Use of Peripherally Inserted Central Catheters in Patients With Advanced Chronic Kidney Disease: A Prospective Cohort Study

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.

A decision-making algorithm proposal for PICCs and midlines insertion in patients with advanced kidney disease: A pilot study

INTRODUCTION

Kidney Disease Outcomes Quality Initiative clinical practice guidelines recommend avoiding placement of peripherally inserted vascular access devices in patients with an estimated glomerular filtration rate (eGFR) <45 ml/min. On the other hand, many patients with severe chronic kidney disease (CKD) have poor prognosis.This study carried out a global assessment of mortality at 2 years through Charlson Comorbidity Index (CCI) and Beclap score in patients with PICCs or Midlines, assuming that in those with an estimated high mortality rate at 2 years, it could be acceptable to implant a peripheral vascular access device (PVAD) despite the presence of CKD.

METHODS

We analyzed data on patients with PICCs or Midlines inserted from October 2018 to November 2019. CCI, Beclap score, and eGFR were calculated for each patient at the time of the catheter insertion. We then followed patients for 2 years to assess 2-year mortality for each.

RESULTS

One hundred and thirty-one patients were enrolled, 49 (37.4%) had eGFR<45 ml. The 2-year mortality rate was 57.3%. The cut off derived from ROC curve analysis of 15 for Beclap score and 5 for CCI, showed good sensitivity and specificity in predicting mortality of the total population, patients without an oncological disease and patients with eGFR<45 ml/min.

CONCLUSION

CCI and Beclap score are good predictors of mortality at 2 years.Physicians and nurses can use these tools in the evaluation of patients at risk for future dialysis, instead of relying exclusively on renal function to decide whether implanting PICCs, Midlines, or other vascular access devices.

PICC insertion and veins of the arm size variation during dialysis treatment: A prospective observational study

BACKGROUND

Peripherally Inserted Central Catheters play an increasingly important role in Central Venous Access Devices. However, the use of these devices should be carefully considered in specific situations such as central catheterisation in patients with chronic kidney disease. When evaluating the feasibility of placement for a patient undergoing dialysis, the relationship between changes in circulating volume before and after dialysis treatment, and potential variations in the size of deep veins in the upper limbs, should be considered.

MATERIALS

Upper limb veins, specifically the basilic or brachial veins, were identified and measured before and after dialysis treatment. Patient data and weight loss data during dialysis treatment were also collected. Linear regression analysis was performed to assess the correlation between the variables.

RESULTS

The average variation in vein size for the entire sample was +0.17 ± 0.43 mm. The mean volume removed was 2.2 ± 0.8 l. In subgroup 1 (fluid volume loss <2000 ml), the population experienced a decrease in the measured vein size after dialysis. In subgroup 2 (fluid volume loss ⩾2000 ml), the population experienced an increase in the measured vein size after dialysis.

CONCLUSIONS

Upper arm vascular access placement in dialysed patients with fluid removal of less than 2000 ml should be performed after the dialysis session. Conversely, in dialysed patients with fluid removal of more than 2000 ml, where a significant increase in vein size was observed, vascular access placement should be performed before the dialysis session when the veins are smaller. Additionally, it should be noted that in patients with chronic kidney disease, the venous system of the upper limbs should be preserved as much as possible to prevent thrombosis and stenosis in potential arteriovenous fistula creation.

Efficacy of antimicrobial peripherally inserted central catheters in line-associated bloodstream infections: A systematic review and meta-analysis

BACKGROUND

Several studies have investigated the safety and efficacy of antimicrobial peripherally inserted central catheters (PICCs), and the results are conflicting. Therefore, in this systematic review and meta-analysis, we aimed to summarize and identify the effect of antimicrobial PICCs on central line-associated bloodstream infection (CLABSI) risk.

METHODS

A systematic search of PubMed, Ovid MEDLINE, Ovid Embase, and Web of Science was performed to identify relevant studies up to December 2022.

