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The Michigan Hospital Medicine Safety Consortium (HMS) Finds Infectious Diseases (ID) Physician Approval for Placement of Peripherally Inserted Central Catheters (PICCs) Prevents Unnecessary PICC Use and Reduces Complications

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February 23, 2022
Summary

With the PICC Use Initiative, the Michigan HMS, which currently includes 62 non-governmental hospitals in Michigan, aims to improve the safety of hospitalized patients by eliminating unnecessary PICC use and preventing PICC-associated complications. Since infectious diseases (ID) physician approval for PICC use is one promising strategy to reduce inappropriate use, the consortium helped promote and facilitate data collection for this patient safety strategy. In total, data comparing placement of PICCs for intravenous antimicrobials with and without ID physician approval are available for 42 hospitals. There was a range of use of ID physicians across sites. Physician approval was obtained in roughly half of all 21,653 PICC placement events. Compared with PICCs with no documented approval, PICCs with approval by an ID physician were more likely to be appropriate; 72.7% (7,446 of 10,238) of PICCs with ID physician approval were appropriate, whereas 45.4% of PICCs without ID physician approval were appropriate. Appropriateness was determined based on use of single lumens, length of placement greater than five days, and avoidance of use in patients with chronic kidney disease (CKD). ID physician approval also was associated with lower odds of PICC-related complications (6.5% versus 11.3%) including catheter occlusion (4.2% versus 8.6%) or deep vein thrombosis (DVT) (1.5% versus 2.1%).

HMS is one of 20+ Collaborative Quality Initiatives (CQIs) funded and in partnership with Blue Cross Blue Shield of Michigan (BCBSM) as a part of its Value Partnerships Program. The collaborative model is intended to support robust data collection and the sharing of best practices, so health professionals and hospitals can improve patient outcomes.

Innovation Patient Safety Focus

The initiative addresses the inappropriate use of, and complications arising from, PICCs, with a focus on use of PICCs and intravenous antibiotics. Potential complications from PICC use include catheter occlusion, DVT or thromboembolism, and central line-associated bloodstream infection (CLABSI).

Resources Used and Skills Needed

The consortium recommends starting the initiative by establishing collective understanding of concepts central to the intervention—for example, developing shared definitions of potential harms, the characteristics of appropriate device use, and vascular access options such as midlines. Hospitals can then develop local guidelines that urge (or require) clinicians to seek ID approval prior to PICC placement if the PICC indication is intravenous antibiotics.

Based on the work of the consortium, to implement ID physician approval of PICC placement, sites should also secure the following:

  • ID physician time and availability—ID physician support can be offered in person or via telehealth. ID physicians can also help design local guidelines and decision-making tools (e.g., decision trees, order sets).
  • Data collectors and data collection training
  • Access to electronic health records
  • Patient inclusion criteria
  • Outcome measures
  • Mechanisms for comparison, data submission, feedback, and sharing best practices

The following resources are needed to operate a similar PICC improvement initiative:

  • A team to collect standardized local data
  • Access to data from other participating (and non-participating) sites
  • Outcome measures
  • ID physician participation
  • Toolkits and agreed-on best practices
  • Training and communication channels (e.g., staff meetings) to disseminate training tools
  • Staff time
  • Audit and feedback processes
  • A central vascular access committee
Use By Other Organizations

The collaborative model has been of interest to providers across the country, and the CQI program has been profiled in presentations in over 30 countries. In 2021, health professionals gathered at an inaugural summit to share information, learn about the University of Michigan’s CQI model, and foster similar initiatives in other states.

Date First Implemented
2013
Problem Addressed

Use of peripherally inserted central catheters (PICCs) in healthcare has increased in the last ten years due in part to the risks involved with central venous catheters and subcutaneous venous ports.1

While PICCs offer several benefits to patients and providers, they are invasive devices that are known to be associated with life-threatening infections in hospitalized patients. In the United States, the CLABSI rate in intensive care units is estimated to be 0.8 per 1,000 central line days.2 Of all the healthcare-associated infections, CLABSIs are associated with the highest cost burden, accounting for approximately $46,000 per case.3 Sepsis is also a concern, and the presence of a PICC has been shown to contribute to increased rates of related bloodstream infections. A meta-analysis found that the presence of catheter-related bloodstream infection with PICC use was 0.48% (127 out of 26,422 participants in studies included in the meta-analysis).4 Additionally, the prevalence of venous thromboembolism with midline catheters and PICCs was found to be 2.29%.5

