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 Vineet Chopra and colleagues at University of Michigan Health System 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 CLABSIs, 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. A subsequent study (Greene 2015) also showed an independent association between PICC lines and lower extremity venous thrombosis, though this association is much less pronounced than that for upper extremity venous thrombosis and cannot be definitely construed as causal. There may even be complications associated with removal of PICC lines, though the risk of air embolism is presumably less than that for removal of conventional central venous catheters (Dobson 2015).
It is also 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. But the initial decision to insert a PICC line (or, for that matter, a conventional central venous catheter) is often done without much thought. We discussed that in our January 21, 2014 Patient Safety Tip of the Week The PICC Myth and a followup column December 2014 Surprise Central Lines in which it was noted that very often that physicians were not even aware that such lines were in place in their patients.
Then in our July 2015 Whats New in the Patient Safety World column Reducing Central Venous Catheter Use we discussed a study showing that use of an online physician audit tool led to a substantial reduction in central venous catheter use (McDonald 2015). The tool listed several potential indications for central venous catheters or PICCs and also allowed for input of other reasons. Its use resulted in a 46.6% reduction in use of CVCs or PICCs compared to the pre-intervention period. But the investigators still found substantial room for improvement in that a third of the CVCs/PICCs were used for ease of drawing blood or just-in-case the patient deteriorates.
That study highlighted a critical question: what are the evidence-based indications for use of PICC lines (or conventional central venous catheters)? And, once again, Michigan to the rescue. Leading experts from the University of Michigan (youll note most of them in our prior columns on PICC lines) along with multiple other experts have put together the Michigan Appropriateness Guide for Intravenous Catheters, also known as MAGIC (Chopra 2015). This was the result of deliberations by a multispecialty panel using the RAND/UCLA Appropriateness Method.
Along with a review of a phenomenal amount of literature, albeit of limited high-level evidence, the panel reviewed 665 scenarios related to PICC use, care and maintenance compared with that of other venous access devices. They found that of the 665 scenarios 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. They then constructed tables showing which type of venous access device is most appropriate for each of a variety of scenarios.
The appropriateness of inserting PICC lines depends upon patient characteristics, purpose of the line, nature of substance being infused, and especially on expected duration of need. They deemed use of PICC lines as appropriate for peripherally compatible infusates when treatment is expected to be 6 or more days (and for non-peripherally compatible infusates for any duration). One area that has always been controversial is use of PICC lines for ease of drawing blood. The panel ultimately concluded that use of a PICC may be appropriate in patients who need frequent blood draws with an expected duration of 6 or more days. PICC is also preferred to tunneled catheter for such frequent phlebotomies with durations of 15-30 days. PICC may be appropriate for patients receiving cyclical or episodic chemotherapy where expected duration of treatment is 3 months or more. PICC may also be appropriate for infusions or palliative treatment during end-of-life care or for delivery of peripherally compatible infusates for patients residing in skilled nursing facilities or transitioning from hospital to home, provided that the proposed duration of such use is ≥15 days. We refer you to the MAGIC document for other details.
The MAGIC has tables that can be easily referred to when a decision about use of PICC or other vascular access device is being considered. The other devices included are peripheral IV catheter, US-guided peripheral IV catheter, midline catheter, nontunneled/acute central venous catheter, tunneled catheter, and port.
The MAGIC also has recommendations regarding care and maintenance of the various catheters and management of complications.
The UM Health System also launched a comprehensive website, ImprovePICC, that offers easy access to the MAGIC recommendations and a host of valuable PICC resources (videos, slides, etc.).
Overall, this is an outstanding endeavor on a much needed resource for healthcare workers in multiple venues.
In addition to MAGICs discussion of catheters other than PICC lines, the New England Journal of Medicine just had a study comparing the intravascular complications of central venous catheterization by insertion site (Parienti 2015). The authors found in a randomized controlled trial that subclavian vein catheterization was associated with a lower risk of bloodstream infection and symptomatic thrombosis and a higher risk of pneumothorax than jugular vein or femoral vein catheterization.
Some of our other columns on central venous catheters and PICC lines:
January 21, 2014 The PICC Myth
December 2014 Surprise Central Lines
July 2015 Reducing Central Venous Catheter Use
Greene MT, Flanders SA, Woller SC, et al. The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities. Am J Med 2015; Published Online: May 01, 2015
Dobson P, Hansel BC. Letter to the Editor: Preventing Air Embolism with PICC Line Removal. Pa Patient Saf Advis 2015; 12(1): 48
McDonald EG, Lee TC. Reduction of Central Venous Catheter Use in Medical Inpatients Through Regular Physician Audits Using an Online Tool. JAMA Intern Med 2015; Published online May 04, 2015
Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med 2015; 163(6_Supplement): S1-S40
Universitiy of Michigan Health System. Improve PICC website.