RESULTS

A total of 9 studies were included for analysis. There were 7 retrospective/prospective cohort studies and 2 randomized controlled trials. The 9 studies involved 51,373 patients with PICCs. Among these patients, 6,563 (12.8%) antimicrobial-coated/impregnated PICCs and 44,810 (87.2%) nonantimicrobial-impregnated PICCs were inserted. The meta-analysis showed that antimicrobial PICCs had a nonsignificant association with lower CLABSI risk compared with noncoated PICCs (relative risk [RR] = 0.67; 95% CI, 0.43-1.05). In the subgroup analysis, minocycline-rifampin-(RR = 0.30; 95% CI, 0.19-0.49) or chlorhexidine-coated (RR = 0.61; 95% CI, 0.04-8.55) PICCs showed an association with reduced risk of CLABSI. In the adult population, antimicrobial PICCs had a nonsignificant association with lower CLABSI risk (RR = 0.50; 95% CI, 0.20-1.22).

CONCLUSIONS

This systematic review and meta-analysis suggested that antimicrobial PICCs had a nonsignificant association with lower CLABSI risk compared with noncoated PICCs. Minocycline-rifampin-or chlorhexidine-coated PICCs showed an association with reduced risk of CLABSI.

Midline catheters in patients with advanced chronic kidney disease

BACKGROUND

Midline catheters (midlines) are increasingly used in patients with advanced chronic kidney disease (CKD).

OBJECTIVE

This study describes current practice and acute complications associated with midlines in CKD patients.

DESIGNS, SETTING, AND PARTICIPANTS

Trained abstractors at 66 hospitals from the Michigan Hospital Medicine Safety (HMS) Consortium collected data on a sample of patients who received a midline during hospitalization. Patients were classified as having advanced CKD if their estimated glomerular filtration rate was <45 mL/min/1.73 m2 .

MAIN OUTCOME AND MEASURES

Midline recipients with advanced CKD were compared to those without advanced CKD by patient, provider, and device characteristics, and by the occurrence of acute complications including major (e.g., upper extremity deep vein thrombosis [UE-DVT] and catheter-related bloodstream infection [CRBSI]) or minor (e.g., catheter occlusion, catheter dislodgement, infiltration, superficial thrombophlebitis, and leaking at insertion site) events. Multivariable mixed effects logistic regression was used to evaluate the association between catheter-related complications and stage of CKD.

RESULTS

Of 21,415 midline recipients, 5272 (24.6%) had advanced CKD, while 16,143 (75.4%) did not. Most midlines were single lumen (90.5%) and remained in place for a median of 6 days. A major or minor midline complication occurred in 804 (15.3%) patients with and 2239 (14.4%) patients without advanced CKD (adjusted odds ratios = 1.04; 95% confidence interval: 0.94-1.14). Among patients with advanced CKD, CRBSI occurred in 13 patients (0.2%) and UE-DVT occurred in 65 patients (1.2%). The proportion of advanced CKD among midline recipients and the frequency of midline-related complications varied across hospitals (interquartile range [IQR] = 19.2% to 29.8% [median = 25.0%] and IQR = 11.0%-18.9% [median = 15.4%], respectively).

The Association of Vasopressor Administration through a Midline Catheter with Catheter-related Complications