PICC placement also incurs costs associated with insertion of the device and subsequent maintenance. One model found that a hospital that places 1,000 PICCs per year (25% of which are single lumen and 75% of which are multi-lumen) experiences annual PICC-related maintenance and complication costs of $1,228,598 (95% confidence interval [CI], $1,053,175–$1,430,958).6

Description of the Innovative Activity

The PICC Use Initiative began as HMS member hospitals voiced concerns over the increasing prevalence of PICCs and potential patient safety issues associated with them. The hospitals elected to focus on the use of PICCs following a survey that showed significant variation in practice and high rates of potentially inappropriate use in ten HMS hospitals.7

Obtaining ID physician approval for PICC insertion was identified as a promising strategy to improve the use of PICCs. While HMS collects data on all aspects of PICC use, intravenous antimicrobial therapy is the most common use for PICCs.

As a first step in HMS’ focus on improving PICC use, in 2015, a group of vascular access experts from around the world, including several HMS member hospitals, and led by Dr. Vineet Chopra, convened to develop guidelines for the appropriate selection of vascular access devices, titled the Michigan Appropriateness Guide for Intravascular Catheters (MAGIC). HMS used the guidelines as a foundation of their PICC work. Subsequently, the collaborative rolled out a two-tiered approach to improving appropriate PICC use starting with sharing of best practices, followed by a more detailed toolkit.8 A total of 42 hospitals joined the initiative, and participation was voluntary. HMS determined the specific patient outcome measures, which included CLABSI, DVT, and catheter occlusion. Appropriateness was defined as use of single lumens, length of placement greater than five days, and avoidance of use in patients with CKD. Trained data abstractors across member hospitals used a standardized template to extract information from medical records. Specifically related to understanding ID physician involvement in placement decisions, the data were used to compare placement of PICCs for intravenous antimicrobials with and without ID physician approval.

Hospitals were also provided incentive-based payments from BCBSM through the pay-for-performance program to improve appropriate PICC use and outcomes.

Context of the Innovation

The innovation took place in the context of increased use of PICCs, with more than 2.7 million PICCs placed per year in the United States.9 Due to the frequency of use and resulting complications, increasing attention is being paid to best practices to prevent PICC complications. These practices cover PICC placement and management. Certain approaches, such as the use of vascular access teams, have shown promise in reducing adverse outcomes associated with PICCs.10 Additionally, it is theorized that ID physicians are more cognizant than other clinicians of appropriate PICC use.11

After considering several other potential projects aimed toward reducing adverse events in hospitalized patients, members of HMS voted to focus on PICC use due to trends in the use of PICCs and emerging best practices. An earlier survey of ten Michigan hospitals found that there was significant variation in clinical practice associated with PICCs. For example, 47% of the respondents indicated that 10–25% of PICCs inserted in their hospitals might be avoidable or might represent inappropriate use. Several other potential concerns were also identified in the survey, including lack of awareness of PICC presence, variability in utilization of PICCs, and management of complications, all of which may cause patient harm and increase costs.

In 2017, the consortium launched an initiative focused on the use of midline catheters, because many hospitals were increasing their use of these devices as an alternative to PICCs.12

The HMS PICC Use Initiative is one of several HMS initiatives. HMS has also focused on risk assessment and therapies for patients at risk for venous thromboembolism, use of midlines, antimicrobial use, and improving care for patients with sepsis.

Results

An observational study of the initiative included data collection over a period of four years and seven months (between January 1, 2015, and July 26, 2019).11 During this time, approval of an ID physician was provided in roughly half of all PICC insertions in a cohort study of 21,653 insertions. Compared with PICCs with no documented approval, PICCs with approval by an ID physician were more likely to be appropriately used; 72.7% (7,446 of 10,238) of PICCs with ID physician approval were appropriate, whereas 45.4% (5,180 of 11,415) of PICCs without ID physician approval were appropriate.

ID physician approval of PICC use was associated with lower odds of a PICC-related complication (6.5% versus 11.3%), including DVT. Additionally, PICCs approved by ID physicians were more often single-lumen catheters.

Rates of ID physician consultation varied greatly across participating hospitals. The variation did not appear to be associated with whether an ID physician was available on site. Of the 42 hospitals, eight did not have an ID physician on site and used telehealth ID physician consultation.

These findings align with studies of ID physician approval for outpatient parenteral antimicrobial therapy.13,14

Some limitations of the study include the possibility that PICCs were not placed in certain circumstances when risk of complications was high. Additionally, there was not a comparison of the role of ID physicians prior to the initiative, and there was no comparison patient group.

