Many hospital patients get medicine or nutrition delivered
straight into their bloodstream through a tiny device called a PICC. In just a
decade, it’s become the go-to device for intravenous care.

But a new study finds that one in every four times a PICC
gets inserted, the patient didn’t need it long enough to justify the risks that
it can also pose.

In fact, in just the five days or less that they had a PICC
implanted in their vein, nearly one in ten of these patients suffered a blocked
line, an infection, a blood clot or another complication linked to the device.

One in three short-term PICC patients also had serious
kidney problems that could make them potential dialysis candidates, the study
also shows. They face special risks from the devices, which can harm blood
vessels and jeopardize a patient’s ability to receive dialysis later, if their
kidneys fail.

The study, published in the February issue of the Journal of Hospital Medicine,
is based on data from 52 hospitals around the state of 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 is a large-scale examination of real-world use of
PICCs, or peripherally inserted central catheters, and the factors associated
with their short-term use.

It 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.

“When PICCs first came out, they became an ‘easy
button’ for vascular access, and the safety issues weren’t recognised,”
says David Paje, MD, MPH, the University of Michigan (U-M) hospitalist who led
the research team. “Now the dynamics have changed, and we need to be more
thoughtful with their use.”

Based on previous studies of PICC-associated risks, the team
assembled an expert panel that developed a guideline for choosing IV devices
appropriately, called MAGIC. They unveiled it in 2015, and turned into a mobile
and web app in 2017.

Hospitals in the Michigan consortium, which is funded by
Blue Cross Blue Shield of Michigan, began receiving training in MAGIC during
the study period, but were still implementing it.

MAGIC guides clinicians to the appropriate option for the
individual patient they’re treating. For instance, instead of a PICC, it
recommends that patients who will need intravenous access for less than five
days should receive a different form of IV device, such as a midline or
peripheral IV.

“This study helps illustrate how medical devices such
as PICCs can be both helpful and harmful,” says senior author and Division
of Hospital Medicine chief Vineet Chopra, MD, MSc, 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.”

As part of the study, Paje and his colleagues looked at
which patients were more likely to receive a PICC for short-term use.

The strongest factor was difficult vascular access. Clinicians
may default to choosing a PICC in these patients in order to keep an
intravenous access point open, rather than having to find a vein each time,
Paje says. Or, some experienced patients may even ask for a PICC to avoid so
many “pokes.”

Patients whose physicians ordered a multilumen IV device, to
avoid contact between different medications or nutrition solutions, were also
more common among short-term PICCs. But Paje notes that few of the patients’
records actually said that they were receiving multiple IV substances that had
to be kept separate. And patients who had a short-term multilumen PICC were
much more likely to suffer a complication.

A recent paper by members of the consortium showed that at
one hospital that implemented MAGIC, inappropriate PICC use decreased compared
with hospitals that didn’t implement it, and PICC-related complications also
decreased modestly.

Paje notes that the body’s own reaction to foreign material,
and the mechanical stress put on veins when a PICC is inserted, can combine to
damage veins and increase the risk of clots or scarring. The damage can keep a
dialysis candidate from being able to successfully establish a vascular
fistula, which would have been the preferred way to receive long-term dialysis.

In all, 9.6% of the short-term PICC patients experienced a
complication, including 2.5% who experienced a blood clot forming in their vein
that could have broken off and caused more serious consequences, and 0.4%
developing a central line associated blood stream infection.

“The use of PICCs exploded because the safety issues
were not initially recognised, 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 recognise 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.”


Reference: Paje
D, et al. Patterns and Predictors of Short-Term Peripherally Inserted Central
Catheter Use: A Multicenter Prospective Cohort Study. Journal of Hospital Medicine, 2018; 13 (2): 76. Published February