patient populations. - norvannorvan.wildapricot.org/resources/documents/2016 edday... ·...

Jamie Bowen Santolucito, RN,CRNI,VA-BC Vascular Access Specialist/EducatorVibra Specialty Hospital Portland, Oregon

Making PICCs Safer—What We Know; What We Don’t Know; What We Need to Know

Disclosures

Speaker Bureau: Bard Access Systems

There is no corporate support for this lecture

Lecture Objectives• Examine and evaluate current research and controversy surrounding the application

of PICCs in vulnerable, high-risk patients.• Explore the evidence and, in some cases, lack of evidence behind current insertion-

related and post-insertion-related practices, techniques and technologies designed to reduce risks associated with PICCs.

• Identify evidence-based interventions shown to significantly improve patient outcomes and reduce risks associated with PICC usage even among some high-risk patient populations.

“Probably half of what we teach you in medicine is right; the problem is, we don’t knowwhich half it is.” George Markelonis, Ph.D

Associate Professor of Anatomy and Neurobiology University of Maryland

“Absolutely do not marry any idea or fact in medicine…it will likely turn out to be only partially true or even false. Find the strength to step out of your comfortable shell. You’re more vulnerable but that is what separates the true learners and teachers from the vast majority. Humility is essential in this process. Remember…where all think alike, no one thinks very much.”

Marc Gosselin, MDAssociate Professor of Diagnostic RadiologyRecipient of the 2013 Faculty Excellence in Education Award Oregon Health & Science University Hospital

What We KnowHow We Provide Healthcare is Dramatically Changing

• Risk reduction is at the forefront of healthcare• Historically hospitals and HCPs received reimbursement based on volume despite

outcomes• Quality vs. quantity

• Oct 2008—CMS discontinued reimbursement for common HAIs• Oct 2015--Hospital-Acquired Condition (HAC) Reduction Program implemented

• Requires CMS to reduce hospital payments to hospitals that rank among the lowest- performing 25 percent with regard to HACs

• Essence of the principle of the Hippocratic Oath, “first, do no harm” is possibly moreevident than ever before

“Be Picky About PICCs”American College of Physicians Hospitalists, 2013

“Don’t Place or Leave in Place PICCs for Patient or Provider

Convenience ”Society of General Internal Medicine Choosing Wisely Campaign, 2013

“PICCs May Be the New Cardiac Stress Test”American College of Physicians, 2012

“Commonly Used Catheters Double Risk of Blood Clots in ICU and Cancer Patients”Infection Control Today, 2013

“Serious Risks from Common IV Devices (PICCs) mean Doctors Should Choose CarefullyScience Daily, March 20, 2015

“Commonly Used Catheter’s Safety Tied to Patient Population” “Study Shows PICCs Have Similar CLABSI Risk in Vulnerable Patients”

SHEA, 2013

“The Problem with Peripherally Inserted Central Catheters”“Physicians Should Exercise Restraint in the Decision to Place PICCs”

JAMA, 2012

“The PICC Myth” “Commonly Used Catheters (PICCs) Pose Significant Risks for Infection,

Thrombosis and other Complications”

Patient Safety Tip of the Week, Jan 21, 2014The Truax Group, Patient Safety Solutions and Healthcare Consulting

Making PICCs SaferWhat We Know; What We Don’t Know; What We Need to Know

• Insertion Risk

Insertion-Related Risks—What We Know

• PICCs are superior to CICCs in minimizing serious insertion-related complications

• Current research has failed to address all aspects of patient risk whencomparing CICCs to PICCs

• CICC mechanical insertion-related complications• Occur at significant rates• Are associated with increased risk for HACs, morbidity, increased

lengthof stay

• Significant portion are never, non-reimbursable events

Risks of Placing and Removing PICCs and CICCs

1Hospital-Acquired Conditions and Present on Admission Indicator Reporting Provision.Centers for Medicare & Medicaid Services. ICN 901046 September 2014

Risk HAC1 PICC CICCPneumothorax X X

Air Embolism X X

CLABSI X X X

Hemothorax X

Arterial Injury(associated with uncontrolled bleeding)

X

Parienti, J.J., et al. (2015) N Engl J Med

• Multicenter randomized controlled trial to evaluate patient risk by CICC insertion site2532 catheters randomly assigned to IJ, SCV or femoral vein•

Insertion-Related Risks—What We Know

• PICCs are superior to CICCs in minimizing serious insertion-relatedcomplications

• Research has repeatedly shown that inexperience and failure to use real-time US-guidance are primary risk factors for CICC insertion-related complications

• Recent estimates report < 70% of practitioners consistently use real-time US guidance for CICC insertion

Empower Vascular Access Specialists to

Perform CICC Insertion• Specialized dedicated vascular access teams using recommended technology– High volume → greater experience/proficiency → reduced complications

• Designate only trained personnel to insert/maintain CVCs (IA)– Currently possess expert-level knowledge and skills

• Use of real-time ultrasound guidance• Vascular anatomy of the upper extremity, neck and thorax• Use of dilators, wires, introducers• Catheter navigation, confirmation systems and/or radiographic assessment to ensure proper catheter tip

position

• Provide crucial resource to patients, staff nurses and physicians– Lack of proficient medical staff available to insert CICCs

• Contributes to suboptimal VAD selection/placement• Jeopardizes patient outcomes and life-sustaining options for future vascular access

O’Grady, N.P., et al (2011) Guidelines for the prevention of intravascular catheter-related infections.