Planning and Development Process

For the pre-implementation planning phase, the consortium recommends that facility efforts should focus on:

  • Forming a multidisciplinary team consisting of key stakeholders to oversee the initiative
  • Planning the approach (e.g., deciding whether to use a tiered implementation approach)
  • Securing resources (e.g., PICC placement toolkit, ID physician access)
  • Beginning to secure leadership and clinician buy-in (e.g., through sharing concerning statistics on inappropriate PICC use)
  • Establishing goals
  • Selecting local champions
  • Engaging in baseline data collection and benchmarking
Resources Used and Skills Needed

The consortium recommends starting the initiative by establishing collective understanding of concepts central to the intervention—for example, developing shared definitions of potential harms, the characteristics of appropriate device use, and vascular access options such as midlines. Hospitals can then develop local guidelines that urge (or require) clinicians to seek ID approval prior to PICC placement if the PICC indication is intravenous antibiotics.

Based on the work of the consortium, to implement ID physician approval of PICC placement, sites should also secure the following:

  • ID physician time and availability—ID physician support can be offered in person or via telehealth. ID physicians can also help design local guidelines and decision-making tools (e.g., decision trees, order sets).
  • Data collectors and data collection training
  • Access to electronic health records
  • Patient inclusion criteria
  • Outcome measures
  • Mechanisms for comparison, data submission, feedback, and sharing best practices

The following resources are needed to operate a similar PICC improvement initiative:

  • A team to collect standardized local data
  • Access to data from other participating (and non-participating) sites
  • Outcome measures
  • ID physician participation
  • Toolkits and agreed-on best practices
  • Training and communication channels (e.g., staff meetings) to disseminate training tools
  • Staff time
  • Audit and feedback processes
  • A central vascular access committee
Funding Sources
Getting Started with This Innovation

To get started, the consortium suggests that sites consider first convening a vascular access committee to review PICC use and outcomes on a monthly to quarterly basis (sites may leverage an existing PICC committee). Such a committee should be a multidisciplinary team consisting of key stakeholders including, but not limited to, organizational leadership (e.g., chief medical officer, chief quality officer, chief nursing officer), vascular access team members, ID physicians, interventional radiology, critical care physicians, hematology/oncology physicians, emergency room physicians, and hospitalists.

It is also important to designate a site-specific internal facilitator for all PICC-related quality improvement efforts. The internal facilitator will work with the coordinating center to identify barriers and facilitators in implementing PICC placement improvement efforts. Additional first steps include compiling training decision tools (e.g., MAGIC,15 WISE,16 and Centers for Disease Control and Prevention [CDC] CLABSI17) and initiating trainings on best practices.

Sustaining This Innovation

The following actions can be useful to help sustain the innovation:18

  • Designating a physician champion to assist with PICC initiatives. The physician champion should work closely with the vascular access team to facilitate changes and support initiatives throughout the project.
  • Convening and maintaining a multidisciplinary team charged with overseeing the direction of the initiative at each hospital. This team should meet quarterly and identify opportunities for improvement by reviewing and comparing data from the site and other participating sites, as well as data available at a regional and national level.
  • Maintaining lines of communication with frontline clinicians to provide feedback on data related to utilization and outcomes involving PICCs.
  • Using tiers of targeted interventions starting with a focus on multiple outcomes (Tier 1), and then narrowing and focusing on one outcome such as DVT, CLABSI, or occlusion (Tier 2).18
  • Fostering an alliance with central administration to maintain and secure resources as needed.
References/Related Articles

Aulagnier J, Hoc C, Mathieu E, Dreyfus JF, Fischler M, Le Guen M. Efficacy of AccuVein to facilitate peripheral intravenous placement in adults presenting to an emergency department: a randomized clinical trial. Acad Emerg Med. 2014;21(8):858-863. doi:10.1111/acem.12437

Chiao FB, Resta-Flarer F, Lesser J, et al. Vein visualization: patient characteristic factors and efficacy of a new infrared vein finder technology. Br J Anaesth. 2013;110(6):966-971. doi:10.1093/bja/aet003

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 Suppl):S1-S40. doi:10.7326/M15-0744

Chopra V, O'Malley M, Horowitz J, et al. Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals [published online ahead of print, 2021 Mar 29]. BMJ Qual Saf. 2021;bmjqs-2021-013015. doi:10.1136/bmjqs-2021-013015

DeVries M, Lee J, Hoffman L. Infection free midline catheter implementation at a community hospital (2 years). Am J Infect Control. 2019;47(9):1118-1121. doi:10.1016/j.ajic.2019.03.001

Drew DA, Weiner DE. Peripherally inserted central catheters (PICCs) in CKD: PICC’ing the best access for kidney disease patients. Am J Kidney Dis. 2016;67(5):724-727. doi:10.1053/j.ajkd.2016.01.013