Rationale: Little is known about the safety of infusing vasopressors through a midline catheter. Objectives: To evaluate safety outcomes after vasopressor administration through a midline. Methods: We conducted a cohort study of adults admitted to 39 hospitals in Michigan (December 2017-March 2022) who received vasopressors while either a midline or peripherally inserted central catheter (PICC) was in place. Patients receiving vasopressors through a midline were compared with those receiving vasopressors through a PICC and, separately, to those with midlines in place but who received vasopressors through a different catheter. We used descriptive statistics to characterize and compare cohort characteristics. Multivariable mixed effects logistic regression models were fit to determine the association between vasopressor administration through a midline with outcomes, primarily catheter-related complications (bloodstream infection, superficial thrombophlebitis, exit site infection, or catheter occlusion). Results: Our cohort included 287 patients with midlines through which vasopressors were administered, 1,660 with PICCs through which vasopressors were administered, and 884 patients with midlines who received vasopressors through a separate catheter. Age (median [interquartile range]: 68.7 [58.6-75.7], 66.6 [57.1-75.0], and 67.6 [58.7-75.8] yr) and gender (percentage female: 50.5%, 47.3%, and 43.8%) were similar in all groups. The frequency of catheter-related complications was lower in patients with midlines used for vasopressors than PICCs used for vasopressors (5.2% vs. 13.4%; P < 0.001) but similar to midlines with vasopressor administration through a different device (5.2% vs. 6.3%; P = 0.49). After adjustment, administration of vasopressors through a midline was not associated with catheter-related complications compared with PICCs with vasopressors (adjusted odds ratios [aOR], 0.65 [95% confidence interval, 0.31-1.33]; P = 0.23) or midlines with vasopressors elsewhere (aOR, 0.85 [0.46-1.58]; P = 0.59). Midlines used for vasopressors were associated with greater risk of systemic thromboembolism (vs. PICCs with vasopressors: aOR, 2.69 [1.31-5.49]; P = 0.008; vs. midlines with vasopressors elsewhere: aOR, 2.42 [1.29-4.54]; P = 0.008) but not thromboses restricted to the ipsilateral upper extremity (vs. PICCs with vasopressors: aOR, 2.35 [0.83-6.63]; P = 0.10; model did not converge for vs. midlines with vasopressors elsewhere). Conclusions: We found no significant association of vasopressor administration through a midline with catheter-related complications. However, we identified increased odds of systemic (but not ipsilateral upper extremity) venous thromboembolism warranting further evaluation.

Asia-Pacific guidelines for standardization of appropriate selection, placement, and management of vascular access devices

Vascular access devices (VADs) are common and essential in the healthcare setting. However, several factors influence VAD selection and management. Wide variations in VAD practices and the degree of VAD awareness are noted across Asia-Pacific (APAC) countries. An international panel was convened that applied the ASA 2020 method to develop standard criteria for use of VADs in the APAC region. After a literature search, scenarios related to VAD use, care, and maintenance were developed according to the patient population, indication for insertion, and duration of use. These scenarios were rated on a scale of 1-5 (1 being strongly disagreed and 5 strongly agreed) by 11 expert members. A total of 48 clinical scenarios were developed: 23 in hospitalized patients, 3 in critical patients, 4 in cancer settings, 7 pertinent to VAD placement, and 11 for VAD maintenance. The multidisciplinary panel generated several recommendations for the use, care, and management of VADs across general hospitalized patients with or without difficult venous access, critically ill patients, patients with malignancy, patients with different stages of chronic kidney disease (CKD) with or without dialysis, and in other special populations through evidence-based standards. These recommendations may help in achieving uniformity in practice patterns and improving the quality of VAD care and quality of life of patients in APAC region.

Peripheral central catheter insertion in low eGFR patients: Retrospective single institution study

PURPOSE

To identify the rate of Peripherally Inserted Central Catheter (PICC) placement in patients with chronic kidney disease (CKD), stage 3B or higher (glomerular filtration rate (eGFR) <45 mL/min/1.73 m²).

MATERIAL AND METHODS

A retrospective study of 2825 adult patients (male 51.2%, female 48.8%) who had a PICC insertion from January 2017 to December 2019. The data collected includes gender, eGFR value at the date of insertion, accessed vein and side, ongoing or subsequent dialysis within 1 year, and death within 1 year of the insertion date. The study excluded pediatric patients, patients with missing eGFR values prior to the procedure and follow-up information.

RESULT

PICC insertion was done in patients with eGFR⩽45 mL/min/1.73 m² in 26.7% (724/2709) of the sample. Ongoing dialysis was documented in 10.2% (198/1946) and subsequent dialysis in 6.5% of the patients within the year after insertion. The overall death rate for the year post PICC insertion was 38.7% (1094/2825), which was significantly higher in low eGFR patients (413/724, 57%) compared to patients with eGFR>45 mL/min/1.73 m² (632/1985, 31.8%) (p-value < 0.0001, odds ratio 2.84 (95% confidence interval 2.38-3.38)). The rate of dialysis initiated in the year post PICC insertion was 5.9% (98/1657). This was significantly higher in patients with a low eGFR and not previously dialyzed (59/310, 19%) compared to patients with eGFR>45 who required dialysis in the year post insertion (39/1347, 2.9%) (p < 0.0001, odds ratio 7.88 (95% confidence interval 5.14-12.07)).