• Insertion Risk• Infection Risk

CLABSI Risk—What We KnowPICCs vs. CICCs

• 2014 SHEA/IDSA Practice Recommendations• PICCs may be associated with lower rates of

CLABSI in out-patient settings• Vulnerable, hospitalized patients may be just as

likely to experience CLABSI with PICCs as with CICCs

• Do not use PICCs as a strategy to reduce the risk of CLABSI

• Standard 26. VAD Planning• Do not use a PICC as an infection prevention

strategy (III)Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN.

Marschall, J., et al. (2014) Infect Control Hosp Epidemiol.

What We Know• Strict adherence to central line bundle works• CDC HAI Progress Report, 2016

– 50% reduction in CLABSI between 2008 and 2014– No change in overall CAUTIs– 17% reduction in SSIs– 8% reduction in C. diff infections– 13% reduction in MRSA bacteremias

• Department of HHS Road Map to Eliminate HAI– Proposed targets for 2020

• 50% reduction from 2015 baseline• Opportunities for improvement still exist

Centers for Disease Control and Prevention (2016) Healthcare-associated infections (HAI) progress report.

What We Know

Real-time catheter navigation and

confirmation systems readily and

accurately detect malpositions and

dramatically reduce the need to

manipulate catheters post-insertion

Opportunities for Improvement Exist

CVAD Tip Confirmation• Standard 23. CVAD Tip Location

– Use methods for identifying CVAD tip location during the insertion procedure (i.e., “real-time”) due to greater accuracy, more rapid initiation of infusion therapy and reduced costs

– Post-procedure radiograph imaging is not necessary if alternative tip location technology confirms proper tip position

– Clinicians with documented competency determine the tip location of a CVAD by using ECG or assessing the post-procedure chest radiograph and initiate therapy based on this assessment

• MAGIC Consensus Statement– Chest radiography verification of the PICC tip

after placement via verified EKG guidance or fluoroscopy is inappropriate

Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN.Chopra, V., et al. (2015) Annals of Internal Medicine.

CVAD Insertion Checklist• Standard 33. Site Preparation and Device Placement

– Standardized checklist should be completed by• Someone other than the CVAD inserter• An educated healthcare clinician

• SHEA/IDSA 2014 Practice Recommendations– Ensure and document adherence to aseptic technique– Documentation should be done by someone other than

the inserter• Nurse, physician or other healthcare personnel who

has received appropriate education to ensure aseptic technique is maintained

Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN.Marschall, J., et al. (2014) Infect Control Hosp Epidemiol.

What We Know

• Use CVADs of all types only when medically necessary and remove promptly when no longer essential (Category 1A)– Provide easy access to an evidence-based list of indications for CVAD

use to minimize unnecessary usage (III)1–

O’Grady, N.P., et al (2011) Guidelines for the prevention of intravascular catheter-related infections.

Marschall, J., et al. (2014) Infect Control Hosp Epidemiol.

What We Know– Everyday a CVAD is in place the risk for CLABSI and DVT

increases– Early removal vs. increased patient risk

– Daily justification for all CVADs– Include assessment for CVADs removal as part of

daily goal sheet– State the line day during rounds as a reminder of how long the

CVAD has been in place– Perform audits to determine whether CVADs

are promptly removed after their intended use– Opportunity for VA specialists?

» Staff vs. VAD specialist motivation– 1

Marschall, J., et al. (2014) Infect Control Hosp Epidemiol.Chopra, V., et al. (2013) Agency for Healthcare Research and Quality Evidence Report/Technology Assessment Making Health Care Safer

II.

• Retrospective observational study in a tertiary care academic medical center– 89 ward patients with 146 CVADs

• 56% were PICCs– Total of 1433 CVAD days

• 361 days were idle (25.2%)• Mean of 4.1 idle days per CVAD

• High proportion of PICCs not removed until discharge even in patients with PIV who were receiving only abx• Conclusion

• Significant ward CVAD days were unjustified• Reducing idle CVAD days may reduce overall CVAD days and CLABSI risk• Provide specialized vascular access teams to encourage US-guided PIV placement in patients with difficult access if

there is no other indication for CVAD

Reducing CVAD Usage/Days

Effective Strategies• Clinically-indicated replacement (CIR) of PIVs• US-guided PIVs• US-guided midlines

CIR of PIVs—What We Know• We have level 1 evidence supporting CIR for PIVs• We have level 2 evidence that its the total length of time of PIV access (not

CIR or RR) that leads to CRBSI• Crucial issues are

– Insert with aseptic, no-touch technique using > 0.5% CHG in alcohol– Assess site q shift for phlebitis, occlusion, infiltration

• Involve patient in assessment– Pain is the earliest, most frequent symptom associated with phlebitis

– Remove PIV promptly when no longer needed

Wallis, M., (2015) Moving to clinically-indicated vs. scheduled replacement: point/counterpoint. Presented at the 29th AVA Scientific Meeting, Dallas, TX.

