Peripherally inserted central catheters (PICCs) may be the new cardiac stress test.
“We began with a device that had clear benefit in a small group of patients, then let it spiral out of control, so to speak, to the point where we're now using it for every Tom, Dick and Harry,” said Vineet Chopra, MD, MSc, FACP, a clinical assistant professor of medicine at the University of Michigan in Ann Arbor. “Whether it's PICCs or stress tests or CT scans, they're so clinically useful and relevant, we forget there's a flip side.”
Dr. Chopra has been focusing research efforts on that flip side, looking at how PICCs have become ever more common, yet gaps in clinician knowledge and complication rates remain significant.
And he's not alone. Other researchers and clinicians have been working recently to highlight the risks of PICCs—especially venous thromboembolism and bloodstream infections—and the best safety strategies, from reducing PICC use to improving infection control and preventing thromboses.
Hospitalists are key to these efforts to make sure that PICCs are used for the appropriate patients for the appropriate indications for the appropriate duration, the experts say.
Popular for a reason
In 1975, when Verne Hoshal first wrote in Archives of Surgery about peripherally inserted central catheters, they were designed to provide total parenteral nutrition (TPN) in post-surgical patients.
“He didn't realize what he was working on would revolutionize the care of millions of patients,” said Dr. Chopra. “If you think about folks that need a few more days of antibiotics, or patients that are really ill getting poked and prodded throughout the day for labs, PICCs have really changed the game when it comes to venous access.”
Patients appreciate that change. “I've had patients say, ‘Please put another PICC in me. It was great last time around. I didn't have to wake up to get stuck 10 times for blood or for treatments,’” Dr. Chopra said. There are also patient-satisfaction, cost and safety benefits to letting patients leave the hospital with a PICC rather than remaining an inpatient.
Increased use of PICCs has also been driven by their obvious safety advantages during insertion, compared to traditional central venous catheters (CVCs). “You can't hit the lung when you're in the arm. You can't hit the carotid artery when you're in the arm,” said Adam Akers, MD, FACP, chief of the division of hospital medicine at the University of Pittsburgh.
In fact, physicians rarely have to worry about causing insertion complications at all, thanks to the advent of PICC teams, whose specialized nurses or radiologists are called in to insert the catheters.
“When I was in training, if a patient needed more than a few days of IV access, and you couldn't get a peripheral IV, it would often be up to me as the resident to insert a CVC in that patient. I had to then plan a one-hour procedure that had obvious risks, including insertion risks such as pneumothorax,” said Dr. Chopra. “PICCs have taken away the procedural risk element and instead, become an order of convenience.”
The ease of ordering has its downsides, he noted. “My biggest worry is that it's made us as a community a lot more mindless because we don't think things through as much as we used to when it comes to venous access,” Dr. Chopra said. The gaps in hospitalists' mental knowledge about PICCs were made apparent in a recent survey he and colleagues published in the June Journal of Hospital Medicine.
A third of the 144 surveyed hospitalists reported never examining PICCs for externally evident problems, such as exit-site infections; almost half said they always waited until discharge to remove a PICC; and more than half admitted that on at least one occasion they had forgotten a patient had a PICC. Almost half the hospitalists also said that a significant number of the PICCs placed at their hospitals may have been inappropriate or avoided.
While knowingly ordering a line for an inappropriate indication—for example, difficulty getting blood draws—is obviously a problem, some confusion over appropriate use is understandable.
“There are no criteria that actually define appropriate use of PICCs,” said Dr. Chopra. “We have good evidence for best practice when it comes to insertion of these devices. We have good evidence for best practice regarding maintenance and prevention of complications, whether it's caring for them or removing them as quickly as possible, or troubleshooting problems. However, there's very little evidence to guide us before the device actually goes in.”
He hopes to remedy that gap within the next two years by convening a panel of experts, including PICC nurses, interventional radiologists, critical care physicians, policymakers and hospitalists, to develop evidence-based guidelines. But, in the meantime, there are a number of measures that can be taken to improve PICC use.
Assess the patient's risks
Concerned hospitalists can start by gaining an accurate understanding of the risks and benefits of PICCs. For example, a study in the February Infection Control and Hospital Epidemiology identified some patient factors that could predict risk for PICC bloodstream infection: congestive heart failure, intra-abdominal perforation, Clostridium difficile infection, recent chemotherapy and presence of tracheotomy.
Physicians may also believe that bloodstream infection is less likely overall with PICCs than with CVCs, noted Michelle Mourad, MD, FACP, director of quality and safety for hospital medicine and an assistant professor at the University of California San Francisco (UCSF). “About four or five years ago, we saw a dramatic increase in PICCs because people thought there were lower rates of infections with PICC lines, which may or may not turn out to be true,” she said.
