with asymptomatic thrombosis, there were 19 (23.5%) venous thrombosis in the deep veins while 62 (76.5%) in the superficial veins. Furthermore, thrombosis stages can be divided into 3 levels: stage I accounted for 51.85% (42/81), stage II accounted for 37.04% (30/81), and stage III accounted for 11.11% (9/81). The group trajectory analysis indicated the 3 changes of blood flow velocity during the follow-up period: downward trend, upward trend, and steady fluctuations. Survival analysis indicated that the cohort with downward trend have the high risk of thrombosis (67.90% vs 19.00% vs 45.10%). Cox proportional hazards model suggested that the patient's Eastern Cooperative Oncology Group score (hazard ratio [HR] 2.791, 95% confidence interval [CI] 0.08-0.76) and blood flow velocity (HR 0.250, 95% CI 2.01-3.87) was the risk of PICC-related asymptomatic thrombosis.PICC catheterization can affect blood flow and asymptomatic thrombosis can occur at an early stage. Patient's upper limb activities should be guided to promoting blood circulation, thus effectively preventing thrombosis. Asymptomatic thrombosis can also be detected by color Doppler ultrasound system, within a recommended time of 1 week after catheterization.

Less Lumens-Less Risk: A Pilot Intervention to Increase the Use of Single-Lumen Peripherally Inserted Central Catheters

To reduce risk of complications, existing guidelines recommend use of peripherally inserted central catheters (PICCs) with the minimal number of lumens. This recommendation, however, is difficult to implement in practice. We conducted a pilot study to increase the use of single-lumen PICCs in hospitalized patients. The intervention included (1) education for physicians, pharmacists, and nurses; (2) changes to the electronic PICC order-set that set single lumen PICCs as default; and (3) criteria defining when use of multilumen PICCs is appropriate. The intervention was supported by real-time monitoring and feedback. Among 226 consecutive PICCs, 64.7% of preintervention devices were single lumen versus 93.6% postintervention (P < .001). The proportion of PICCs with an inappropriate number of lumens decreased from 25.6% preintervention to 2.2% postintervention (P < .001). No cases suggesting inadequate venous access or orders for the placement of a second PICC were observed. Implementing a single-lumen PICC default and providing education and indications for multilumen devices improved PICC appropriateness.

Risk of Venous Thromboembolism Following Peripherally Inserted Central Catheter Exchange: An Analysis of 23,000 Hospitalized Patients

BACKGROUND

Catheter exchange over a guidewire is frequently performed for malfunctioning peripherally inserted central catheters (PICCs). Whether such exchanges are associated with venous thromboembolism is not known.

METHODS

We performed a retrospective cohort study to assess the association between PICC exchange and risk of thromboembolism. Adult hospitalized patients that received a PICC during clinical care at one of 51 hospitals participating in the Michigan Hospital Medicine Safety consortium were included. The primary outcome was hazard of symptomatic venous thromboembolism (radiographically confirmed upper-extremity deep vein thrombosis and pulmonary embolism) in those that underwent PICC exchange vs those that did not.

RESULTS

Of 23,010 patients that underwent PICC insertion in the study, 589 patients (2.6%) experienced a PICC exchange. Almost half of all exchanges were performed for catheter dislodgement or occlusion. A total of 480 patients (2.1%) experienced PICC-associated deep vein thrombosis. The incidence of deep vein thrombosis was greater in those that underwent PICC exchange vs those that did not (3.6% vs 2.0%, P < .001). Median time to thrombosis was shorter among those that underwent exchange vs those that did not (5 vs 11 days, P = .02). Following adjustment, PICC exchange was independently associated with twofold greater risk of thrombosis (hazard ratio [HR] 1.98; 95% confidence interval [CI], 1.37-2.85) vs no exchange. The effect size of PICC exchange on thrombosis was second in magnitude to device lumens (HR 2.06; 95% CI, 1.59-2.66 and HR 2.31; 95% CI, 1.6-3.33 for double- and triple-lumen devices, respectively).

CONCLUSION

Guidewire exchange of PICCs may be associated with increased risk of thrombosis. As some exchanges may be preventable, consideration of risks and benefits of exchanges in clinical practice is needed.