Webster, J., et al. (2010) Cochrane Database Syst Rev.Ricard, C.M., et al. (2012) Lancet, 380;1066-1074.

Webster, J., et al. (2015) Cochrane Database Syst Rev.

PIV/Midline Removal

• Standard 44. VAD Removal– VADs are not removed solely on length of dwell time because there

is no known optimum dwell time– Remove short peripheral and midline catheters

in pediatric and adult patients when clinically indicated– Remove the short peripheral catheter if it is no longer included in the

plan of care or has

not been used for 24 hours or more

Infusion Nurses Society (2016) Infusion Therapy Standards of Practice. JIN.

CIR of PIVs—What We Don’t Know

• Should CIR PIVs be placed using sterile technique?– Standard 33. Site Preparation and Device Placement

• Consider increased attention to aseptic technique including– Strict attention to skin antisepsis– Use of sterile gloves (V, Committee Consensus)

• What about dressing/extension set/needleless connector change frequency?– Standard 41. VAD Assessment, Care and Dressing Changes

• Perform dressing changes on PIVs at least q 5-7 days and prn (V)• Change add-on device with new VAD insertion,

with administration set replacement, or as defined bythe organization and whenever integrity is compromised (V)

• Anti-microbial patches?


Ultrasound-Guided PIVs• Rapidly evolving practice• Standard 22. Vascular Visualization

– Use US for short PIV placement in adult and pediatric patients with difficult venous access to increase success rates and decrease the need for CVADs

– Sterile technique?• Use a large sterile transparent membrane dressing

over the probe or sterile sheath cover and sterile gel (V)

• Opportunity to provide proper education, training and competency validation– Particularly in the absence of 24/7 coverage

Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice . JIN.

• Prospective, pilot study– 31 adult SICU patients• Indication for midline– CVAD removal = 51.6%– IV access = 48.4%

••

25 (83%) of patients did not require any other IV access for the remainder of their hospitalization 283 central line days avoided

– Mean of 10 days/patient Complications (12.8%)

•– IV site leakage 3 (9.6%)– Superficial phlebitis 1 (3.2%)

• Conclusion– US-guided midlines provide a cost-effective alternative for patients in the SICU with difficult IV access– Successful placement may facilitate early CVAD removal and may reduce CLABSI rates

Deutsch, G.B., et al. (2013) Journal of Surgical Research.

– Two year retrospective cohort study to determine impact of midlines on CLABSI rates– Policy for replacing CVAD with a midline

• Femoral CVAD• CVAD in place for > 1 week• Patients not receiving inotropes, vasopressors or TPN• Patients discharged to SNF on antibiotic therapy

– Results• Significant decrease in CVAD catheter days and CLABSI rates

– Year prior to introduction of midlines» 2408 CVAD catheter days» 8 CLABSIs (3.32 per 1000 CDs)

– Year following introduction of midlines» 1521 CVAD catheter days» 0 CLABSIs per 1000 CDs

• No BSIs associated with midline use

Pathak, R, et al. (2015) Infectious Diseases in Clinical Practice.

• Purpose: Retrospective descriptive review to evaluate the effectiveness of a midlineprogram at 2 ACHs– Both hospitals demonstrated reduced rates

of CLABSI• Hospital 1

– CLABSI rates decreased from1.7/1000 CDs to 0.2/1000 CDs

» 78% reduction in CLABSI rates

– Cost saving of > 500,000/annually

– No midline-associated infections reported in either hospital

– Conclusions:– Midline catheters provide reliable vascular

access, reduce multiple PIVs and invasive CVADs, CVAD days and CLABSI rates

Moureau, N. et al. (2015) JAVA.

