By Kelly M. Pyrek
Within the last decade, peripherally inserted central catheters (PICCs) became the go-to intravenous device of choice among clinicians but a group of researchers is asking physicians and other stakeholders to rethink the appropriateness of a short-term catheter shown to have significant risks.
David Paje, MD, MPH, a University of Michigan hospitalist, recently led a team of investigators who studied patient, provider and device characteristics as well as the clinical outcomes associated with short-term PICCs. The researchers found that 1 in every 4 times a PICC is inserted, the patient didn't need it long enough to justify the risks that it can also pose, and additionally, in just the five days or less that they had a PICC implanted in their vein, nearly 1 in 10 of these patients suffered a blocked line, an infection, a blood clot or another complication linked to the device.
The study, published in the Journal of Hospital Medicine, is based on data from 52 hospitals in Michigan taking part in a massive quality improvement and patient safety effort. It's a detailed analysis of records from 15,397 PICC placements over a two-year period from 2014 to 2016, just before and after guidelines for safe and appropriate PICC use made their debut. The study, which is a large-scale examination of real-world use of PICCs and the factors associated with their short-term use, highlights the need for efforts to reduce short-term use of PICCs and help medical care teams understand current practice and consider other alternatives for short-term IV access that pose less risk.
Paje, an assistant professor of internal medicine, also helps lead the Medical Short Stay Unit at Michigan Medicine, U-M's academic medical center. For the new study, he worked with senior author and Division of Hospital Medicine chief Vineet Chopra, MD, MSc, and co-author Scott Flanders, MD, who directs the Michigan Hospital Medicine Safety Consortium that provided the data for the study. Colleagues from several Michigan hospitals are co-authors.
Paje says the impetus for the study included his areas of interest -- blood clots and anticoagulation -- as well as the desire of the researchers associated with the Michigan Hospital Medicine Safety (HMS) Consortium to reduce PICC-related complications (including hospital-acquired blood clots in the legs and in the lungs) among hospital inpatients.
"When PICCs first came out, they became an 'easy button' for vascular access, and the safety issues weren't recognized," he says. Now the dynamics have changed, and we need to be more thoughtful with their use." Paje recalls, "Around the time I was doing my clinical training 20 years ago, we were using all central lines for patients with poor venous access; it was a time when there was significant difficulty inserting central lines, particularly since we were placing them blindly because ultrasound guidance was not readily available. So, the introduction of PICCs in practice was welcomed as a great solution to our problems. PICCs became more widely used, initially in the outpatient setting but and later it was transitioning toon in the inpatient setting and later in the inpatient setting. PICCS became the easier approach for clinicians and were initially thought to be safe for patients. Of course, we eventually realized that PICCs were not so free of problems after all; there are many complications associated with PICCs, such as infections, blood clots, and even device failure."
"One of the things we identified during the initial pilot when we were looking at patterns of use is that a lot of PICCs were being placed short-term," Paje adds. "So, we looked at the larger data set to see what factors predict shorter PICC dwell time and what kind of complications are seen during this short period of exposure to PICCs. What was surprising was the magnitude of the issue, in that one-fourth of the PICCs placed were for the short term. We knew that it was common but to think that 25 percent of PICCs are being placed for less than five days, tells you that there is a huge opportunity to reconsider using PICCs in many of our patients. When we did the multivariable analysis, we found that poor or difficult vascular access predicts a short-term dwell time. This is an area where we can explore other alternatives such as ultrasound guidance when inserting peripheral lines, and the utilization of special teams of clinicians who are more proficient at inserting lines. The problem is, when PICCs became a popular option, clinicians became less proficient at inserting peripheral lines as we used to be, because we had the 'easy button' with PICCs. I think that having a well-trained vascular access and/or phlebotomy team to tackle those lines that the primary team cannot insert can make a difference. It's also time to explore alternatives to PICCs, devices that are less risky including midline devices, a shorter line that does not get as far as the subclavian vein."
A midline is a type of peripheral IV catheter that is about 7.5 cm to 25 cm in length and is typically inserted in the larger diameter veins of the upper extremity, such as the cephalic or basilic veins, with the tip terminating distal to the subclavian vein. As Paje, et al. (2018) note, "While there is a paucity of information that directly compares PICCs to midlines, some data suggest a lower risk of bloodstream infection and thrombosis associated with the latter. For example, at one quaternary teaching hospital, house staff who are trained to insert midline catheters under ultrasound guidance in critically ill patients with difficult venous access reported no CLABSI and DVT events."