Ehrhardt BS, Givens KEA, Lee RC. Making it stick: developing and testing the difficult intravenous access (DIVA) tool. Am J Nurs. 2018;118(7):56-62. doi:10.1097/01.NAJ.0000541440.91369.00

Gorski LA. An introduction to the 2021 Infusion Therapy Standards of Practice. MedBridge Education blog. March 2, 2021. Accessed November 17, 2021. https://www.medbridgeeducation.com/blog/2021/03/introduction-2021-infusion-therapy-standards-practice

Govindan S, Jobe A, O'Malley ME, Flanders SA, Chopra V. To PICC or not to PICC? A cross-sectional survey of vascular access practices in the ICU. J Crit Care. 2021;63:98-103. doi:10.1016/j.jcrc.2021.02.004

HMS. The W.I.S.E Tool for assessment of short term PICC use. https://mi-hms.org/sites/default/files/WISE_040716_FINAL.pdf

HMS PICC toolkit. HMS. Accessed November 17, 2021. https://mi-hms.org/hms-picc-toolkit

Lindquester WS, Dhangana R, Warhadpande S, Amesur NB. Effects of the MAGIC guidelines on PICC placement volume: advanced practice provider and physician trends among Medicare beneficiaries from 2010 to 2018. AJR Am J Roentgenol. 2021;216(5):1387-1391. doi:10.2214/AJR.20.23704

Marschall J, Mermel LA, Fakih M, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(7):753-771. doi:10.1086/676533 https://www.jstor.org/stable/10.1086/676533#metadata_info_tab_contents

McGill RL, Tsukahara T, Bhardwaj R, Kapetanos AT, Marcus RJ. Inpatient venous access practices: PICC culture and the kidney patient. J Vasc Access. 2015;16(3):206-210. doi:10.5301/jva.5000340

Moureau N, Chopra V. Making the MAGIC: guiding vascular access selection for intensive care – a summary of Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). ICU Management & Practice. 2016;16(2):76-78. https://healthmanagement.org/c/icu/issuearticle/making-the-magic

Reinheimer D. CQIs: a 20-year partnership. Value Partnerships blog. Accessed January 1, 2022. https://www.valuepartnerships.com/vp-blog/cqis-a-20-year-partnership

Saint S, Kowalski CP, Banaszak-Holl J, Forman J, Damschroder L, Krein SL. The importance of leadership in preventing healthcare-associated infection: results of a multisite qualitative study. Infect Control Hosp Epidemiol. 2010;31(9):901-907. doi:10.1086/655459

Schultz M, Brancaccio A, Nagel J, et al. Adult Guideline for Administration of Antibiotics via Midline Catheter. Michigan Medicine. June 2021. Accessed November 17, 2021. https://mi-hms.org/sites/default/files/Adult%20Guideline%20for%20Admin%20of%20Antibiotics%20via%20Midline%20Catheter.pdf

Shingarev R, Allon M. Peripherally inserted central catheters and other intravascular devices: how safe are they for hemodialysis patients? Am J Kidney Dis. 2012;60(4):510-513. doi:10.1053/j.ajkd.2012.07.003

Sou V, McManus C, Mifflin N, Frost SA, Ale J, Alexandrou E. A clinical pathway for the management of difficult venous access. BMC Nurs. 2017;16:64. Published 2017 Nov 17. doi:10.1186/s12912-017-0261-z

Stolz LA, Stolz U, Howe C, Farrell IJ, Adhikari S. Ultrasound-guided peripheral venous access: a meta-analysis and systematic review. J Vasc Access. 2015;16(4):321-326. doi:10.5301/jva.5000346

Targeted Assessment for Prevention (TAP) central line-associated bloodstream infections (CLABSI) implementation guide: links to example resources. CDC. Last reviewed March 5, 2021. Accessed November 17, 2021. https://www.cdc.gov/hai/prevent/tap/clabsi.html

University of Michigan. Less lumens = less risk. Improve PICC. Accessed November 17, 2021. http://www.improvepicc.com/uploads/5/6/5/0/56503399/michigan_less_lumens_less_risk.pdf

Vaughn VM, O'Malley M, Flanders SA, et al. Association of infectious disease physician approval of peripherally inserted central catheter with appropriateness and complications. JAMA Netw Open. 2020;3(10):e2017659. Published 2020 Oct 1. doi:10.1001/jamanetworkopen.2020.17659