CONCLUSION

PICC insertion in patients with CKD is practiced frequently. Rigorous strategies should be implemented to improve adherence to clinical practice guidelines and reduce unnecessary insertions and preserve veins for when an AVF may be required.

Barriers and facilitators for implementing peripherally inserted central catheter (PICC) appropriateness guidelines: A longitudinal survey study from 34 Michigan hospitals

Peripherally inserted central catheters (PICCs) are prevalent devices for medium-to-long-term intravenous therapy but are often associated with morbid and potentially lethal complications. This multi-center study sought to identify barriers and facilitators of implementing evidence-based appropriateness criteria to improve PICC safety and patient outcomes in a pay-for-performance model. Participating hospitals received an online toolkit with five recommendations: establishing a vascular access committee; implementing a clinical decision tool for PICC appropriateness; avoiding short-term PICC use (≤5 days); increasing use of single-lumen PICCs; and avoiding PICC placement in patients with chronic kidney disease. Longitudinal online surveys conducted biannually October 2014–November 2018 tracked implementation efforts. A total of 306 unique surveys from 34 hospitals were completed. The proportion of hospitals with a dedicated committee overseeing PICC appropriateness increased from 53% to 97%. Overall, 94% of hospitals implemented an initiative to reduce short-term and multi-lumen PICC use, and 91% integrated kidney function into PICC placement decisions. Barriers to implementation included: achieving agreement from diverse disciplines, competing hospital priorities, and delays in modifying electronic systems to enable appropriate PICC ordering. Provision of quarterly benchmarking reports, a decision algorithm, access to an online toolkit, and presence of local champion support were cited as crucial in improving practice. Structured quality improvement efforts including a multidisciplinary vascular access committee, clear targets, local champions, and support from an online education toolkit have led to sustained PICC appropriateness and improved patient safety.

Safety and Outcomes of Midline Catheters vs Peripherally Inserted Central Catheters for Patients With Short-term Indications: A Multicenter Study

IMPORTANCE

Peripherally inserted central catheters (PICCs) and midlines are frequently used for short-term venous access; whether one is safer than the other in this setting has not been adequately reported.

OBJECTIVE

To compare outcomes between patients who had a PICC vs midline placed for the indication of difficult vascular access or antibiotic therapy for 30 or fewer days.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed data from a multihospital registry including patients admitted to a participating site from December 2017 through January 2020 who had a PICC or midline placement for the indications of difficult venous access or intravenous antibiotic therapy prescribed for 30 or fewer days. Data were analyzed from October 2020 to March 2021.

EXPOSURES

PICC and midline placement.

MAIN OUTCOMES AND MEASURES

Major complications, including a composite of symptomatic catheter-associated deep vein thrombosis (DVT), catheter-related bloodstream infection, and catheter occlusion. Logistic regression and Cox proportional hazards regression models (taking into account catheter dwell) were used to estimate risk for major complications, adjusting for patient and device characteristics and the clustered nature of the data. Sensitivity analyses limiting analyses to 10 days of device dwell were performed.

RESULTS

Data on 10 863 patients, 5758 with PICCs and 5105 with midlines (median [IQR] age of device recipients, 64.8 [53.4-75.4] years; 5741 [52.8%] were female), were included. After adjusting for patient characteristics, comorbidities, catheter lumens, and dwell time in logit models, patients who received PICCs had a greater risk of developing a major complication compared with those who received midlines (odds ratio, 1.99; 95% CI, 1.61-2.47). Reduction in complications stemmed from lower rates of occlusion (2.1% vs 7.0%; P < .001) and bloodstream infection (0.4% vs 1.6%; P < .001) in midlines vs PICCs; no significant difference in the risk of DVT between PICCs and midlines was observed. In time-to-event models, similar outcomes for bloodstream infection and catheter occlusion were noted; however, the risk of DVT events was lower in patients who received PICCs vs midlines (hazard ratio, 0.53; 95% CI, 0.38-0.74). Results were robust to sensitivity analyses.

