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Figure.
Variation in Volume and Indications for Peripherally Inserted Central Catheter (PICC) Placement by Hospital
Variation in Volume and Indications for Peripherally Inserted Central Catheter (PICC) Placement by Hospital
Table.  
Hospital Characteristics, PICC Use, and Complications
Hospital Characteristics, PICC Use, and Complications
1.
O’Brien  J, Paquet  F, Lindsay  R, Valenti  D.  Insertion of PICCs with minimum number of lumens reduces complications and costs.  J Am Coll Radiol. 2013;10(11):864-868.PubMedGoogle ScholarCrossref
2.
Gibson  C, Connolly  BL, Moineddin  R, Mahant  S, Filipescu  D, Amaral  JG.  Peripherally inserted central catheters: use at a tertiary care pediatric center.  J Vasc Interv Radiol. 2013;24(9):1323-1331.PubMedGoogle ScholarCrossref
3.
Chopra  V, Flanders  SA, Saint  S.  The problem with peripherally inserted central catheters.  JAMA. 2012;308(15):1527-1528.PubMedGoogle ScholarCrossref
4.
Greene  MT, Flanders  SA, Woller  SC, Bernstein  SJ, Chopra  V.  The association between PICC use and venous thromboembolism in upper and lower extremities.  Am J Med. 2015;128(9):986-93.e1.PubMedGoogle ScholarCrossref
5.
Flanders  SA, Greene  MT, Grant  P,  et al.  Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study.  JAMA Intern Med. 2014;174(10):1577-1584.PubMedGoogle ScholarCrossref
6.
Chopra  V, Flanders  SA, Saint  S,  et al; Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) Panel.  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. PubMedGoogle ScholarCrossref
7.
Fitch  K, Bernstein  SJ, Aguilar  MD,  et al.  The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corp; 2001.
Research Letter
Less Is More
April 2016

Variations in Peripherally Inserted Central Catheter Use and Outcomes in Michigan Hospitals

Author Affiliations
  • 1Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
  • 2Patient Safety Enhancement Program, VA Ann Arbor Health Care System, Ann Arbor, Michigan
  • 3Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
  • 4Department of Internal Medicine, Beaumont Hospital, Dearborn, Michigan
  • 5Department of Internal Medicine, Integrated Healthcare Associates and St Joseph Hospital, Ann Arbor, Michigan
  • 6Department of Internal Medicine, Hurley Medical Center, Flint, Michigan
 

Copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.

JAMA Intern Med. 2016;176(4):548-551. doi:10.1001/jamainternmed.2015.8402

Use of peripherally inserted central catheters (PICCs) has grown substantially in hospitalized medical patients.1,2 However, data regarding PICC placement largely originate from single-center experiences or studies of highly select populations and outcomes.3 Consequently, little is known about variation in PICC use or outcomes across hospitals. To examine this, we conducted a prospective study at 10 hospitals through the Michigan Hospital Medicine Safety (HMS) Consortium, a quality–improvement initiative dedicated to preventing adverse events in hospitalized medical patients.

Methods

The design and sampling strategy of HMS have been previously described.4,5 Between December 1, 2013, and January 30, 2015, trained data abstractors at 1 of 10 participating HMS hospitals collected information including history and laboratory and medication data from patients who received PICCs in intensive care unit (ICU) and non-ICU settings. Information related to PICCs (eg, indication, gauge, number of lumens) was obtained from vascular nursing or interventional radiology insertion records. All patients were followed until PICC removal or 60-days after PICC insertion, whichever occurred first. Major PICC complications were defined as central line–associated bloodstream infection and symptomatic venous thromboembolism, whereas minor complications included mechanical problems (migration, kinking), catheter occlusion, exit-site infection, and thrombophlebitis. All outcomes were ascertained by medical record review, telephone follow-up, or both, which occurred at 14, 30, and 60 days after PICC placement. Indication for PICC insertion, dwell time, device characteristics, and complications were tabulated using descriptive statistics. PICC use rates for each hospital were estimated by expressing the proportion of PICCs placed in adult nonsurgical patients to the total number of nonsurgical adult discharges during the study period. Multilevel mixed-effects and logit models were then fitted to examine hospital-level differences in PICC use and complications. The study was classified as having a “not regulated” status from the institutional review boards at all of the participating hospitals. Therefore, patient consent was not required, and all data were deidentified.