It's not true, according to a study by Dr. Chopra, published in the September Infection Control and Hospital Epidemiology. “There's no difference between PICCs and CVCs in terms of bloodstream infection risk. When you look at hospitalized patients specifically, the risk of infection is exactly the same,” he said.
PICCs perform even worse on the other major complication—deep venous thrombosis (DVT), he added. “We found that PICCs were two and a half times more likely to cause DVT than CVCs,” Dr. Chopra reported, citing a study published online by The Lancet in May.
Researchers at Intermountain Healthcare in Salt Lake City made similar findings. “Our PICC team was having trouble with DVTs…We've been able to bring the PICC-associated infections down quite a bit, so the PICC DVT became the most common problem,” said Scott Evans, PhD, medical informatics director for Intermountain.
Their solution was to study the root causes of the DVTs. “There were three patient risk factors: previous DVT, surgery greater than an hour, and the size of the PICC—whether it was a single lumen, double or triple,” said Dr. Evans.
To lower their DVT rate, his health care system focused on the third factor, replacing six French triple-lumen PICCs with five French ones and encouraging clinicians to order the minimum number of lumens needed. “We use significantly more single lumens now than we used to,” said Dr. Evans. “Whether the patient had a previous DVT, there's nothing we could do about that. Surgery greater than an hour, there's nothing we could do about that. But the size of the PICC—we went after that.”
Other options exist
There may be something else physicians can do for those at risk of DVT or infection: Don't order a PICC in the first place.
“The question about whether a patient actually needs a PICC is probably the most important question to ask,” said Craig A. Umscheid, MD, FACP, assistant professor of medicine and epidemiology at the University of Pennsylvania in Philadelphia.
Dr. Umscheid and colleagues recently conducted a review of nonpharmacologic interventions for preventing catheter thromboses, published in the June Journal of Critical Care. “What we found was the PICC lines were higher risk than some of the other types of central lines…and the best way to prevent these clots was really to avoid using these PICC lines,” he said.
In high-risk patients, consider alternatives, from no line at all to tunneled central lines to less commonly used options, the experts advised. “Many of my colleagues tell me, ‘If you don't want me to put a PICC in someone, what do I do?’…There are other devices,” said Dr. Chopra.
“People forget about midlines, which offer some advantages,” he offered as an example. “You don't have to check the position of the tip with an X-ray. It's much more convenient from a resource perspective…. Midlines have not been as well studied, but I do think they're less likely to cause DVT and infections because they have shorter dwell times and are non-central in their termination.”
The non-tunneled catheter is another alternative, especially for patients with end-stage renal disease, since a prior PICC can cause problems with future dialysis access. “They're thinner, they're less likely to cause venous scarring and central vein stenosis, but they need to be put in by interventional radiologists and nephrologists,” Dr. Chopra said.
Finally, peripheral IVs could be a good alternative, especially if insertion success could be improved. “We suspect that many PICC lines are being placed because the nurses couldn't get a peripheral,” said Dr. Akers. “Our project now is to try to train physicians and nurses how to place peripheral IVs using ultrasounds.” Other hospitals have opted to have existing PICC specialists also respond to requests for ultrasound-guided IV placement.
Future technological innovations may also encourage greater use of peripheral IVs.”New designs in peripheral IV cannulas are being developed which may reduce vein wall trauma, reduce phlebitis and infection risk and extend dwell time,” said Gail Egan, NP, interventional radiology nurse practitioner with Community Care Physicians in Albany, N.Y.
In addition to difficulty with insertion, lack of knowledge about medications going through the lines may lead clinicians to place unnecessary PICCs. “Understand which antibiotics really need that larger vein, which antibiotics are really irritants. That goes the same for nutrition products that are infused through these lines,” Dr. Umscheid said.
Broader dissemination of recent research findings about the safety of keeping peripheral IVs in for longer than three days could also encourage peripheral IV use, Dr. Chopra said, citing a study in The Lancet in September 2012 in which IVs were changed only when clinically indicated. “If you could buy a couple more days per IV, you may be able to get by with not needing to worry about other forms of venous access in your patients,” said Dr. Chopra.
Since physicians need to be familiar with a large quantity of still-developing evidence to optimize PICC use, experts are looking for ways to simplify decision making.
At UCSF, the effort started with a long paper form that PICC-ordering clinicians submitted to the access team, explaining the indication for line placement, whether it would be needed for more than three days, any comorbidities of concern, whether the patient would require sedation, and how many lumens were needed. Then the PICC team would conduct an assessment. “They would take the form and do a quick chart review on the patient, review platelets, [international normalized ratio], creatinine,” said Dr. Mourad.
