Thrombosis and bloodstream infections are serious complications of IV catheterization with a central line, including peripherally inserted central catheters (PICCs). Thrombosis and bloodstream infections are also both preventable in PICCs if appropriate steps are taken. But the best preventive measures sometimes go beyond the practices and technologies that most hospitals utilize.
To learn more about the best and most recently proven preventive approaches, we spoke to Nancy Moureau, RN, BSN, CPUI, CRNI, VA-BC, who is the CEO of PICC Excellence, Inc. Moureau is a vascular access consultant, speaker and educator. Her articles have appeared in more than 50 medical and trade journals.
Q: What are your biggest concerns regarding the vascular access devices you work with?
A: As a vascular access clinician, my work goes much better when the devices can be inserted and maintained efficiently, and when the devices last as long as the maximum recommended dwell time. That said, though, my patients’ comfort and safety will always be the most important consideration in my work. In other words, my highest priority for the devices is that they be associated with the fewest complications possible. With some kinds of vascular access devices -- such as IV needleless connectors and central IV catheters themselves -- devices can really vary in how safe they are for patients.
Q: Since complications are your biggest concern, which complications concern you most?
A: Thrombosis and bloodstream infections (BSIs) are the two most serious complications of vascular access. Of the two, BSIs are the most dangerous because they are fatal in up to 25 percent of cases. They also add considerable expenses for hospitals because they can cost tens of thousands of dollars to treat. They extend patients’ length of stay in the hospital and are not reimbursed by Medicare and many private insurers. They can expose hospitals to lawsuits, as well, because they are widely believed to be preventable.
Thrombosis doesn’t present the same level of risk as a BSI, but it can be a substantial threat to a patient’s well-being. What makes thrombosis more worrisome still is that it can lay the groundwork for a bloodstream infection.
Q: Tell us more about thrombosis in PICCs, including the connection to bloodstream infections.
A: While BSIs are a greater threat to a patient’s life, thrombosis is the source of considerable morbidity and is far more common than BSI. In the past, it’s been thought that PICCs were less prone to complications than centrally inserted catheters (CVCs). However, a recent meta-analysis published in The Lancet concluded that PICCs have a higher risk of deep vein thrombosis than CVCs. A separate meta-analysis published in Infection Control and Hospital Epidemiology noted that PICC use has "grown exponentially in vulnerable populations" and that PICCs are equally prone to CLABSIs, when compared to standard CVCs in this patient group. Simply having an indwelling central venous catheter is the greatest risk factor for upper-extremity deep vein thrombosis. We’re talking about a verified prevalence of 27 percent to 66 percent according to researcher M. Verso in the Journal of Clinical Oncology. When affected patients reach the point of suffering post-thrombotic syndrome, the consequences can include impaired functional abilities, both physiologically and psychologically, that reduce patients’ quality of life and limit their daily activities. The relationship of thrombosis to BSIs is pretty straightforward when you understand that BSIs are caused by biofilm. Biofilm is bacterial colonization that is nurtured by the fibrin in blood. Bacterial colonization rates are nearly double in catheters associated with thrombosis. Catheter sepsis rates are more than double and septicemia rates triple in these circumstances.
Q: There has been a lot of focus on preventing BSIs in recent years, including the development of effective bundles of evidence-based preventive practices and devices. Do you think those bundles are sufficient?
A: The correct answer is yes and no. Some hospitals have completely eliminated catheter-related BSIs – whether with PICCs or CVCs -- for a sustained period after implementing the standard bundles recommended by organizations like the Society for Healthcare Epidemiology of America (SHEA) and the Institute for Healthcare Improvement (IHI). Other hospitals have implemented these bundles but have gotten less satisfactory results. Any BSI rate greater than zero is unsatisfactory in my opinion, because I agree with those who say these infections are avoidable. While education is the best approach to establishing compliance with infection prevention, a hospital that has not achieved a zero rate should look beyond the bundle and take additional steps.
Q: What are some of those steps?
A: I’m going to mention three devices that can really help. Two of them, a disinfection cap and a dressing containing chlorhexidine gluconate, are effective in reducing BSI rates but do not affect thrombosis. The third helps resist both BSIs and thrombosis – and, of course, as I pointed out earlier, reducing thrombosis can also reduce the risk of a BSI. The device I’m referring to is an antimicrobial, antithrombotic PICC that is impregnated with chlorhexidine inside and out. Clinicians should look at what the organizations recommending these bundles actually write about them. For instance, SHEA recommends a basic bundle but it also recommends steps for hospitals to take if “outcome data and/or risk assessment suggest lack of effective control despite implementation of basic practices.” One of those steps, says SHEA, is to “use antiseptic- or antimicrobial-impregnated central venous catheters for adult patients.” The CDC and Infusion Nurses Society say something similar. For example, the CDC recommends use of an antimicrobial central line “in patients whose catheter is expected to remain in place greater than five days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing.”
Q: You’ve written about the “ideal catheter.” What do you mean by that?
A: The ideal catheter isn’t my concept. This is a long-running topic of discussion in the field of vascular access. There’s general agreement that catheters should be designed to minimize infections and thrombosis, have long dwell times, and not harm blood vessels. But I do think we can add to this list antimicrobial catheters and the use of antiseptics such as chlorhexidine in catheter materials. For PICCs specifically, I think the ideal catheter should include an antimicrobial agent that reduces bacterial colonization because that will also reduce infection risk. In addition, the antimicrobial agent impregnating the catheter should be effective against a broad range of pathogens. The impregnation should extend the entire length of the catheter and be both extraluminal and intraluminal, because we know that infections can begin extraluminally and intraluminally. An ideal PICC should also resist adherence of blood cells internally and externally, unlike most catheters today. This would reduce thrombus accumulation while helping to maintain blood flow. Finally, all of these protections should last at least 30 days. And, no, this is not just a fantasy list. These properties are available today in a single device. The fantasy part is that too few hospitals use them.
Q: Why do you think that is?
A: I can’t tell you why some hospitals use devices that have been shown to be relatively risky and ignore devices that have recommendations supporting risk reduction. Maybe they’re not aware that newer, better technology is available. Maybe they have contractual arrangements with group purchasing organizations that preclude certain devices. And, of course, some organizations will try to avoid the extra cost of an antimicrobial PICC, disinfection cap, or CHG dressing, not understanding that there is a cost savings involved with their usage, as was identified in the Hockenhull economic study from Critical Care Medicine published in 2009. That is the part that always puzzles me. The cost of such devices is tiny when compared to the treatment costs, lawsuit risk, and loss of patient patronage associated with high infection rates. If it was my decision to make, I would do what was best for my patients, but I would do that with the knowledge that it was also the smartest thing to do for the hospital’s long-term financial health. And I know the results would prove me correct, as they already have for many institutions.
Q: You recently had a paper published on the connection between thrombosis and BSIs in PICCs, with tips on how to prevent both of these complications. Where can readers find it?
A: Thank you for asking about that. The paper can be downloaded at: http://bit.ly/1bECf4T.