Patient Safety Tip
of the Week
March 27, 2018 PICC Use Persists
One of our most frequently accessed columns is our January 21, 2014 Patient Safety Tip of the Week The PICC Myth. In that column and the others listed below we noted that the presumed safety advantage of PICC catheters compared to central lines may be misleading.
Then in our December
2014 What's New in the Patient Safety World column Surprise
Central Lines we noted that very often responsible physicians are surprised
to find their patient has either a central line or PICC line. We followed that
up with our What's New in the Patient Safety World columns for July 2015 Reducing
Central Venous Catheter Use and October 2015 Michigan
Appropriateness Guide for Intravenous Catheters to discuss guidelines for
appropriate use of such lines and ways to reduce their inappropriate use.
But a new study in
the Journal of Hospital Medicine shows that inappropriate use of PICC lines
persists (Paje
2018). Guidelines for
peripherally inserted central catheters (PICCs) recommend avoiding insertion
if the anticipated duration of use is ≤5 days. The researchers collected
data from medical records of adults that received PICCs during hospitalization
at 52 Michigan Hospital Medicine Safety (HMS) Consortium sites. They found
that, of the 15,397 PICCs placed, 25.3% had a dwell time of ≤5
days. Among those with short-term PICCs, 9.6% experienced a complication (2.5%
experiencing VTE and 0.4% experiencing CLABSI events). The most common minor
complications were catheter occlusion (4%) and tip migration (2.2%).
Some of the factors
identified with short-term PICCs included difficult venous access, multilumen devices, and teaching hospitals. They conclude
that short-term use of PICCs is common and associated with patient, provider,
and device factors and that because PICC placement, even for brief periods, is
associated with complications, efforts targeted at factors underlying such use
appear necessary.
One contributing
factor that we have seen is that its too easy to order a PICC insertion. Most
hospitals today have PICC line teams led by nurses skilled at PICC insertion.
So its very easy for a physician, who need not be
bothered by the effort to insert a line, to simply order a PICC line and have
the team insert one.
Weve discussed
unnecessary central venous catheter or PICC line use in our previous
columns of January 21, 2014 The
PICC Myth and December 2014 Surprise
Central Lines. In the latter we noted that oversight is needed to avoid
what we consider an 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.
But the best interventions are those that can be delivered before a central venous catheter or PICC line are placed. There are two ways to do this. One is to require an order in CPOE that requests the indication before the catheter insertion kit is dispensed. The other is a paper-based checklist with indications that is filled out before the catheter insertion kit can be opened. We actually prefer the latter since your checklist can and should also include all the elements for proper catheter insertion, i.e. the classic Pronovost checklist (see our March 2011 Whats New in the Patient Safety World column Michigan ICU Collaborative Wins Big), and correct patient and procedure verification.
So we hope your organization is following the Michigan Appropriateness Guide for Intravenous Catheters, also known as MAGIC (Chopra 2015) that we discussed in our October 2015 What's New in the Patient Safety World column Michigan Appropriateness Guide for Intravenous Catheters for appropriate use of such lines and ways to reduce their inappropriate use. The UM Health System also has a comprehensive website, ImprovePICC, that offers easy access to the MAGIC recommendations and a host of valuable PICC resources (videos, slides, etc.).
Also, we hope you
have a formal mechanism for tracking PICC lines and assessing their
appropriateness.
Update:
Since we first posted this column a report was published on results of a
Michigan collaborative using the MAGIC guideline (Swaminathan 2018). A multimodal intervention (tool,
training, electronic changes, education) derived from MAGIC was implemented at
one hospital and rates of inappropriate PICCs and patient outcomes were
compared to 9 other hospitals over a 2 year period
from 2014 to 2016. Absolute rates of inappropriate PICC use decreased
substantially at the study site versus controls after implementation but, after
adjusting for underlying trends and patient characteristics, there was only a
marginally significant 13.8% decrease in inappropriate PICC use at the study
site (P=0.048). Also, while the incidence of all PICC complications decreased to a greater extent at the study site, the absolute
difference between controls and intervention was small. The authors caution that,
given the size and resources required for this study and the modest
improvements seen, future work should consider cost-to-benefit ratio of similar
approaches.
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
October 2015 Michigan
Appropriateness Guide for Intravenous Catheters
References:
Paje D, Conlon A, Kaatz S, et al. Patterns and Predictors of Short-Term Peripherally Inserted Central Catheter Use: A Multicenter Prospective Cohort Study. J. Hosp Med 2018; 13(2): 76-82
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
http://annals.org/article.aspx?articleid=2436759&atab=7
Universitiy of Michigan Health System. Improve PICC website.
Swaminathan L, Flanders S, Rogers M, et al. Improving PICC
use and outcomes in hospitalised patients: an
interrupted time series study using MAGIC criteria. BMJ Qual
Saf 2018; 27: 271-278
http://qualitysafety.bmj.com/content/27/4/271
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