CONCLUSIONS AND RELEVANCE

In this cohort study among patients with placement of midline catheters vs PICCs for short-term indications, midlines were associated with a lower risk of bloodstream infection and occlusion compared with PICCs. Whether DVT risk is similar or greater with midlines compared with PICCs for short-term use is unclear. Randomized clinical trials comparing these devices for this indication are needed.

Comparing peripherally inserted central catheter-related practices across hospitals with different insertion models: a multisite qualitative study

BACKGROUND

Peripherally inserted central catheters (PICCs) provide reliable intravenous access for delivery of parenteral therapy. Yet, little is known about PICC care practices or how they vary across hospitals. We compared PICC-related processes across hospitals with different insertion delivery models.

METHODS

We used a descriptive qualitative methodology and a naturalist philosophy, with site visits to conduct semistructured interviews completed between August 2018 and January 2019. Study sites included five Veterans Affairs Medical Centres, two with vascular access teams (VATs), two with PICC insertion primarily by interventional radiology (IR) and one without on-site PICC insertion capability. Interview participants were healthcare personnel (n=56), including physicians, bedside and vascular access nurses, and IR clinicians. Data collection focused on four PICC domains: use and decision-making process, insertion, in-hospital management and patient discharge education. We used rapid analysis and a summary matrix to compare practices across sites within each domain.

RESULTS

Our findings highlight the benefits of dedicated VATs across all PICC-related process domains, including implementation of criteria to guide PICC placement decisions, timely PICC insertion, more robust management practices and well-defined patient discharge education. We also found areas with potential for improvement, such as clinician awareness of PICC appropriateness criteria and alternative devices, deployment of VATs and patient discharge education.

CONCLUSION

Vascular access nurses play critical roles in all aspects of PICC-related care. There is variation in PICC decision-making, care and maintenance, and patient education across hospitals. Quality and safety improvement opportunities to reduce this variation are highlighted.

Associations of frontal QRS-T angle with left ventricular volume and function derived from ECG-gated SPECT in patients with advanced chronic kidney disease

BACKGROUND

The frontal QRS-T angle is one of markers of ventricular repolarization. We investigated whether or not the frontal QRS-T angle could predict left ventricular (LV) volume and function derived from ECG-gated SPECT in patients with advanced chronic kidney disease (CKD).

METHODS

Two hundred and twelve patients with advanced CKD defined as estimated glomerular filtration rate of < 45 ml min-1/1.73 m2 were enrolled. Wide QRS-T angle was defined as its angle of > 90°, and was considered abnormal. Enlarged LV end-diastolic volume (LVEDV) was defined as LVEDV index of > 76 ml m-2 in men and > 57 ml m-2 in women. Reduced LV ejection fraction (LVEF) was defined as LVEF of < 40%.

RESULTS

Fifty-one patients (24%) had wide QRS-T angle, and 161 patients (76%) had normal QRS-T angle. Patients with wide QRS-T angle had larger SSS [9 (5-16) vs 4 (1-9), p < 0.001], larger LVEDV index (69 ± 29 vs 50 ± 18 ml m-2, p < 0.001) and lower LVEF (47 ± 13 vs 59 ± 12%, p < 0.001) than those with normal QRS-T angle. Multivariate analysis showed that wide QRS-T angle (odds ratio 5.93; 95% CI 2.55-14.33; p < 0.001) was significantly associated with enlarged LVEDV, whereas SSS severity was not. Severely abnormal SSS (odds ratio 3.80; 95% CI 1.16-14.05; p < 0.03) and wide QRS-T angle (odds ratio 5.67; 95% CI 2.10-16.22; p < 0.001) were significantly associated with reduced LVEF.

CONCLUSIONS

Our results suggest that wide QRS-T angle is associated with LV remodeling such as enlarged LVEDV or reduced LVEF in patients with advanced CKD.

Effects of upright T-wave in lead aVR on left ventricular volume and function derived from ECG-gated SPECT in patients with advanced chronic kidney disease

BACKGROUND

Numerous studies have shown the association between chronic kidney disease (CKD) and adverse cardiac events. We investigated whether or not the upright T-wave in lead aVR (TaVR) could predict left ventricular (LV) volume and function derived from ECG-gated SPECT in patients with advanced CKD.