The relationship between perceived role and appropriate use of peripherally inserted central catheters: A survey of vascular access nurses in the United States

BACKGROUND

The presence and proliferation of vascular access nursing in hospital settings has been identified as a potential contributor to growing demand, and possible overuse, of peripherally inserted central catheters (PICCs).

OBJECTIVE

We examined vascular access nurses' perceived role related to use of PICCs and the association with appropriateness of PICC use in hospitals.

DESIGN

A web-based survey was administered to members of two vascular access professional organizations.

PARTICIPANTS

Of 2762 potentially eligible respondents who accessed the link, 1698 (61%) completed the survey. This sample was further restricted to vascular access nurses who worked in a U.S. hospital (n=1147).

METHODS

Respondents were categorized based on perceived role: 1) an operator who inserts PICCs; 2) a consultant whose views are not valued by the care team (unvalued consultant); 3) a consultant whose views are valued by the care team (valued consultant). Facility and respondent characteristics, reported practices, leadership support and relationships with other providers were compared across groups using chi-squared tests and analysis of variance. Multivariable logistic regression was used to assess the association between perceived role and reported percentage of PICCs placed for inappropriate reasons.

RESULTS

Among the 1147 respondents, 210 (18%) viewed themselves as operators, 683 (59%) as valued consultants, 236 (21%) as unvalued consultants, and 18 (2%) could not be categorized. A significantly higher percentage (93%) of valued consultants reported that vascular access nurses placed the majority of PICCs at their facility, compared to operators (83%) or unvalued consultants (76%) (p<0.001). After adjustment, compared with operators, valued consultants were significantly more likely to report that <10% of PICCs at their facility were inserted for inappropriate reasons (OR 1.7, p=0.002); the finding was reversed for unvalued consultants (OR 0.69, p=0.06).

CONCLUSIONS

Vascular access nurses and their perceived role as part of the healthcare team are associated with PICC use in hospitals. Strong inter-professional collaboration and respect may help ensure more appropriate use of PICCs.

Hospitalists and Their Impact on Quality, Patient Safety, and Satisfaction

The forces promoting the hospitalist model arose from the need for high-value care; therefore, improving quality and cost has been part of the hospitalist formula for success. The factors driving the rapid growth of generalist and subspecialty hospitalists include nationally mandated quality and safety measures, increasing age and complexity of the hospitalized patient, reduced residency duty hours, increased economic pressures to contain costs and reduce length of stay, and also primary care physicians, and specialists, relinquishing hospital privileges to focus on outpatient practices. Hospitalists are playing key roles in patient safety and quality as either leaders or practitioners in the field.

Can the identification of an idle line facilitate its removal? A comparison between a proposed guideline and clinical practice

BACKGROUND

There are 250,000 cases of central line-associated blood stream infections in the United States annually, some of which may be prevented by the removal of lines that are no longer needed.

OBJECTIVE

To test the performance of criteria to identify an idle line as a guideline to facilitate its removal.

METHODS

Patients with central lines on the wards were identified. Criteria for justified use were defined. If none were met, the line was considered "idle." We proposed the guideline that a line may be removed the day following the first idle day and compared actual practice with our proposed guideline.

RESULTS

One hundred twenty-six lines in 126 patients were observed. Eighty-three (65.9%) were peripherally inserted central catheters. Twenty-seven percent (n= 34) were placed for antibiotics. Seventy-six patients had lines removed prior to discharge. In these patients, the line was in place for 522 days, of which 32.7% were idle. The most common reasons to justify the line included parenteral antibiotics and meeting systemic inflammatory response (SIRS) criteria. In 11 (14.5%) patients, the line was removed prior to the proposed guideline. Most (n = 36, 47.4%) line removals were observed to be in accordance with our guideline. In another 29 (38.2%), line removal was delayed compared to our guideline.

CONCLUSIONS

Idle days are common. Central line days may be reduced by the consistent daily reevaluation of a line's justification using defined criteria. The practice of routine central line placement for prolonged antibiotics and the inclusion of SIRS criteria to justify the line may need to be reevaluated. Journal of Hospital Medicine 2016;11:489-493. © 2016 Society of Hospital Medicine.