A COST-EFFECTIVE, PEER-DRIVEN APPROACH TO REDUCING UNNECESSARY UTILIZATION OF PERIPHERALLY- INSERTED CENTRAL VENOUS CATHETERS AND CENTRAL LINE-ASSOCIATED BLOOD STREAM INFECTIONS

Cynthia Wallace, MD,MSPH, Jamie Bowen Santolucito, RN,CRNI,VA-BC, Dana Kellis, MD,MBA,PhD

Background:Central line-associated bloodstream infections (CLABSIs) are an undisputed issue in hospital medicine. CLABSIs increase cost, morbidity and mortality, and hospital length of stay, thereby increasing risk of additional hospital-associated complications. There are two primary methods to reduce the incidence of CLABSIs – first, ensuring appropriate placement and management techniques for necessary central lines and second, reducing unnecessary utilization of these lines. Achieving maximal CLABSI reduction requires attention to both.Purpose:The goal of our intervention was to reduce inappropriate peripherally-inserted central venous catheter (PICC) utilization and CLABSIs in inpatients at a long-term acute care hospital (LTACH) without incurring additional cost.Description:In December 2013, we implemented a comprehensive program to reduce inappropriate PICC utilization in a 75-bed LTACH in Portland, Oregon. We had a vascular access team in placewith board-certified vascular access RNs and strict adherence to PICC management bundles performed only by this team. Our strategy was to improve compliance with evidence-based recommendations through increased awareness, improved multi-disciplinary and physician team communication, and staff empowerment. We used Choosing Wisely recommendations from the American Society of Nephrology, Society for Hospital Medicine and Society of General Internal Medicine to support the initiative. Selected recommendations were discussed in physician staff meetings, posted prominently in the physician workroom and distributed to all physicians via email. Multi-disciplinary bedside rounds involving nursing, therapies, case management and physician staff were implemented 2-3x/week, depending on patient acuity. The Choosing Wisely recommendations were discussed on rounds, and rounds scripting included questions regarding PICC presence and indication. Noon physician daily report was initiated with opportunity for further discussion of PICC utility in specific situations. Providers were expected to have an evidence-based justification for PICC placement and continuation. Finally, the vascular access team and other staff were empowered to question PICC placement indication and encourage prompt removal of unnecessary PICCs.Subsequent to implementation, there was a precipitous drop in PICC utilization (7.2 to 2.3 insertions per 1000 patient days (PD)). The decrease in infection rate was even more compelling(1.1 to 0.10 per 1000 PD), due to decrease in insertions and duration of PICC use. Mortality was stable with an overall decrease in cost PPD of ~20%, decrease in readmission rates and increased physician efficiency.Conclusions:Physicians and other care providers have a strong desire to provide high quality care. Providing education and peer support to do so can markedly improve adherence to evidence-based recommendations and patient outcomes, without financial outlay and with improved cost-effectiveness of care.

Midline OutcomesData from Vibra Specialty Hospital, Portland, OR

66%

14%

2%9%

9%

Indication for Midline Removal

Completed IVT

Kinking/occlusion/leakage

Pain/phlebitis

Transferred/expired

Required CVAD

••

100 midlines in 87 patients Indications

– Anti-infective agents– Hydration– Pain mgmt/comfort care– Antiemetics– Contrast– PPN—2 cases with poor outcomes

••••

Dwell times ranged from 3-57 days Average dwell time = 9.8 daysFailure rate = 16% (PIV failure rate=35-50%)1

No clinical s/s of DVT/infection

1 Helm, et all (2015) Accepted but unacceptable: peripheral IV failure rate. JIN.

PICC Usage per Patient DaysData from Vibra Specialty Hospital, Portland, Oregon

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3 A

ug-1

3 S

ep-1

3 O

ct-1

3 N

ov-1

3 D

ec-1

3 Ja

n-14

Fe

b-14

M

ar-1

4 A

pr-1

4 M

ay-1

4 Ju

n-14

60%

50%

40%

30%

20%

10%

0%

.

Patients with PICCs

Average before Intervention

Average after Intervention

CLABSI EventsData from Vibra Specialty Hospital, Portland, Oregon

0.16/mo0

1

2

4

3

Jan-

13

Feb-

13

Mar

-13

Apr

-13

May

-13

Jun-

13

Jul-1

3 A

ug-1

3S

ep-1

3 O

ct-1

3 N

ov-1

3 D

ec-1

3 Ja

n-14

Fe

b-14

M

ar-1

4 A

pr-1

4 M

ay-1

4

Jun-

14

CLABSIs per Month

Average before Intervention

Average after Intervention1.3/mo

Choosing Wisely CampaignAn Initiative of the American Board of Internal Medicine Foundation (ABIM)

• The initiative addresses the top 5 common practices and procedures that physicians and patients should question

– Society of General Internal Medicine➢ “Don’t place or leave in place PICCs for patient or provider convenience”

– American Society of Nephrology➢ “Don’t place PICCs in stage III-V CKD patients without consulting nephrology”

– Society of Hospital Medicine➢ “Don’t perform repetitive CBC/chemistry testing in the face of clinical and laboratory stability”

“Hospitalized patients frequently have considerable volumes of blood drawn for diagnostic testing during shortperiods of time. Phlebotomy is highly associated with changes in hgb and hct levels and can contribute to anemia. This anemia may have significant consequences, especially for patients with cardio-respiratory diseases. Additionally, reducing the frequency of daily unnecessary phlebotomy can result in significant cost savings for hospitals.”