Parienti J-J, Mongardon N, Mιgarbane B, et al. Intravascular Complications of Central Venous Catheterization by Insertion Site. New Engl J Med 2015; 373(13): 1220-1229
Our September 8, 2015 Patient Safety Tip of the Week TREWScore for Early Recognition of Sepsis discussed a new real-time early warning score developed at Johns Hopkins (Henry 2015) to identify patients at risk for septic shock and several similar tools to identify sepsis earlier.
But how about identifying sepsis patients even before they reach the hospital! A new study suggests that may be possible. Polito and colleagues at Emory University (Polito 2015) derived and validated a predictive model and novel emergency medical services (EMS) screening tool for severe sepsis. The PRESS score defined at-risk patients as having all 3 of the following criteria present in the EMS setting: (1) heart rate greater than 90 beats/min, (2) respiratory rate greater than 20 beats/min, and (3) systolic blood pressure less than 110 mm Hg. Six EMS characteristics were found to be predictors of severe sepsis: older age, transport from nursing home, Emergency Medical Dispatch (EMD) 9-1-1 chief concern category of sick person, hot tactile temperature assessment, low systolic blood pressure, and low oxygen saturation. Sensitivity of the final model was 91% in the derivation group and 78% in the validation group. At a predefined threshold of 2 or more points, prehospital severe sepsis (PRESS) score sensitivity was 86% and specificity of 47%. The authors noted that additional validation is needed before this tool can be recommended for widespread clinical use.
Though we agree that the PRESS score needs to be validated at other sites before widespread adoption, this is most encouraging. Identification of patients likely to have sepsis before they even reach the ED should make early intervention much more likely and improve patient outcomes. Its even conceivable that someday the early sepsis interventions might even begin while the patient is in transport to the hospital.
Hopefully, tools like the TREWScore and PRESS score will prove to be valuable additions to our armamentarium of tools in our fight to reduce morbidity and mortality from sepsis.
Some of our other columns dealing with sepsis, severe sepsis, and septic shock:
Henry KE, Hager DN, Pronovost PJ, Saria
S. A targeted real-time early warning score (TREWScore)
for septic shock. Science
Translational Medicine 2015; 299(7): 299ra122; 05 Aug 2015
Polito CC, Isakov A, Yancey AH, et al. Prehospital recognition of severe sepsis: development and validation of a novel EMS screening tool. Amer J Emerg Med 2015; 33(9): 11191125 Published online: April 22 2015
Weve done several articles on delirium every year since 2008 (see the full list at the end of todays column). The Pennsylvania Patient Safety Authority has noted a 7-fold increase in patient safety events related to delirium reported to the Pennsylvania Patient Safety Reporting System (PA-PSRS) over a 10-year period from 2005 to 2014 (Feil 2015). The author, Michelle Feil, attributes this increase largely to increased awareness and better recognition of delirium rather than to a true increase in the incidence and prevalence of delirium.
Though the PA-PSRS data are limited in some respects to the data input by the reporters, Feil was able to determine both predisposing factors and likely precipitating factors in many cases. Male gender and age 65 or older were noted as predisposing factors in 57% and 54.3% of reports, respectively. Pre-existing cognitive dysfunction (14.3%), depression (10.8%), and serious illness (11.7%) were other frequent predisposing factors but were likely underreported compared to age and sex, which were required entries in their own fields in the reports. The most common precipitating factors mentioned were intercurrent illness or other physiologic cause (45.7%), specific medications (29.4%), environmental factors (22.9%), and surgery or procedure requiring sedation (10.8%).
Almost all areas of care were represented in the PA-PSRS data. General care areas accounted for about 50% of reports, ICUs 11.7% and psychiatry or chemical dependency services 12.3%. The delirium-related patient safety events ran the gamut of incident types, with 35% being falls. Sometimes delirium delayed recognition of other serious condition (eg. sepsis).
Feil goes on to describe strategies to prevent delirium, such as the HELP program and guidelines from several specialty societies on management of delirium as weve described in several previous columns. Multimodal non-pharmacologic approaches remain the mainstay in management of delirium. Pharmacologic management remains controversial. A recent meta-analysis (Kishi 2015) suggests that second generation antipsychotics have a benefit for the treatment of delirium with regard to efficacy and safety compared with haloperidol. However, the numbers are small and even those authors acknowledge that larger studies are needed.
It is well recognized that the occurrence of delirium has prognostic significance for patients. It is associated with increased morbidity and mortality, longer lengths of hospital stay, increased likelihood of institutionalization, and higher healthcare costs. But does the subtype of delirium have any predictive value? Hypoactive delirium is the subtype most often overlooked yet it is just as important to recognize this subtype. A new study in terminally ill cancer patients found that such patients with hypoactive or mixed delirium were more likely to have shorter survival periods (Kim 2015).