The PICC team could follow up with ordering physicians to ask questions or make suggestions, but their authority to change the order was limited. “The PICC nurses aren't really in the place to be telling the physician, ‘I'm sorry, you're going to have to find IV access another way, because I don't think this is an appropriate indication,’” said Dr. Mourad.
Of course, physicians could ask the PICC inserters for their expertise (“Talk to your PICC nurse,” urged Dr. Chopra), but the advent of electronic medical records (EMRs) has actually decreased the required communication between parties. “Given how everything is so easily seen in our EMR now, the thought was that we didn't need physicians to fill out this long, cumbersome paper form. We left our expert PICC nurses to review the chart themselves,” said Dr. Mourad.
Health information technology does hold other potential to improve the PICC ordering process, according to Dr. Umscheid. “This is a really good area for decision support and informatics interventions,” he said. “We're creating a decision support here at Penn, which asks the user up-front a number of questions…like ‘What are you using it for? Are you using it for TPN? Are you using it just for IV fluids? Are you using it for chemotherapy? Are you using it for antibiotics? If antibiotics, what type?’”
Based on the answers, the system will recommend a type of line, and even a number of lumens. “You can try to educate providers about this, but oftentimes that's not enough. There's just so much information to remember that if a system can help aid your decision making, it's even better,” Dr. Umscheid said.
If you pick a PICC
After the decision-making process is complete and a PICC is scheduled for insertion, there's already a well-known system for reducing the risk of complications—the central line bundle.
But one cause of PICC infections may be sloppy application of this evidence-based checklist. “Everyone thinks that they're applying the central line bundle, which includes hand hygiene, site selection, maximum sterile barriers, use of chlorhexidine and alcohol as skin disinfection, and review of device necessity daily. Most hospitals are applying it a variety of ways and not very well,” said Nancy L. Moureau, RN, chief executive officer of PICC Excellence, Inc, an educational company focused on vascular access, based in Hartwell, Ga.
Because PICC insertions are lengthy procedures, “we have to be even more concerned about the central line bundle,” she said. One common deviation from the bundle is not having someone at the bedside to assure that the PICC inserter actually went through every step. “The inserter should not be checking off [her] own checklist,” Ms. Moureau said.
The requirement to review the device's necessity daily is another common oversight. “‘Has the patient had anything for the last 24 hours intravenously? If they have, can that medication be switched over to oral?’ Those are questions that need to be asked every day, not just by the bedside nurse, but also by the hospitalist,” said Ms. Moureau.
“Once the device is in, don't forget about it,” agreed Dr. Chopra. “We know that the earlier you remove a PICC, the better off you are when it comes to prevention of complications. As hospitalists, we really have an opportunity to impact outcomes because early removal remains in our domain.”
When it's time for PICC removal, make sure that whoever is doing the procedure knows the proper technique. “A lot of people don't know how to remove PICC lines, or think there's no risk of air embolism,” said Dr. Mourad. “If you just put the patient in Trendelenburg [position], but don't make sure that the arm is lower than the heart, that is not going to help.”
She added, “Fewer and fewer hospitalists are putting [PICCs] in, but we often have to remove them, so [I'm interested in] investigating what are programs doing to ensure safe central line removal.”
Hospitalists could also shoulder some responsibility for the PICCs that don't come out before discharge. Patients need a lot of education to maintain their devices, and insurance coverage for home nurse visits is often limited, said Ms. Egan, who is a trustee of the Oley Foundation, a patient organization for those receiving home parenteral or enteral nutrition.
In addition to the basics of flushing, hooking up to an infusion, and troubleshooting, “they need to know how do I live my life with this device…How do I take a shower? How do I go to my job?” she said. She provides a packet of information to discharged patients, including information on how to contact a clinician or a peer through the Oley Foundation.
Case managers and bedside nurses will typically provide this education, but hospitalists should at least make sure that follow-up contact information has been provided to the patient.
“An extremely important question that often gets overlooked is ‘Who do I call with questions?’ Is it the primary care physician? Is the infectious disease doctor who has given me the antibiotic? Is it the surgeon who is giving me the TPN?” said Dr. Chopra. “As hospitalists, our job is, before discharge, identifying that person very clearly.”
From preinsertion dilemmas to postdischarge planning, optimizing PICC use may sound like a lot of work for hospitalists, but don't lose hope. “I don't think PICCs are worse,” said Dr. Mourad. “I just think they haven't been historically treated with the same care, caution and thought to indications, contraindications and timely removal as other central lines. What I'd like to see is PICCs treated with the same caution and diligence.”
“Being mindful is the first step,” agreed Dr. Chopra.