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
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
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