Footnotes
  1. Johansson E, Hammarskjöld F, Lundberg D, Arnlind MH. Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: a systematic review of the literature. Acta Oncol. 2013;52(5):886-892. doi:10.3109/0284186X.2013.773072
  2. Haddadin Y, Annamaraju P, Regunath H. Central line associated blood stream infections. In: StatPearls. StatPearls Publishing; August 22, 2021. https://www.ncbi.nlm.nih.gov/books/NBK430891
  3. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32(2):101-14. PMID: 21460463. doi:10.1086/657912
  4. Lu H, Hou Y, Chen J, et al. Risk of catheter-related bloodstream infection associated with midline catheters compared with peripherally inserted central catheters: a meta-analysis. Nurs Open. 2021;8(3):1292-1300. doi:10.1002/nop2.746
  5. Lu H, Yang Q, Yang L, et al. The risk of venous thromboembolism associated with midline catheters compared with peripherally inserted central catheters: a systematic review and meta-analysis. Nurs Open. 2021;00:1-10. doi:10.1002/nop2.935
  6. Ratz D, Hofer T, Flanders SA, Saint S, Chopra V. Limiting the number of lumens in peripherally inserted central catheters to improve outcomes and reduce cost: a simulation study. Infect Control Hosp Epidemiol. 2016 Jul;37(7):811-7. doi:10.1017/ice.2016.55
  7. Peripherally Inserted Central Catheter (PICC) Use Initiative. HMS. Accessed November 17, 2021. https://mi-hms.org/quality-initiatives/peripherally-inserted-central-catheter-picc-use-initiative
  8. HMS PICC toolkit. HMS. Accessed November 17, 2021. https://mi-hms.org/hms-picc-toolkit
  9. Over 2.7 million PICC line insertion procedures are performed each year in the United States. iData Research website. Accessed December 22, 2021. https://idataresearch.com/over-2-7-million-picc-line-insertion-procedures-are-performed-each-year-in-the-us/#:~:text=the%20United%20States-,Over%202.7%20million%20PICC%20line%20insertion%20procedures%20are,year%20in%20the%20United%20States&text=According%20to%20the%20latest%20vascular,year%20in%20the%20United%20States
  10. Moureau N. Preventing PICC complications: whose line is it? Morbidity & Mortality Rounds on the Web: Case Studies. Patient Safety Network. December 1, 2012. Accessed November 17, 2021. https://psnet.ahrq.gov/web-mm/preventing-picc-complications-whose-line-it  
  11. Vaughn VM, O’Malley M, Flanders SA, et al. Association of infectious disease physician approval of peripherally inserted central catheter with appropriateness and complications. JAMA Netw Open. 2020;3(10):e2017659. Published 2020 Oct 1. doi:10.1001/jamanetworkopen.2020.17659
  12. Midline Use Initiative. HMS. Accessed November 17, 2021. https://mi-hms.org/quality-initiatives/midline-use-initiative
  13. Norris AH, Shrestha NK, Allison GM, et al. 2018 Infectious Diseases Society of America Clinical Practice Guideline for the Management of Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis. 2019;68(1):1-4. doi:10.1093/cid/ciy867 
  14. Shah A, Petrak R, Fliegelman R, et al. Infectious diseases specialty intervention is associated with better outcomes among privately insured individuals receiving outpatient parenteral antimicrobial therapy. Clin Infect Dis. 2019;68(7):1160-1165. doi:10.1093/cid/ciy674
  15. 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 Suppl):S1-S40. doi:10.7326/M15-0744
  16. HMS. The W.I.S.E Tool for assessment of short term PICC use. https://mi-hms.org/sites/default/files/WISE_040716_FINAL.pdf
  17. TAP central line-associated bloodstream infections (CLABSI) implementation guide: links to example resources. CDC. Last reviewed December 16, 2021. Accessed December 22, 2021. https://www.cdc.gov/hai/prevent/tap/clabsi.html
  18. Flanders S, Chopra V. PICC Tier 1 interventions webinar. HMS. February 28, 2017. Accessed November 17, 2021. https://mi-hms.org/sites/default/files/PICC%20Tier%201%20Webinar%20022817%20FINAL.pdf
Date Verified by Innovator
Date Verified by Innovator indicates the most recent date the innovator provided feedback during the review process.
January 19, 2022

FYI: You may notice that PSNet Innovations Exchange has recently been updated (June 2022) to remove the evidence rating section. For more information or questions, please email psnetsupport@ahrq.hhs.gov

The inclusion of an innovation in PSNet does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or of the submitter or developer of the innovation.
Contact the Innovator

Valerie Vaughn, Valerie.Vaughn@hsc.utah.edu

Elizabeth McLaughlin, HMS Program Manager, emcnair@umich.edu

Scott Flanders, HMS Program Director

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