At the heart of the issue is determining when the use of PICCs is appropriate. Several years ago, recommendations addressing how to quantify the appropriateness, qualify existing use, and improve care of PICCs and related devices in hospitalized patients were developed and are beginning to infiltrate care. These recommendations, called the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), were created by an expert panel that desired to guide clinicians to the appropriate option for the individual patient they are treating. MAGIC was introduced in 2015, and developed into a mobile and web app in 2017.
MAGIC's 15-member multidisciplinary panel applied the RAND/UCLA Appropriateness Method to generate novel criteria for use, care, and management of PICCs in hospitalized patients. In addition, panelists rated the comparative utility of other VADs in relation to PICCs, providing new insights for decision making in venous access. As the MAGIC acknowledges, "As with many healthcare innovations, PICCs were introduced to solve an important clinical problem in a defined population. However, over time, the use of PICCs has evolved to span diverse indications and patient populations. In hospital settings, accumulating evidence suggests that placement of PICCs may occur for potentially inappropriate reasons. Notwithstanding such benefits as convenience, comfort, and economic efficiency, PICC insertion may introduce unnecessary risk and potential for preventable harm."
MAGIC panelists call their work "a departure from the status quo" in several ways: "First, they offer clinical granularity for clinicians. For example, existing guidelines recommend 'use of midline catheters or PICCs instead of a short peripheral intravenous catheter when the duration of IV therapy will likely exceed six days.' Our criteria build on this advice by adding such details as what patient-specific considerations should be incorporated in this decision, which other devices may be appropriate, and when PICC use for shorter durations might be reasonable. Second, whereas existing recommendations target proceduralists or specialties that most often insert devices, our criteria are the first to provide direction to clinicians, such as internists or hospitalists, who order PICCs. Thus, these criteria fill a critical gap, bringing recommendations to those that drive the decision to place such devices. Finally, by tackling some of the most controversial topics of venous access—including when to adjust the PICC position, appropriate indications for removal, and indications for reinsertion of PICCs after complications— our criteria advance the science of vascular access in important and innovative ways."
As Chopra, et al. (2015) explain, "Reliable venous access is a cornerstone of safe and effective care of hospitalized patients. Spurred by technological advances, several venous access devices (VADs) for use during and beyond hospitalization are available to meet this need. In recent years, PICCs have become popular for venous access in hospital settings. Compared with traditional central venous catheters (CVCs), PICCs offer several advantages, including safer insertion in the arm, cost-effective and convenient placement via vascular access nursing teams, and selfcare compatibility that facilitates use beyond hospitalization. It is therefore not surprising that use of PICCs has grown considerably worldwide. Despite these advantages, PICCs are central venous catheters that may lead to important complications. For instance, problems such as luminal occlusion, mal-positioning, and dislodgement occur frequently with these devices. Similarly, superficial thrombophlebitis or infection at the site of PICC insertion may occur despite uneventful and optimal placement. In addition, PICCs are associated with morbid complications, including venous thromboembolism and central line-associated bloodstream infection. Ensuring appropriate use of PICCs is thus vital to preventing these costly and potentially fatal adverse events."
Chopra, et al. (2015) point to a growing number of studies suggesting substantial variation and potentially inappropriate use of PICCs in hospitalized patients. For example, in a study from a large academic medical center, many PICCs were not actively used or were inserted in patients who also had peripheral intravenous catheters. The researchers note, "In a decade-long study conducted in a tertiary hospital, changes in patterns of PICC use, including shorter dwell times and ambiguous indications for insertion, were reported. Additional cause for concern comes from a recent study, which found that 1 in 5 inpatient providers did not know that their patients had CVCs, with lack of awareness being greatest for PICCs. Surveys of inpatient providers have also demonstrated knowledge gaps related to appropriate indications and care practices for PICCs. Collectively, these data have not only led to reviews of PICC use in hospitals but also to calls by the Choosing Wisely initiative to improve PICC practices across the U.S. The concepts of inappropriate overuse and underuse of medical devices are by no means unique to PICCs. Rather, such issues accompany the diffusion of many novel health technologies. In many such instances, a key barrier to achieving appropriate use is the fact that evidence at a level of detail needed to apply to the range of patients seen in everyday practice is not available. Nevertheless, clinicians must make choices regarding such innovations on a daily basis, potentially fueling inconsistent practice. In the absence of high-quality evidence, an approach that combines available data with the experience and insight of clinical experts is valuable as it would provide guidance where none is otherwise available."
MAGIC offers a list of appropriate indications for use of PICCs in relation to other vascular access devices (VADs); defines the best practices associated with the insertion and care of PICCs; and recommends practices for treatment and prevention of PICC complications.