Limiting the Number of Lumens in Peripherally Inserted Central Catheters to Improve Outcomes and Reduce Cost: A Simulation Study

BACKGROUND

The number of peripherally inserted central catheter (PICC) lumens is associated with thrombotic and infectious complications. Because multilumen PICCs are not necessary in all patients, policies that limit their use may improve safety and cost.

OBJECTIVE

To design a simulation-based analysis to estimate outcomes and cost associated with a policy that encourages single-lumen PICC use.

METHODS

Model inputs, including risk of complications and costs associated with single- and multilumen PICCs, were obtained from available literature and a multihospital collaborative quality improvement project. Cost savings and reduction in central line–associated bloodstream infection and deep vein thrombosis events from institution of a single-lumen PICC default policy were reported.

RESULTS

According to our model, a hospital that places 1,000 PICCs per year (25% of which are single-lumen and 75% multilumen) experiences annual PICC-related maintenance and complication costs of $1,228,598 (95% CI, $1,053,175–$1,430,958). In such facilities, every 5% increase in single-lumen PICC use would prevent 0.5 PICC-related central line-associated bloodstream infections and 0.5 PICC-related deep vein thrombosis events, while saving $23,500. Moving from 25% to 50% single-lumen PICC utilization would result in total savings of $119,283 (95% CI, $74,030–$184,170) per year. Regardless of baseline prevalence, a single-lumen default PICC policy would be associated with approximately 10% cost savings. Findings remained robust in multiway sensitivity analyses.

CONCLUSION

Hospital policies that limit the number of PICC lumens may enhance patient safety and reduce healthcare costs. Studies measuring intended and unintended consequences of this approach, followed by rapid adoption, appear necessary.

Infect Control Hosp Epidemiol 2016;37:811–817

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.

Do clinicians know which of their patients have central venous catheters?: a multicenter observational study

BACKGROUND

Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown.

OBJECTIVE

To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients.

DESIGN

Multicenter, cross-sectional study.

SETTING

3 academic medical centers in the United States.

PATIENTS

Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings.

MEASUREMENTS

To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests.

RESULTS

990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003).

LIMITATIONS

Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded.

CONCLUSION

Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted.

PRIMARY FUNDING SOURCE

None.

Peripherally inserted central catheter-related deep vein thrombosis: contemporary patterns and predictors

BACKGROUND

Despite growing use, peripherally inserted central catheters (PICCs) are associated with risk of deep vein thrombosis (DVT). We designed a study to determine patient, provider and device factors associated with this outcome.

METHODS

This was a retrospective cohort study of adults who underwent PICC placement between 1 June 2009 to 30 June 2012. Symptomatic PICC-associated DVT was confirmed by ultrasound. Because PICCs are also recognized risk factors for lower-extremity DVT, lower-extremity DVT occurring while the PICC was in situ was included. Multivariable logistic and Cox-proportional hazards regression models were fit to examine the association between covariates specified a priori and PICC-DVT. Odds ratios (ORs) and hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were generated.

RESULTS

Of 966 unique PICC placements, 33 patients developed symptomatic PICC-associated DVT and 9 developed lower-extremity DVT, accounting for 42 thrombotic events. On bivariate analysis, recent diagnosis of cancer, interventional radiology placement, chemotherapy administration, number of lumens and PICC-gauge were associated with PICC-DVT. Following multivariable adjustment, recent cancer diagnosis (OR 1.95 [95% CI 1.01-3.76]) and PICC gauge (HR 2.21 [95%CI 1.04-4.70] and HR 3.56 [95%CI 1.31-9.66] for 5-Fr and 6-Fr PICCs, respectively) remained associated with thrombosis.

CONCLUSIONS

Recent diagnosis of cancer and PICC gauge are associated with PICC-DVT. These findings have important clinical ramifications and suggest that placement of large gauge PICCs or PICCs in patients with cancer may provoke thrombosis. Improved policies and procedural oversights in these areas appear necessary to prevent PICC-DVT.