Society of General Internal Medicine Choosing Wisely Campaign (2013). American Society of Nephrology Choosing Wisely Campaign (2012).

Society of Hospital Medicine Choosing Wisely Campaign (2013).

Additional Strategies to Reduce CVAD Days➢ Daily multidisciplinary bedside rounds to justify all CVADs with low tolerance for

“idle” CVAD dayso Designate Vascular Access Specialist to justify ongoing need for all VADs

• Access pharmacy data daily to justify CVAD– Abx, parenteral nutrition, vasopressors, inotropes, chemotherapy

• Blood sampling and/or narcotics generally do not warrant continued CVAD use

➢ As soon as clinically feasible, transition to oral equivalent medications and discontinue CVAD

➢ Don’t place PICCs for administration of empiric anti-infective agentso Use PIVs or US-guided midlines until central venous access is clearly

justified

Indications/Contraindications for Midlines• Standard 22. VAD Planning

o Consider infusate characteristics in conjunction with anticipated duration of treatment ( e.g., 1-4weeks) (IV)

o Indications• Medication and solutions such as antimicrobials, fluid replacement

and analgesics with characteristics that are well tolerated by peripheral veins (V)

o Contraindications• Continuous vesicants, parenteral nutrition or infusates with osmolarity

> 900 mOsm/L (V)o Avoid the use of a midline catheter in patients with a history of

thrombosis, hypercoagulability, decreased venous flow to the extremities, or end-stage renal disease requiring vein preservation (IV)

• Use caution with administration of intermittent vesicantso Vancomycin administration via midlines for < 6 days was found

to be safe in one study (V)Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN.

• Prospective randomized clinical trial to determine the safety of intermittent vancomycin via a midline catheter

• 54 patients receiving vancomycin over a minimum of 60min at a concentration of 4mg/ml, either q d or BID– 29 patients received midlines

• Average dwell time was 5.8 days• Complication rate was 19.9%

– 3 infiltrations without tissue damage– 2 dislodgements– 1 leakage

• 25 patients received PICCs– Average dwell time was 6.3 days– Complication rate was 17.9%

– 1 suspected BSI– 4 dislodgements

• Conclusions: Shot-term intravenous vancomycin can be safely and cost-effectively administered in the deep veins of the upper arm via a midline catheter with less risk of DVT and CLABSI associated with PICCs.Study limitations: Small sample size

•

Caparas, J.V., Hu, J.P. (2014) Jour Vasc Access.

Considerations for Midlines

• Standard 33.Vascular Access Site Preparation and Device Placement

• Consider the use of maximum sterile barrierprecautions with midline catheter insertion. (V)

• MST vs. new generation midlines?• Consider the use of labels to differentiate midlines

from PICCs?

Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN.

What We Know• Select insertion site with lowest bacterial risk

– Included in the IHI Central Line Bundle and CDC Guidelines• Avoid femoral exit site (1A)• Use subclavian site over jugular site in adults (1B)• Avoid subclavian site in advanced CKD (1A)• What about PICCs?

Chopra,V., et al. (2013) Prevention of central line bloodstream infections: brief update review. AHRQ Making Healthcare Safer II.Institute for Healthcare Improvement (2014) Implement the IHI Central Line Bundle. O’Grady, N.P., et al

(2011) Guidelines for the prevention of intravascular catheter-related infections.

Tunneling PICCs?

• Toh, L.M., et al. (2013) JVIR– Tunneled PICCs were significantly more likely to provide access until the end of therapy

and were associated with lower rates of infection, malposition and thrombosis than non-tunneled PICCs

• Use tunneling for high-risk areas to reduce infection and thrombosis risk (Pittiruti, 2014 & 2015AVA Scientific Meetings)

What We Know

• Presence of thrombi facilitate adhesion of bacteria, colonization andCLABSI

• Standard 48. CVAD Occlusion– Do not leave a CVAD with an occlusion untreated;

do not leave an occluded CVAD lumen untreated becauseanother lumen is patent

– Stop all infusions, when possible, when treating a multilumen CVAD to optimize thrombolysis during dwell time

• Proper dosing?


Study Purpose: Evaluate the efficacy and economic impact of intraluminal volume (1mg/1mL) vs. standard (2mg/2mL ) dosing• 2mg/2mL dosing has been well studied• Little research available regarding the efficacy of

intraluminal volume (1mg/1mL) dose• Intraluminal volume of most PICCs is < 0.8 mL• Approximately half of each standard dose is wasted

with significant cost to institutions• 3 month trial including data from 270 occlusions in 168

patients

Sapienza, S.P., Ciaschini, D.R. (2015) Hosp Pharm.