For hospitalized medical patients, the MAGIC recommendations considered insertion of PICCs for delivery of peripherally compatible infusates as inappropriate if the expected duration of use was five or fewer days. In such scenarios, use of peripheral intravenous catheters or ultrasonography-guided peripheral intravenous catheters was rated as appropriate. If the proposed duration of infusion was 6 to 14 days, panelists rated PICC use as appropriate but indicated a preference for midline catheters and ultrasonography-guided peripheral intravenous catheters over PICCs for this period. This rating reflected evidence from observational studies that suggested both efficacy and lower risk for complications associated with these devices compared with PICCs for this interval. According to MAGIC, when the proposed duration of infusion was 15 or more days, PICCs were preferred to midline catheters, given the possibility of failure of the latter beyond this period. However, panelists recognized that midline catheters may be used for up to four weeks and are approved for such duration of use. Use of tunneled catheters and implanted ports were rated appropriate only if the proposed duration of infusion was 31 or more days.
MAGIC panelists noted that these more invasive devices should be reserved for instances when use of PICCs is not feasible (for example, no suitable vein or site of insertion for PICC is identified), is relatively contraindicated (for example, recent history of thrombosis), or when episodic infusions over several months are necessary. For infusion of irritants or vesicants, such as parenteral nutrition or chemotherapy, PICC use was rated as appropriate at any proposed duration of use. Because peripheral intravenous catheters, ultrasonography-guided peripheral intravenous catheters, and midline catheters would not provide central venous access, these VADs were rated as inappropriate for this indication for all durations of use. MAGIC panelists rated use of non-tunneled CVCs as appropriate when the expected duration of use was 14 or fewer days. Panelists also rated use of tunneled, cuffed catheters and implanted ports as appropriate for infusion of irritants or vesicants, but only when the proposed duration of therapy was 15 or more days or 31 or more days, respectively
MAGIC panelists disagreed on the appropriateness of PICC placement when the indication was frequent obtaining of blood samples (=3 phlebotomies per day) or difficult or poor peripheral venous access for proposed durations of five or fewer days. Our patient panel member actively participated in this discussion, suggesting that such decisions should be individualized between the patient and provider after discussing risks and benefits related to PICC use and alternative options. Insertion of PICCs was rated as appropriate when the proposed duration of use for frequent phlebotomy or difficult venous access was six or more days. In patients with difficult venous access, ultrasonography-guided peripheral intravenous catheters and midline catheters were preferred over PICCs when the expected duration of use was 14 or fewer days. Panelists rated use of CVCs for both difficult venous access and frequent phlebotomy as appropriate, provided the proposed duration of use was 14 or fewer days. Placement of tunneled catheters for patients with difficult venous access was rated as appropriate only if the proposed duration of use was 31 or more days. Ports were rated as inappropriate for frequent obtaining of blood samples at all durations and appropriate for difficult venous access if use for 31 or more days was expected.
As part of their study, Paje and his colleagues examined which patients were more likely to receive a PICC for short-term use. The most significant factor was difficult vascular access, a catch-all phrase that indicates it had been challenging to start an IV in the patient in previous visits or earlier in the hospital stay. Paje says clinicians may default to choosing a PICC in these patients to keep an intravenous access available, rather than having to find a vein each time, or some experienced patients may even ask for a PICC to avoid so many needle jabs.
"I think PICCs are so common partly due to a perception among some clinicians that inserting venous access is something that is trivial," Paje says, "but if you take the patient's perspective, you worry about being poked so many times, and about potentially suffering from a phlebitis, a blood clot or a bloodstream infection, then you start putting more serious thought behind making decisions about line placement. Clinicians must think about potential downstream complications and respect line insertion as the serious task that it is."
Paje continues, "The data from our study speak for themselves. Now that we have seen that one-fourth of the PICCs we use are not staying there long-term, we must consider other devices or other strategies institutionally to better serve our patients. We must ask ourselves, do we really need to place a patient on an intravenous antibiotic or other IV treatment if we know it is not that easy to put a line in this patient? One institution required a conversation with infectious disease experts prior to placing PICCs to administer IV antibiotics. As a result, a significant number of patients who would have otherwise received a PICC, did not. In most of these cases, it was decided that the treatment was no longer necessary or that there were alternative orally administered antibiotics that could be used. So, when you place a PICC, from now on you must consider it to be a serious clinical decision. Someone may say, 'Oh, it's only for one or two days and we won't have any problems,' but as our paper shows, we encountered a significant number of problems, even with a short dwell time."