A recent review of risk stratification models for predicting delirium actually found a need for better predictive tools (Newman 2015). The authors found only 10 cohort studies of validated tools for predicting delirium. Quality of the studies was moderate to good but there was substantial heterogeneity and only one study was replicated. The most common risk factors identified were pre-existing cognitive impairment, medical comorbidity, elevated BUN, and impaired ADLs (activities of daily living).
While we agree with the Newman study that the tools for predicting delirium may not yet be perfect, we still strongly recommend consideration of risk factors for delirium in any patient scheduled to undergo surgery. In fact, we think it is one of the three most important considerations in the pre-operative evaluation (the other two being assessing risk for obstructive sleep apnea and frailty). Particularly in patients identified as having risk factors for delirium it makes sense to avoid those potential precipitating factors that can be avoided and to screen these patients more frequently for delirium.
Some of our prior columns on delirium assessment and management:
· October 21, 2008 Preventing Delirium
· October 14, 2008 Managing Delirium
· February 10, 2009 Sedation in the ICU: The Dexmedetomidine Study
· March 31, 2009 Screening Patients for Risk of Delirium
· June 23, 2009 More on Delirium in the ICU
· January 26, 2010 Preventing Postoperative Delirium
· August 31, 2010
· September 2011 Modified HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery
· December 2010 The ABCDE Bundle
· February 28, 2012 AACN Practice Alert on Delirium in Critical Care
· April 3, 2012 New Risk for Postoperative Delirium: Obstructive Sleep Apnea
· August 7, 2012 Cognition, Post-Op Delirium, and Post-Op Outcomes
· September 2013 Disappointing Results in Delirium
· October 29, 2013 PAD: The Pain, Agitation, and Delirium Care Bundle
· February 2014 New Studies on Delirium
· March 25, 2014 Melatonin and Delirium
· May 2014 New Delirium Severity Score
· August 2014 A New Rapid Screen for Delirium in the Elderly
· August 2014 Delirium in Pediatrics
· November 2014 The 3D-CAM for Delirium
· June 16, 2015 Updates on Delirium
Feil M. Delirium: Patient Safety Event Reporting and Strategies to Improve Diagnosis, Prevention, and Treatment. Pa Patient Saf Advis 2015; 12(3): 85-95
Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry 2015; Published online first September 4, 2015
Kim S-Y, Kim S-W, Kim J-M, et al. Differential Associations Between Delirium and Mortality According to Delirium Subtype and Age: A Prospective Cohort Study. Psychosomatic Medicine 2015; Post Author Corrections: September 18, 2015
Newman MW, O'Dwyer LC, Rosenthal L. Predicting delirium: a review of risk-stratification models. Gen Hosp Psych 2015; 37(5): 408-413
Print October 2015 Predicting Delirium
So why do patients whom we identify as being at high risk for falls still fall? One reason may be that the patients themselves do not perceive that they are at risk for falling. A new study used several survey tools to assess patients perceptions of fall risk and compared these to nursing assessments of fall risk (Twibell 2015). Twibell and colleagues surveyed 158 patients identified by nurses as been high risk for falls (most had fallen in the previous year). They found a striking disparity between the perceptions of patients and nurses regarding the risk of falling. More than half the patients deemed at risk by nurses did not perceive themselves as being at risk for falling. Those patients who had a low intention to participate in fall prevention reported a low fear of falling, low perceived likelihood of adverse outcomes from falling, few consequences of falling, and high confidence in safely performing risky behaviors.
The study strongly suggests that a measure of the patients perception of fall risk needs to be part of any fall prevention program individualized for each patient. Twibell and colleagues stress the importance of teach-back in helping the patient understand both the risk of falling and the dangers they may encounter if they do fall. The same recommendation for teach-back was stressed by Quigley (Quigley 2015) in our August 2015 Whats New in the Patient Safety World column Not All Falls Are the Same.
In the latter column we noted the VA National Center for Patient Safety Falls Tool Kit which has many very useful fall prevention resources available for download. In addition, the Joint Commission Center for Transforming Healthcare now has a Targeted Solutions Tool for Preventing Falls. The 7 hospitals participating in that project were able to reduce the rate of patient falls by 35 percent and the rate of patients injured in a fall by 62 percent. Extrapolated to a typical 200-bed hospital the number of patients injured by falls could be reduced from 117 to 45 annually and almost $1 million in cost reduction.
Some of our prior columns related to falls:
Twibell RS, Siela D, Sproat T, Coers G. Perceptions Related to Falls and Fall Prevention Among Hospitalized Adults. Am J Crit Care 2015; 24: e78-e85
Quigley P. Types of Falls and Suggestions to Reduce Them. VA TIPS (Topics in Patient Safety) 2015; 15(4): 3
VA National Center for Patient Safety. Falls Tool Kit.
Joint Commission Center for Transforming Healthcare. Targeted Solutions Tool for Preventing Falls.
Print October 2015 Predicting Delirium
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