In our January 21, 2014 Patient Safety Tip of the Week “The PICC Myth” we challenged the view widely held by clinicians that PICC (peripherally inserted central catheter) lines are safer than the more traditional central lines. The potential complications of PICC lines are at least as frequent as and probably more frequent than those from more traditional central lines. True, the most feared complications of those central line insertions (pneumothorax for the subclavian line, carotid arterial puncture for the jugular line) are not seen with PICC insertions but a host of serious potential complications are associated with PICC’s. We noted studies done by Chopra and colleagues (Chopra 2013a) that showed PICCs were associated with a more than two-fold increased risk of deep vein thrombosis. (OR 2.55) and another (Chopra 2013b) that found no significant difference in CLABSI rate between the CVC and PICC groups.
Now yet another study from Chopra and colleagues (Chopra 2014) has characterized some of the factors associated with PICC-associated bloodstream infections. They retrospectively reviewed data on 966 PICC lines in 747 patients over a 3-year period. The indications for PICC insertion were: long-term antibiotic administration (52%), venous access (21%), total parenteral nutrition (16%), and chemotherapy (11%).
Overall, 6% of PICC lines were associated with bloodstream infection, with an infection rate of 2.16 per 1000 catheter days. The median time to infection was 10 days.
While multiple factors correlated with bloodstream infection on bivariate analysis, only hospital length of stay, ICU status, and number of PICC lumens remained significantly associated with PICC bloodstream infection on multivariable analysis. Most notably the hazard ratio for bloodstream infections increased over 4 times with double lumen catheters and over 8 times with triple lumen catheters.
The authors also found a significant association between time to infection and the number of catheter lumens, i.e. the higher the number of lumens the shorter the time to infection.
The authors question the use of PICC lines at all in critically ill or immune-suppressed patients. The authors suggest potential approaches to limit use of multiple lumen catheters, such as limiting their availability or enhancing the physician decision making process for these. They also strongly recommend use of interventions to limit the duration of PICC lines, such as reminders, automatic stop orders, electronic surveillance for PICC presence, etc.
Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. The Lancet 2013; 382(9889): 311-325
Chopra V, O'Horo JC, Rogers MA, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2013; 34(9): 908-918
Chopra V, Ratz D, Kuhn L, et al. PICC-associated Bloodstream Infections: Prevalence, Patterns, and Predictors. American Journal of Medicine 2014; 127(4): 319–328
Another of our favorite soapbox topics: we focus on the wrong things preoperatively. For many years (see our August 17, 2010 Patient Safety Tip of the Week “”) we have recommended the need for more focus on three things that impact surgical outcomes significantly: obstructive sleep apnea, delirium, and frailty. Frailty, in particular, has been associated with a variety of undesirable post-surgical outcomes (see the list of our prior columns at the end of today’s column).
Yet another new study (Kim 2014) demonstrates that a multidimensional frailty score can predict postoperative mortality risk in elderly patients undergoing surgery. The researchers used their own frailty tool, based on subsets of the Comprehensive Geriatric Assessment (CGA), in patients aged 65 and older who were undergoing intermediate- or high-risk elective surgery. Their scoring tool (referred to as the Multidimensional Frailty Score or MFS) used malignant disease, the Charlson Comorbidity Index, dependence in activities of daily living, dependence in instrumental activities of daily living, dementia, risk of delirium, short midarm circumference, and malnutrition risk as variables.
The key findings were that the MFS score was predictive of 1-year all-cause mortality, length of hospital stay, and likelihood of discharge to a nursing facility or long-term care facility. And the higher the MFS score, the greater the likelihood of mortality.
Technically, the Kim study did not demonstrate a statistically significant association between frailty and specific surgical complications (as opposed to mortality, length of stay and discharge to a nursing home or long-term care facility). But that was likely because the study was underpowered to show such association.
Most importantly, their MFS score was considerably better than the time-honored ASA (American Society of Anesthesiologists) score at predicting these unfavorable outcomes.
This study adds to the many studies we’ve discussed in past columns demonstrating the link between frailty and unfavorable surgical outcomes. While we have our doubts that surgeons or primary care physicians will perform a full comprehensive geriatric assessment preoperatively, don’t forget that there are numerous shorter assessments of frailty (eg. the timed up-and-go test) that are very useful.
Some of our prior columns on preoperative assessment and frailty:
Kim S, Han J, Jung H, et al. Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surg 2014; Published online May 07, 2014. doi:10.1001/jamasurg.2014.241
Epidural steroids are still widely used for treatment in patients with low back pain despite conflicting evidence on their efficacy and fact that they are not FDA-approved for that indication.