Paje and colleagues found that 9.6 percent of the short-term PICC patients experienced a complication, including 2.5 percent who experienced a blood clot forming in their vein that could have broken off and caused more serious consequences, and 0.4 percent developing a central line-associated blood stream infection (CLABSI).
As Paje, et al. (2018) note, " PICC-related complications occurred in 18.5 percent (2,848) of the total study cohort. Although the overall rate of PICC complications with short-term use was substantially lower than long-term use (9.6 percent vs. 21.5 percent), adverse events were not infrequent and occurred in 374 patients with short-term PICCs. Furthermore, complication rates from short-term PICCs varied across hospitals (median was 7.9 percent) and were lower in teaching versus nonteaching hospitals (8.5 percent vs. 12.1 percent). The most common complication associated with short-term PICC use was catheter occlusion (n = 158, 4.0 percent). However, major complications, including 99 (2.5 percent) VTE and 17 (0.4 percent) CLABSI events, also occurred. Complications were more frequent with multi-lumen compared to single lumen PICCs (10.6 percent vs. 7.6 percent). In particular, rates of catheter occlusion (4.5 percent vs. 2.9 percent) and catheter tip migration (2.6 percent vs. 1.3 percent) were higher in multi-lumen devices placed for five or fewer days."
"The use of PICCs exploded because the safety issues were not initially recognized, including those associated with clots and infections," says Paje. "Now we're coming back full circle, and we need to adapt and implement quality improvement processes to be more judicious with their use. We need to recognize that PICCs are not without any consequence, even for short-term use."
He notes that most of the reasons cited for PICC use in the patient records used in the study -- such as delivering antibiotics -- do not require the deep access to the central bloodstream that PICC provides.
Even as clinicians get the word about the MAGIC guidelines and implement measures to right-size PICC uses, Paje calls on patients and family members to speak up and ask questions before a PICC gets placed. "Patients or their representatives should be actively engaged, and informed," he says. "Find out what lines they're putting in, and ask questions."
As Paje, et al. (2018) note, "We observed that short-term PICCs were more common in teaching compared to nonteaching hospitals. While the design of the present study precludes understanding the reasons for such a difference, some plausible theories include the presence of physician trainees who may not appreciate the risks of PICC use, diminishing peripheral IV access securement skills, and the lack of alternatives to PICC use. Educating trainees who most often order PICCs in teaching settings as to when they should or should not consider this device may represent an important quality improvement opportunity. Similarly, auditing and assessing the clinical skills of those entrusted to place peripheral IVs might prove helpful. Finally, the introduction of a midline program, or similar programs that expand the scope of vascular access teams to place alternative devices, should be explored as a means to improve PICC use and patient safety."
"This study helps illustrate how medical devices such as PICCs can be both helpful and harmful," says Chopra, who led the development of MAGIC and is a member of the U-M Institute for Healthcare Policy and Innovation. "Understanding how best to balance appropriate use -- using tools like MAGIC -- is the way to safe and better patient care."
Paje emphasizes the importance of hospitals making available a policy or adopting a strategy that helps clinicians with decision-making around placement of vascular access devices. "MAGIC is a good place to start. As a first step, hospitals need to form a multi-disciplinary team that has the support of institutional leadership. The members of the team should be comprised of key stakeholders such as hospitalists, nursing, vascular access specialist or interventional radiologists who are inserting these lines, pharmacists, infectious disease consultants, intensivists, and nephrologists, among others. This committee should be tasked with evaluating existing published evidence and guidelines, such as MAGIC, and coming up with an institutional guidance for when PICCs are appropriate. MAGIC helps you do that by successfully implementing its recommendations to the needs of your institution, depending on your resources. Nowadays, we can also leverage the ability of electronic medical records systems to assist with decision-making at the point of PICC ordering. For example, PICC placement ordering can be standardized using order sets that reflect recommendations from MAGIC. When ordering a PICC, it must be clear what the indication is, reflect on how long you think the patient needs it, and then check whether it is appropriate or if there are other alternatives by referencing MAGIC recommendations."
Paje D, Conlon A, Kaatz S, Swaminathan L, Boldenow T, Bernstein SJ, Flanders SA and Chopra V. Patterns and Predictors of Short-Term Peripherally Inserted Central Catheter Use: A Multicenter Prospective Cohort Study. J. Hosp. Med 2018;2;76-82. Accessible at: https://www.journalofhospitalmedicine.com/jhospmed/article/157107/hospit...
Chopra V, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med. Vol. 163, No. 6 (Supplement). Sept. 15, 2015.
Recommended reading: Infusion Therapy Standards of Practice. Journal of Infusion Nursing. January/February 2016 supplement. Vol. 39, No. 1S.