METHODS

Two hundred and sixty-one patients with advanced CKD [estimated glomerular filtration rate (eGFR) < 45 ml/min/1.73 m2] were enrolled. Upright TaVR was defined as a wave with a positive deflection of > 0 mV. Enlarged LV end-diastolic volume (LVEDV) was defined as LVEDV index of > 76 ml/m2 in men and > 57 ml/m2 in women. Reduced LV ejection fraction (LVEF) was defined as LVEF of < 40%.

RESULTS

Forty-six patients (18%) had upright TaVR, and 215 patients (82%) had negative TaVR. Summed redistribution score (SRS) [ 6 (1-12) vs. 2 (0-5), p < 0.001] and summed difference score (SDS) [4 (1-6) vs. 2 (0-4), p = 0.004] were significantly larger in patients with upright TaVR than those with negative TaVR. Patients with upright TaVR had larger LVEDV index (75 ± 33 ml/m2 vs. 50 ± 18 ml/m2, p < 0.001) and lower LVEF (43 ± 14% vs. 58 ± 11%, p < 0.001) compared to those with negative TaVR. After adjusted for other variables including SRS and SDS, upright TaVR remained a significant predictor of enlarged LVEDV (odds ratio 5.45; 95% CI 2.16-14.22; p < 0.001) and reduced LVEF (odds ratio 4.54; 95% CI 1.70-12.23; p = 0.003).

CONCLUSIONS

Our data suggested that upright TaVR could predict LV volume and function derived from ECG-gated SPECT in patients with advanced CKD.

Thermal Perception Abnormalities Can Predict Diabetic Kidney Disease in Type 2 Diabetes Mellitus Patients

BACKGROUND

Previous studies have illustrated clinical associations between diabetic peripheral neuropathy (DPN) and diabetic kidney disease (DKD). Quantitative sensory testing (QST) can accurately detect thermal perception abnormalities and aid in the early diagnosis of asymptomatic small-fiber DPN in patients with type 2 diabetes. The aim of this study was to determine the predictive value of thermal perception abnormalities by QST to detect DKD.

METHODS

We prospectively enrolled 432 patients with type 2 diabetes (50.2% male, mean age 57.2 years, and average duration of diabetes 9.9 years) at our hospital between 2016 and 2017. Demographic and clinical data of the patients were recorded and analyzed. Diagnosis and staging of DKD were determined by urinary albumin excretion rate and estimated glomerular filtration rate. The presence of thermal perception abnormalities was determined by QST. Multiple logistic regression and receiver operating characteristic (ROC) analyses were performed to investigate the relationships between thermal perception abnormalities and DKD in these patients.

RESULTS

In multiple regression analysis, abnormal cold perception in the lower limbs was associated with an increased risk of advanced DKD. Area under the ROC curve analysis revealed that four-limb cold perception abnormalities had the best discriminatory power (0.741 ± 0.053) to predict advanced DKD.

CONCLUSIONS

Our results demonstrate the value of using thermal perception abnormalities to identify patients with type 2 diabetes also at risk of DKD.

Safe use of Peripherally Inserted Central Catheters for chemotherapy of solid malignancies in adult patients: A 1-year monocentric, prospectively-assessed, unselected cohort of 482 patients

INTRODUCTION

Aim of this study was to analyze the overall complication and failure rates of Peripherally Inserted Central Catheters (PICCs), in a 1-year consecutive unselected cohort of 482 adult patients, affected by non-hematological malignancies undergoing chemotherapy.

METHODS

Adult outpatients (aged 18-75 years), with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2, bearing solid tumors and candidates for intravenous chemotherapy were eligible for the study. Exclusion criteria were active infections, coagulopathy (defined as platelet count <50,000/μL and/or prothrombin time more than 18 s), life expectancy <6 months, or inability to give written informed consent. Devices were all implanted in an outpatients' hospital facility, following predefined evidence-based institutional guidelines and protocols by a PICC-dedicated team at the European Institute of Oncology in Milan, Italy, during the 12-month period from January 1 to December 31, 2019.