While questions about efficacy have always existed, most have had little concern about the safety of epidural steroids. Then in 2012 and 2013 there was the infamous multistate outbreak of fungal meningitis and other infections among patients who received contaminated preservative-free steroid injections from a Massachusetts compounding pharmacy. While infections from those affected any space into which the contaminated steroids were injected, many such cases involved fungal meningitis, epidural abscess, arachnoiditis and other localized spinal or paraspinal infections following epidural steroid injection.
Now the FDA has just issued a warning about other potential complications of epidural spinal injections (FDA 2014), unrelated to the above outbreak. The FDA is requiring a warning on the drug labels of injectable corticosteroids to indicate the risk for serious adverse effects including loss of vision, cortical blindness, spinal cord infarction, paraplegia, quadriplegia, stroke, seizures, nerve injury, cerebral edema, and death. The FDA identified such complications from their FDA Adverse Event Reporting System (FAERS) and review of the literature. In many cases the adverse neurological event followed the epidural injection within minutes to 48 hours. They provide an excellent bibliography of 17 articles on complications of epidural steroid injections.
The FDA further plans to convene an Advisory Committee meeting of external experts in late 2014 to discuss the benefits and risks of epidural corticosteroid injections and to determine if further FDA actions are needed.
FDA. FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain. FDA Safety Announcement April 23, 2014
The most common cause of gait instability in the elderly is the “multiple sensory deficit” syndrome. That means that disturbances of proprioception, vision, vestibular function, and maybe even hearing, each of which may not be enough to affect gait become severe enough collectively to affect gait. So, as a neurologist, we are often recommending to our patients with gait disturbances that they get their vision corrected.
But in our June 2010 What’s New in the Patient Safety World column “Seeing Clearly a Common Sense Intervention” we noted that sometimes new glasses may paradoxically result in increased falls.
Recently we came across an outstanding paper in the optometry literature (Elliott 2014) that nicely summarizes the physiological links between vision and gait, the epidemiology of falls and vision disturbances, and the evidence base linking falls to changes in patients’ corrective lenses.
The author notes that 57% of falls in older adults are due to trips, slips, and stumbles and that steps, stairs and curbs are the most common environmental hazards contributing to falls. He also notes that falls with injury are 3 times more likely when descending stairs compared to ascending them. He goes on to describe how corrections to vision that involve magnification and/or changes in astigmatism may affect their function during such activities as descending stairs.
Elliott describes the literature linking visual impairment to falls and notes this is likely an underestimate. But he then goes on to describe the literature on the impact of optometric interventions and/or cataract surgery on the fall rate. One of the most striking studies cited was a randomized controlled trial (RCT) in which community-dwelling patients aged 70 and older were given an optometric intervention (most often new glasses) compared to those receiving just usual care (Cumming 2007). Surprisingly, the fall rate was higher in the intervention group in the first year (65% vs. 50%).
Elliott also notes the literature on the relationship between bifocals and progressive lenses and falls (see also our June 2010 What’s New in the Patient Safety World column “Seeing Clearly a Common Sense Intervention” regarding bifocals).
Elliott concludes with several practical recommendations for optometrists:
We don’t expect that you’ll read through all the optometric details in the paper. But you should be cognizant of the practical recommendations in the paper to be conservative with any changes made to correct your patients’ vision. We’d actually go as far as recommending that, for your patients who have multiple fall risk factors, you provide them a copy of this paper to take with them to their ophthalmologist or optometrist visit!
Elliott DB. The Glenn A. Fry Award Lecture 2013: Blurred Vision, Spectacle Correction, and Falls in Older Adults. Optometry & Vision Science 2014; 91(6): 593-601
Cumming RG, Ivers R, Clemson L, Cullen J, Hayes MF, Tanzer M, Mitchell P . Improving vision to prevent falls in frail older people: a randomized trial. J Am Geriatr Soc. 2007; 55: 175–81
The Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA) and other collaborators have just released the SHEA/IDSA Practice Recommendations for prevention of CAUTI (catheter-associated urinary tract infections), SSI’s (surgical site infections), and C. diff infections. These are updates of previous recommendations that were published in 2008. Each has an extensive bibliography with links you can click on to take you to most of the source articles.
You’ll find these updates to be evidence-based, comprehensive, and practical.
Lo E, Nicolle LE, Coffin SE, et al. Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology 2014; 35(5): 464-479 May 2014
Anderson D, Podgornny K, Berrios-Torres S, et al. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology 2014; 35(6): 605-627 (June 2014) electronically published May 5, 2014
Dubberke ER, Carling P, Carrico R, et al. Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update
Infection Control and Hospital Epidemiology 2014; 35(6): 628-645 (June 2014) electronically published May 5, 2014