What’s New in the Patient Safety World
December 2014
Surprise Central Lines
One of our earliest Patient Safety Tips of the Week was our May 8, 2007 column “Doctor, when do I get this red rubber hose removed?”. In that column we related how embarrassed we were as a young physician when a patient asked that question as we were providing discharge instructions to her. That led us to one of our first patient safety projects in the early 1990’s to reduce the unnecessary use of urinary catheters. Of course, the most important intervention to avoid CAUTI’s is to avoid such catheters in the first place and limit duration of catheters in those patients who do have a legitimate initial indication for one. We were amazed at how often the Foley catheter appears unbeknownst to the primary physician responsible for the patient’s care and how often they are placed without legitimate medical indication.
The same obviously applies to indwelling catheters in any area of the body. The great work done by Peter Pronovost and colleagues on prevention of CLABSI’s emphasized careful attention not just to insertion and maintenance of central lines but also to the issue of indications or continued indications for the central lines.
Now a new study
assessed how often clinicians are unaware of central venous catheters, both
traditional triple-lumen catheters and PICC (peripherally inserted
central catheter) lines, at 3 academic
medical centers (Chopra
2014). In almost 1000 patients the prevalence of a triple-lumen central
venous catheter or PICC line was 21.1% (60% if these were PICC’s). Clinicians
responsible for care of those patients were unaware of the presence of these
catheters in 21.2% of cases. Such unawareness was more common for PICC lines
and more common in non-ICU settings. Teaching attendings
and hospitalists were more often unaware than were housestaff
or physician extenders.
Our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” focused on the widespread use of PICC lines and the general lack of awareness by clinicians of their potential complications. Previous work by Chopra and colleagues as well as others has shown potential complications of PICC lines are at least as frequent as and probably more frequent than those from more traditional central lines. Complications include CLABSI’s, deep vein thrombosis, catheter tip malpositioning, thrombophlebitis, and catheter dysfunction. Both patient-related and device-related factors are important in leading to complications of central lines and PICC lines. But it is clear that the duration of catheter use is an important factor in leading to complications and that many times the catheters are left in place longer than necessary.
One of the most important interventions in prevention of
CLABSI’s (or, for that matter, infection of any indwelling device) is asking on
a daily basis whether the catheter is still necessary. With PICC’s we often
forget to do that, particularly when the patient is not in the ICU. In that January 21, 2014 Patient Safety Tip of the
Week “The
PICC Myth” we noted a study by Tejedor and
colleagues (Tejedor
2012) looking at how often central venous catheters and PICC lines
were retained when not needed ("idle days") on non-ICU wards. They
found that significant proportions of ward central line days were
unjustified. Patients with PICCs had
more days in which the only justification for the CVC was intravenous
administration of antimicrobial agents. They suggest that reducing "idle
CVC-days" and facilitating the appropriate use of peripheral IV’s may
reduce central line days and CLABSI risk.
Also in that January
21, 2014 Patient Safety Tip of the Week “The
PICC Myth” we stressed how our systems make it very easy for a patient to
get a PICC line, often for reasons of staff convenience rather than for
evidence-based indications. Sometimes they are ordered at night by a
cross-covering physician. And since most PICC lines are inserted by specially
trained nurses, most physicians are not involved in insertion of the PICC. So
it’s fairly easy to be unaware of a PICC line. We’re not at all surprised by
the findings of the current Chopra study.
The editorial accompanying the Chopra study (Taichman 2014) questions that, if we are not seeing catheters when we round on our patients daily, “what else are we missing?”. Is it that we are doing perfunctory exams on such rounds or not even doing that? Are we missing things like early decubiti?
The bottom line is
that we are all human and we tend to look for things we expect or things we are
trying to avoid. If we are not expecting our patient to have a central line or
PICC line we may easily overlook its presence when we are rounding. This might
even be another example of “inattentional blindness”.
Therefore, we need
to include such oversight as another example of a predictable error and
put systems in place to help us avoid the problem. One of the items on our
checklist for daily rounds on patients in all locations should be “Does this
patient have any catheters or lines in place and, if so, are they still necessary?”
Use of such lines should be evidence-based where possible. Alert fatigue aside,
we also recommend that flags be set in the electronic medical record (EMR) to
highlight for the clinician that such catheters are in place and need to be
reviewed for continuation on a daily basis.
See also our updates on
central venous catheters and PICC lines:
October 2015 “Michigan
Appropriateness Guide for Intravenous Catheters”
References:
Chopra V, Govindan S, Kuhn L, et al. Do Clinicians Know Which of Their Patients Have Central Venous Catheters?: A Multicenter Observational Study. Ann Intern Med 2014; 161(8): 562-567
http://annals.org/article.aspx?articleid=1916822
Tejedor SC, Tong D, Stein J, et al. Temporary central venous catheter utilization patterns in a large tertiary care center: Tracking the "Idle central venous catheter". Infection Control and Hospital Epidemiology 2012; 33(1): 50-57
Taichman DB. Whose Line Is It Anyway? Ann Intern Med 2014; 161(8): 607-608
http://annals.org/article.aspx?articleid=1916831
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