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One of the tenets of managing patients with chronic kidney disease (CKD) is planning ahead and being able to avoid “emergency” dialysis. That means we need to anticipate having good vascular access at the time hemodialysis is initiated and thereafter. Preserving veins for future creation of an arterio-venous fistula (AVF) is paramount to ensure better outcomes for patients with CKD who may eventually need hemodialysis.
One of the recommendations from the American Society of Nephrology in the Choosing Wisely campaign is “Don’t place peripherally inserted central catheters (PICC) in stage III-V CKD patients without consulting nephrology.” (Choosing Wisely 2012). The recommendation notes “Venous preservation is critical for stage III–V CKD patients. Arteriovenous fistulas (AVF) are the best hemodialysis access, with fewer complications and lower patient mortality, versus grafts or catheters. Excessive venous puncture damages veins, destroying potential AVF sites. PICC lines and subclavian vein puncture can cause venous thrombosis and central vein stenosis. Early nephrology consultation increases AVF use at hemodialysis initiation and may avoid unnecessary PICC lines or central/peripheral vein puncture.” The evidence base and rationale for this recommendation were published when the recommendation was made in 2012 (Williams 2012).
So, how are we doing with regard to following this recommendation? Paje and colleagues (Paje 2019) looked at hospitalized medical patients who received a PICC in 52 hospitals participating in the Michigan Hospital Medicine Safety Consortium. Unfortunately, they found that placement of PICC’s in those with CKD was common and not concordant with clinical guidelines. Of over 20,000 patients who had PICC’s placed, 23.1% had an estimated GFR (eGFR) less than 45 mL/min/1.73 m2 and 3.4% were receiving hemodialysis. Many were large-diameter lines and multi-lumen PICC’s were placed more frequently than single-lumen PICC’s. PICC placement in these patients was more common in the intensive care unit (ICU) compared to wards (30.9% vs. 19.3%). They also noted that PICC complications occurred in roughly 15% of ward patients and 23% of ICU patients regardless of eGFR status. They did note considerable variation in PICC use rates across hospitals. They were unable to determine how often nephrologist approval for the PICC placement had been obtained.
Obviously, the message is not getting across. So, what should your facility be doing to prevent inappropriate use of PICC’s in these more advanced CKD patients without getting approval from a nephrologist? We wouldn’t count on education to solve this problem. You could, and should, require an order via CPOE for a PICC insertion and then you could use a CDSS alert to remind the practitioner that PICC’s should be avoided in late-stage CKD patients. Of course, you’d also include the other appropriateness criteria for PICC’s that we’ve discussed in our prior columns on PICC use (see list below).
But we suspect at most hospitals a busy physician simply grabs a PICC procedure kit and does not use CPOE. So, this is a problem that calls for use of either a forcing function or constraint. In our June 6, 2011 Patient Safety Tip of the Week “Timeouts Outside the OR” we discussed how access to procedure kits should be used to get everyone to do the correct things. Your nursing staff should control the access to the procedure kits. And each procedure kit should have a checklist attached to the outside that must be completed before the kit is opened. On that checklist you would include an item about checking the eGFR and, if the patient has stage III-V CKD, ensure that nephrology has been consulted.
In that column we cited a project at Northwestern University (Barsuk 2011) to re-engineer their processes for compliance with Universal Protocol for bedside procedures. They looked at lumbar punctures, thoracenteses and paracenteses done on the medicine services at their facilities. Analyzing their processes, they found that staff were often unaware of Universal Protocol (or perhaps unaware that it was required not just for OR procedures, but for bedside procedures as well) and that nurses were frequently never notified by physicians when their patients were undergoing such procedures. In their redesigned process the physician initiates the process by entering an order via CPOE with an anticipated time. This order would automatically populate the nurse’s alert list and provide the nurse with a timeout form and notice of a procedure-specific supply kit to procure. Only the nurse has a key to those procedure kits. This is a forcing function that forces the physician-nurse communication to take place. The nurse brings the timeout checklist and the kit to the bedside at the specified time and the nurse and physician go through the timeout procedure, which gets documented in the EMR. Compliance with Universal Protocol went from 16% before to 94% after implementation of this redesigned process.
Take a look at your data. It should be easy for you to identify patients in whom a PICC had been inserted. Then you should be able to easily stratify by eGFR, which is available today in almost all patient records. If you confirm high rates of PICC use in patients with Stage III-V CKD, as we suspect you will, make sure you implement procedures like those above to begin avoiding inappropriate PICC use.
Some of our other columns on IV access, central venous catheters and PICC lines:
January 21, 2014 “The PICC Myth”
December 2014 “Surprise Central Lines”
July 2015 “Reducing Central Venous Catheter Use”
October 2015 “Michigan Appropriateness Guide for Intravenous Catheters”
March 27, 2018 “PICC Use Persists”
February 26, 2019 “Vascular Access Device Dislodgements”
Choosing Wisely. Recommendation from the American Society of Nephrology: Don’t place peripherally inserted central catheters (PICC) in stage III-V CKD patients without consulting nephrology. Released April 4, 2012
Williams AW, Dwyer AC, Eddy AA, et al. Critical and Honest Conversations: The Evidence Behind the “Choosing Wisely” Campaign Recommendations by the American Society of Nephrology. Clin J Am Soc Nephrol 2012; 7: 1664-1672
Paje D, Rogers MA, Conlon A, Flanders SA, Bernstein SJ, Chopra V. Use of Peripherally Inserted Central Catheters in Patients with Advanced Chronic Kidney Disease: A Prospective Cohort Study. Ann Intern Med 2019; Epub ahead of print 4 June 2019
Barsuk JH, Brake H, Caprio T, et al. Process Changes to Increase Compliance with the Universal Protocol for Bedside Procedures. Arch Intern Med. 2011; 171(10): 947-949
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