RESULTS

Five-hundred PICCs were implanted in a cohort of 482 patients during the time interval of this study. Thirty devices were overall removed (6.2%), 23 as a consequence of a complication occurred, and seven inadvertently. The inserted PICCs accounted for a total of 49,718 catheter days in situ, median duration was 85.5 days [interquartile range (IQR): 56-146]. Overall there were 42 (8.7%) complications, corresponding to 0.84 catheter-adverse events (CAE)/1000 PICC-days (95% CI: 0.61-1.14). There were N = 13 (2.7%) thromboses, N = 11 (2.3%) irreversible occlusions, N = 7 (1.5%) accidental removals, N = 5 (1.0%) infections [two Catheter Related Blood Stream Infection (CRBSI) and three exit site/local infection], N = 3 (0.6%) ruptures and N = 3 (0.6%) primary or secondary malpositions.

CONCLUSION

This large prospective study supports the increasing use of PICCs in adult oncology outpatients treated in specialized centers with chemotherapy for non-hematological malignancies. In this clinical setting, PICC failure occurred in 6% only of the inserted devices.

Association of Infectious Disease Physician Approval of Peripherally Inserted Central Catheter With Appropriateness and Complications

IMPORTANCE

Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous antimicrobial therapy. However, inappropriate PICC use may lead to patient harm.

OBJECTIVE

To evaluate whether infectious disease physician approval prior to PICC placement for intravenous antimicrobials is associated with more appropriate device use and fewer complications.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 21 653 PICCs placed for a primary indication of intravenous antimicrobial therapy between January 1, 2015, and July 26, 2019, was conducted in 42 hospitals participating in a quality collaborative across Michigan among hospitalized medical patients.

MAIN OUTCOMES AND MEASURES

Appropriateness of PICCs was defined according to the Michigan Appropriateness Guide for Intravenous Catheters as a composite measure of (1) single-lumen catheter use, (2) avoiding use of PICCs for 5 days or less, and (3) avoiding use of PICCs for patients with chronic kidney disease (defined as an estimated glomerular filtration rate <45 mL/min/1.73 m2). Complications related to PICCs included catheter occlusion, deep vein thrombosis, and central line-associated bloodstream infection. The association between infectious disease physician approval, device appropriateness, and catheter complications was assessed using multivariable models, adjusted for patient comorbidities and hospital clustering. Results were expressed as odds ratios with 95% CIs.

RESULTS

A total of 21 653 PICCs were placed for intravenous antimicrobials (11 960 PICCs were placed in men [55.2%]; median age, 64.5 years [interquartile range, 53.4-75.4 years]); 10 238 PICCs (47.3%) were approved by an infectious disease physician prior to placement. Compared with PICCs with no documented approval, PICCs with approval by an infectious disease physician were more likely to be appropriately used (72.7% [7446 of 10 238] appropriate with approval vs 45.4% [5180 of 11 415] appropriate without approval; odds ratio, 3.53; 95% CI, 3.29-3.79; P < .001). Furthermore, approval was associated with lower odds of a PICC-related complication (6.5% [665 of 10 238] with approval vs 11.3% [1292 of 11 415] without approval; odds ratio, 0.55; 95% CI, 0.50-0.61).

CONCLUSIONS AND RELEVANCE

This cohort study suggests that, when PICCs were placed for intravenous antimicrobial therapy, infectious disease physician approval of PICC insertion was associated with more appropriate device use and fewer complications. Policies aimed at ensuring infectious disease physician approval prior to PICC placement for antimicrobials may improve patient safety.

Reducing Phlebotomy in Hemodialysis Patients: A Quality Improvement Study

Rationale & Objective

Hospitalized patients receiving hemodialysis frequently have routine, daily laboratory studies drawn by peripheral venipuncture-a painful process that damages peripheral veins that may be needed for future dialysis access. Some of these peripheral venipunctures are likely preventable by drawing blood samples off the hemodialysis machine circuit. We describe an initiative to allow and encourage blood to be drawn “with dialysis.”

Study Design

Quality improvement study.

Setting & Participants

Non–critically ill adult patients treated with hemodialysis at Stanford Health Care between September 2018 and September 2019.

Quality Improvement Activities

We modified the electronic health record to allow providers to order laboratory studies with the frequency “with dialysis.” Use of the “with dialysis” frequency was promoted through educational efforts aimed at primary medical teams, nephrology consult staff, and nephrology advanced practice providers.