85.60%84%

82%

87.20%

93.30%

90%

94.40%

80%

86%

88%

94%

96% Intraluminal vs. Standard Alteplase Dosing

Patency after 1st dose Patency after 2cd dose

1mg/1mL

2mg/2mL

Sapienza, S.P., Ciaschini, D.R. (2015) Intraluminal volume dose alteplase for the clearance of occluded peripherally inserted central catheter lines at a long-term acute care hospital; efficacy and economic impact. Hosp Pharm.

Conclusion: For the clearance of occluded PICC lines there was no statistical difference in the efficacy of intraluminal volume dose

alteplase versus the standard dose. Use of intraluminal volume dose alteplase was found to be significantly more cost-effective.

What We Don’t Know

• Antimicrobial impregnated catheters– Evidence to date shows no significant benefit of antimicrobial impregnated catheters

in reducing sepsis/mortality

Lai, N.M., et al. (2013) Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults.

Cochrane Data Base of Systematic Reviews.

• 56 studies representing 16,512 catheters– 11 types of antimicrobial impregnations– Benefit varied according to study setting

• Significant reduction in catheter colonization in ICU patients

• No evidence of benefit in hematology/oncology/long-term TPN patients

– Conclusion• “While there is convincing evidence on the

benefits of antimicrobial-impregnated CVCs in reducing CRBSI and catheter colonization in the ICU setting, limited evidence to date shows no significant benefit of these catheters in reducing clinically diagnosed sepsis and mortality.”

– Of the individual studies that provided data on sepsis and mortality rates, the findings consistently revealed no reduction in clinically-diagnosed sepsis and mortality

Lai, N.M., et al. (2013) Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Data Base Syst Rev.

• Conclusion– Limited evidence suggests that

antimicrobial CVCs do not appear to significantly reduce clinically diagnosed sepsis or mortality. Our findings call for caution in routinely recommending the use of antimicrobial-impregnated CVCs across all settings.

• Implications for future research– Whether these catheters reduce

overall rates of sepsis and mortality is now the critical research question.

Lai, N.M., et al. (2013) Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Data Base Syst Rev.


• Insertion Risk• Infection Risk• Venous Thrombosis

Risk

• Largest meta-analysis to date– 64 studies including 29,503 patients

• 52 non-comparative studies• 12 comparative studies

– Pooled meta-analysis showed PICCs were associated with 2.5-fold greater increase in UEDVT

– Conclusions• PICCs associated with a greater risk of UEDVT than were CICCs

– Critically-ill and cancer patients• Physicians should weigh the risk of PICC DVT against benefits of this device especially in high-risk patients

– Standard 26. VAD Planning (2016 INS SOP, pg. S52)• Use a PICC with caution in patients who have cancer or are critically-ill due to venous thrombosis and infection risk

(III)

– Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)• CICC preferred to PICC for < 14 days in critically-ill patients

Chopra, V., et al. (2013) Lancet.

Study Limitations• Meta-analyses ideally comprised of prospective RCTs published in peer- reviewed journals– No RCTs in this review

• Included any type of clinical paper (retrospective, non-randomized) and even abstracts and papers published in non-peer-reviewed journals– Approximately one-third of studies included were published in abstract form only


– Failure to measure the same clinical outcome• Asymptomatic vs. symptomatic DVT vs. SVT vs. catheter occlusion

– Inclusion criteria extremely heterogeneous• Many studies did not represent contemporary practice and technology

– AC vs. upper arm PICC insertion– Different generations of devices over 16 years– Most studies provided little or no information about tip position

• Oncology and non-oncology patients• Some studies included PICCs in patients with obvious contraindication

Study Limitations


Rates of Symptomatic PICC DVT Following Implementationof an Effective DVT Prevention Bundle

Average rate of symptomatic PICC DVT = 1.5%

“When PICCs are inserted above the elbow into larger vessels or when the vein diameter is checked before PICC insertion, the risk of DVT decreases.”

Chopra, et al, 2013

• Meyers, 2011 1.4%• DeLemos, 2011 (Neuro) 3%• Pittiruti, 2012 (ICU) 3.1%• Cotogni, 2013 (Hem-onc) 0%• Evans, 2013 1.9%• Mermis, 2014 (4FR only) 0%• Pittiruti, 2014 (Hem-onc) 0.5%• Wilson, 2014 1.6%• Cotogni, 2015 (Hem-onc) 1.1%• Dupont, 2015 2%• Nolan, 2016 (ICU) 2%

••

Mayo Clinic retrospective cohort study Purpose: Limited contemporary data describing rates of CRT and CLABSI for PICCs and CICCs inthe ICUObjective: To assess/compare symptomatic CRT and CLABSI rates for PICCs and CICCs in the ICUConclusions: No significant difference in CRT andCLABSI rates.PICCs dwelled 2.7 times longer than CICCs. When followed until hospital discharge CRT rate was

•

•

– 4% for PICCs– 1% for CICCs

Half of PICC DVTs occurred on the general floor, and like all central catheters placed in the ICU, PICCs should be aggressively discontinued when no longer absolutely needed.