Outcomes

We tracked the number of “with dialysis” blood draws and the number of eligible patients per week during the first year of implementation.

Analytical Approach

The number of “with dialysis” blood draws and eligible patients per week were measured over time. Cost savings were estimated by multiplying the difference in cost between peripheral venipuncture and “with dialysis” blood draw by the number of “with dialysis” blood draws performed.

Results

Uptake during the first year of implementation was an average of 6.3 “with dialysis” draws per 100 eligible patients per week. Estimated savings exceeded $7,000 in the first year of the program.

Limitations

Our single-center study may not be generalizable to other institutions, especially those without dialysis ordering and laboratory ordering housed within the same electronic system. We were unable to track additional outcomes, including the number of peripheral venipunctures and delays in laboratory results.

Conclusions

The prevention of unnecessary peripheral venipuncture in hospitalized patients receiving hemodialysis is a promising and valuable quality improvement target, which may be aided by the electronic health record. Future work is needed to increase recognition and use of “with dialysis”blood work options.

How ESKD complicates the management of diabetic foot ulcers: The vital role of the dialysis team in prevention, early detection, and support of multidisciplinary treatment to reduce lower extremity amputations

Diabetic foot ulcers do not heal as well in ESKD as in the absence of kidney failure, and rates of recurrent foot ulcers, as well as lower extremity amputation, are higher. This review of the literature highlights the vital role of the dialysis team in prevention, early detection, and support of treatment of diabetic foot ulcers. Our review has five goals-(a) increase nephrologists' understanding of the high morbidity and mortality associated with chronic foot ulcers and (lower extrimity) LE amputations in ESKD; (b) promote nephrologists' understanding of grading systems for diabetic foot ulcer severity, in order to expedite communication with local diabetic foot experts; (c) promote collaboration between nephrologists and infectious disease specialists regarding the dose, route, and delivery logistics of intravenous antibiotics for infected chronic foot ulcers, in particular in the presence of osteomyelitis and other deep-seated infections; (d) increase the awareness of dialysis nurses, technicians, dietitians, social workers and administrators regarding evidence-based and multidisciplinary approaches to patients' diabetic foot ulcers; (e) encourage the application of published works integrating patient-centered diabetic foot education into the dialysis setting to reduce lower extremity amputations.

Appropriateness of peripherally inserted central catheter use among general medical inpatients: an observational study using routinely collected data

Background

Peripherally inserted central catheters (PICC) are among the most commonly used medical devices in hospital. This study sought to determine the appropriateness of inpatient PICC use in general medicine at five academic hospitals in Toronto, Ontario, Canada, based on the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).

Methods

This was a retrospective, cross-sectional study of general internal medicine patients discharged between 1 April 2010 and 31 March 2015 who received a PICC during hospitalisation. The primary outcomes were the proportions of appropriate and inappropriate inpatient PICC use based on MAGIC recommendations. Hospital administrative data and electronic clinical data were used to determine appropriateness of each PICC placement. Multivariable regression models were fit to explore patient predictors of inappropriate use.

Results

Among 3479 PICC placements, 1848 (53%, 95% CI 51% to 55%) were appropriate, 573 (16%, 95% CI 15% to 18%) were inappropriate and 1058 (30%, 95% CI 29% to 32%) were of uncertain appropriateness. The proportion of appropriate and inappropriate PICCs ranged from 44% to 61% (p<0.001) and 13% to 21% (p<0.001) across hospitals, respectively. The most common reasons for inappropriate PICC use were placement in patients with advanced chronic kidney disease (n=500, 14%) and use for fewer than 15 days in patients who are critically ill (n=53), which represented 14% of all PICC placements in the intensive care unit. Patients who were older, female, had a Charlson Comorbidity Index score greater than 0 and more severe illness based on the Laboratory-based Acute Physiology Score were more likely to receive an inappropriate PICC.

Conclusions

Clinical practice recommendations can be operationalised into measurable domains to estimate the appropriateness of PICC insertions using routinely collected hospital data. Inappropriate PICC use was common and varied substantially across hospitals in this study, suggesting that there are important opportunities to improve care.