Nolan, M.E., et al. (2016) Jour of Crit Care.

PICCs (5&6 FR)

(N=200)CICCs (N=200)

Indwelling days 750 535

Median Indwelling ICU Catheter Days

2.3 2.0

No significant difference in indwelling ICU days

Symptomatic CRDVT

2%(3:1 vein-to-catheter ratio)

1%

No significant difference in DVT rates P=0.685

CLABSI 0 0

What We Know

• “There is convincing clinical evidence that proper patient and vein selection as well as proper insertion and post-insertion techniques effectively reduce PICC-associated venous thrombosis”

Pittiruti, M. (2015) What the world needs now is an insertion bundle to prevent catheter-related thrombosis.

Presented at the 29th AVA Scientific Meeting, Dallas, TX.

Reducing PICC-Associated Venous Thrombosis Risk

• Thorough pre-insertion assessment• Determine that a CVAD is warranted• Ensure that a PICC is the best device

• Past and present medical history• Assess for CKD stage 3b or greater• Avoid extremity affected by axillary node dissection, reduced mobility due

to neurologic or orthopedic conditions• Relevant laboratory values

• BUN, creatinine, GFR• WBC and recent culture results• Severe coagulopathies

• Relevant radiographic studies

MC-PP-769

12.5 cm


• Thorough pre-insertion assessment• Appropriate vein selection

• Select mid upper arm• Avoid thrombosed/stenosed veins• Right vs. left side approach?

Right vs. left sided approach?––

Compelling evidence for right-sided approach for CICCs…but what about PICCs? Asymptomatic DVT rates

» Bonizzoli, et al. (2010) Intensive Care Medicine• 114 PICC insertions

••

Left arm = 37.1%Right arm =18.3%

– Symptomatic DVT rates» Sperry, et al. (2012) Jour of Vascular

Access• 798 PICC insertions• Overall incidence of UE PICC DVT rate = 1.25%

••

Left arm = 1.3%Right arm = 1.25%

» Chopra, et al. (2014) Jour of Thrombosis and Haemotology

• 966 PICC insertions• Overall incidence of UE DVT = 3.4%; incidence of LE DVT = 1%•

•Left arm = 33% Right arm = 66/7%

» Sharp, et al. (2015) International Jour of Nurs Studies

• 136 PICC insertions• Overall incidence of UE DVT = 2.9%•

•Left arm = 25% Right arm = 75%

– MAGIC Consensus Statement• Avoiding PICC insertion in the dominant arm as a strategy to prevent complications was rated as inappropriate, given the

lack of convincing data to support this practice. Consider technical aspects and patient preference when selecting arm of insertion.


• Thorough pre-insertion assessment• Ensure adequate vein-to-catheter ration

• May be most modifiable risk for reducing PICC-associated DVT• Consider 4 FR PICC as default catheter size

• Require clinical justification for 5 FR catheters• Avoid 6 FR catheters


• Nolan, M.E., et al. (2016) Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. Jour of Critical Care

• Meyer, B.M. (2011) Managing Peripherally Inserted Central Catheter Thrombosis Risk: A Guide for Clinical Best Practice. JAVA– Retrospective analysis of 1307 PICC insertions– 2:1 vein-to-catheter ratio criteria implemented– Symptomatic PICC DVT rates declined from 2.9% to 1.4%

• Evans,R.S., (2013) Reduction of peripherally inserted central catheter-associated DVT.CHEST

– 3 year prospective observational study– Replaced 6 FR TL PICC with 5 FR triple lumen PICC– Default catheter was 4 FR single lumen PICC

• VAT required clinical justification for each lumen of the PICC– Symptomatic PICC-associated DVT rate declined significantly

Evans,R.S., Sharp,J.H., Linford,L.H., et al. (2013) Reduction of peripherally inserted central catheter-associated DVT. CHEST 143(3);627-33.

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Reducing PICC-Associated Venous Thrombosis Risk• Sharp, R., et al. (2015) The catheter to vein ratio and rates of symptomatic thromboembolism in patients with

aPICC: a prospective cohort study. International Jour of Nurs Studies– Prospective study to identify optimal catheter-to-vein ratio cut-off point to reduce rates of VTE

– 136 patients (50% cancer; 44% infection; 6% other)– 4 cases of confirmed symptomatic DVT (2.9%)– Vein, arm, number or attempts, presence of malignancy or duration of dwell were not associated with VTE– Catheter size had a significant influence on risk

• For each increase in FR size there was 9 times increased risk for VTE• Mermis, J.D., et al. (2014) Quality improvement initiative to reduce deep vein thrombosis associated with PICCs

in adults with cystic fibrosis. Annals of American Thoracic Surg– 5-year retrospective cohort study– 369 PICCs in 117 patients for a total of 5,437 catheter days– Strongest predictors of DVT occurrence

• Warfarin use• Previous history of PICC-associated DVT• Catheter size

– Implemented QI initiative to encourage judicious PICC use and 4 FR as standard for CF patients– Incidence of PICC-associated DVT rate declined from 9.5% to 3.4%

4 FR 5 FR 6 FR

The odds of PICC-associated DVT were reduced by approximately 70% after the QI initiative.

Before Intervention

After Intervention

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

0%

65.80%

16.30%

24.80%

82.10%

6.80%

Proportion of PICC Size Inserted Before and After Intervention

Mermis, J.D., et al. (2014) Quality improvement initiative to reduce deep vein thrombosis associated with PICCs in adults with cystic fibrosis. Annals of American Thoracic Surg

Recommendations for Catheter-to-Vein Ratio

1 Infusion Nurses Society (2016) Infusion Therapy Standards of Practice. Jour of Infusion Nurs. 39(1S):S112.2Sharp, R., et al. (2015) The catheter to vein ratio and rates of symptomatic thromboembolism in patients with a PICC: a prospective cohort study. International Jour of Nurs Studies

3 Meyers, B.M. (2011) Managing Peripherally Inserted Central Catheter Thrombosis Risk: A Guide for Clinical Best Practice. JAVA. 16(3):144-147.4 Pittiruti, M. (2015) What the world needs now is an insertion bundle to prevent catheter-related thrombosis. Presented at the 29th AVA Scientific Meeting, Dallas, TX.

5Nolan, M.E., et al. (2016) Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. Jour of Critical Care.*Use smallest size catheter and fewest number of lumens to accommodate therapy.

**The use of 6 FR PICCs have shown to significantly increase the risk of venous thrombosis.

Catheter Size* Minimum Vein Diameter (without tourniquet)

Catheter-to-vein ratio < 45% 1,2 2 x’s thecatheter size 3

3 x’s thecatheter size 4,5

3 FR / 20 g 2.1 mm 2 mm 3 mm

4 FR / 18 g 2.7 mm 2.6 mm 4 mm

5 FR / 16 g 3.5 mm 3.3 mm 5 mm

6 FR / 14 g** 4.2 mm 4 mm 6 mm


• Thorough pre-insertion assessment• Empower vascular access specialist to insert CICCs when PICC is contraindicated• Ensure vein-to-catheter ratio is at least 2:1• Default catheter is single lumen 4 FR in adults—require clinical justification for additional lumens

• Minimize trauma during insertion• Dedicated, specialized teams using real-time US, navigation/confirmation

systems• Use floppy 0.018 nitinol MST wire• Use dilator-introducer sheath with superior transition• Avoid tourniquet or place loosely and remove asap




• Thorough pre-insertion assessment• Ensure adequate vein-to-catheter ratio• Minimize trauma during insertion

• Proper catheter tip position on insertion and thereaftero Improper catheter tip position is a primary risk factor for CRT and catheter

malfunctiono Pre-insertion measurement alone is inadequateo Post-procedural CXR alone results in the acceptance of suboptimal tip positionso Current best practice incorporates the use of real-time navigation and confirmation to

achieve intraprocedural verification of proper catheter tip position



Proper CVAD Tip Position

• Redefine guidelines for CVAD tip position?

Proper PICC Tip Position• Standard 53. CVAD Malposition

– For PICCs with intracardiac location that is more than 2 cm below the cavoatrial junction, retract catheter based on ECG results or from measurement of the specific distance on the chest radiograph

– Avoid intracardiac tip location in neonates and infants less than 1 year of age, as thistip location has been associated with vessel erosion and cardiac tamponade (II)

• MAGIC Consensus Statement– Adjustment of PICC tips that reside in the lower one third of the superior vena cava,

cavoatrial junction, or right atrium is inappropriate– Only adjust PICCs that terminate in the upper or middle one third of the superior

vena cava or right ventricle

Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JINChopra, V., et al. (2015) Annals of Internal Medicine

Addressing PICC-Associated Venous Thrombosis Risk

• Thorough pre-insertion assessment• Empower vascular access specialist to insert CICCs when PICC is contraindicated• Ensure vein-to-catheter ratio is at least 2:1• Default catheter is single lumen 4 FR in adults—require clinical justification for additional lumens• Minimize trauma during insertion• Proper catheter tip position on insertion and thereafter• Routine use of real-time navigation/confirmation systems

• Avoid “idle” PICC days• Daily assessment for all VAD necessity

• Promptly remove all intravascular catheters when no longer essential• US-guided midlines has shown to facilitate early removal of CVADs

O’Grady, N.P., Alexander, M., Burns, L.A., et al (2011) Guidelines for the prevention of intravascular catheter-related infections.Deutsch, G.B., et al. (2013) Journal of Surgical Research. Pathak, R., et al. (2015) Infectious

Diseases in Clinical Practice. Moureau, N., Sigl, G., Hill, M. (2015) JAVA.

“Success is moving from failure to failure withcontinued exuberance.”

Winston Churchill

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