Results

Data on 3378 PICCs placed in 3201 patients were available. Most PICCs (2406 [71.2%]) were placed by vascular access nurses and were double-lumen devices (1784 [52.8%]). Although the median dwell time for PICCs across hospitals was 10 days (range, 1 to >60 days), 817 PICCs (24.2%) were removed within 5 days of insertion. The most common indications for PICC insertion were difficult venous access (1387 [41.1%]) and home antibiotics (971 [28.7%]) (Figure).

A PICC-related complication occurred in 646 cases (19.1%). Catheter occlusion was the most frequent complication, occurring in 340 cases (10.1%) (Table). Symptomatic deep vein thrombosis and pulmonary embolism occurred in 177 (5.2%) cases and were more frequent in patients in the ICU compared with non–ICU settings (65 [6.3%] vs 112 [4.8%], respectively; P = .06). Although central line-associated bloodstream infection was documented in only 38 cases (1.1%), PICCs were frequently removed by physicians for suspected central line-associated bloodstream infection (63 cases [1.9%]).

The absolute volume of PICC use across the participating hospitals during the study period ranged from 73 to 479 devices, with corresponding use ratios of 2.5% to 8.2% (P < .001). Variation in PICC use was not explained by underlying severity of patient illness (r = −0.43) or by hospital-level factors, including volume, bed number, type (teaching vs non-teaching), or location (urban vs rural). In addition, indications for PICC placement varied significantly across hospitals. For example, placement of PICCs for difficult venous access ranged from 10% to 64% (P < .001). Similarly, the frequency of PICC complications also varied, from 4.1% to 35.9%, or 0.041 to 0.406 complication per PICC, across hospitals (P < .001). Notably, patterns of complications also differed across hospitals. For example, catheter thrombosis was the most prevalent complication at 6 hospitals, whereas venous thromboembolism was the most prevalent adverse event in 2 hospitals.

Discussion

This multicenter study found substantial variation in PICC indications, patterns of use, and outcomes at 10 Michigan hospitals. Because PICCs are associated with numerous complications, it is necessary to understand the factors responsible for variations in their use. Additionally, because up to 24.2% of PICCs were removed within 5 days of insertion, guidance to better inform physicians about when a PICC may be appropriate appears necessary. The recently developed Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) guidelines6 are well suited to this purpose. Created by an international, multidisciplinary panel of vascular access experts and a patient representative, development of the MAGIC guidelines used the RAND, University of California, Los Angeles appropriateness method7 to define when PICC insertion is appropriate, inappropriate, or uncertain as compared with the use of other vascular access devices. Among several appropriateness ratings, key recommendations of MAGIC include avoidance of placing PICCs for delivery of peripherally compatible infusions when the expected duration of such use is 5 days or greater; avoidance of inserting PICCs in patients with active cancer for chemotherapy when such treatment is expected to last less than 3 months and can be delivered through peripheral veins; and avoidance of placing PICCs in patients with kidney disease of stage 3b or higher or in those receiving renal replacement therapy. In contrast, the MAGIC panelists rated PICC placement in hospitalized patients appropriate for indications such as the delivery of irritants or vesicants regardless of duration (eg, parenteral nutrition), invasive hemodynamic monitoring in critically ill patients who will require venous access for more than 15 days, and frequent phlebotomy when this is expected to last longer than 6 days.6 To operationalize recommendations, MAGIC offers algorithmic decision trees tailored to clinical parameters, such as proposed duration of treatment, nature of infusate, and patient or device characteristics. Understanding how best to implement MAGIC guidelines across hospitals is thus an important next step that will both inform quality improvement efforts and improve the safety of venous access in hospitalized patients.

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Article Information

Corresponding Author: Vineet Chopra, MD, MSc, 2800 Plymouth Rd, Bldg 16, #432W, Ann Arbor, MI 48109 (vineetc@umich.edu).

Published Online: February 15, 2016. doi:10.1001/jamainternmed.2015.8402.

Author Contributions: Drs Chopra and Smith had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Chopra, Flanders.

Acquisition, analysis, or interpretation of data: Chopra, Smith, Swaminathan, Boldenow, Kaatz, Bernstein.

Drafting of the manuscript: Chopra, Smith.

Critical revision of the manuscript for important intellectual content: Chopra, Swaminathan, Boldenow, Kaatz, Bernstein, Flanders.

Statistical analysis: Chopra, Smith.

Obtained funding: Chopra, Flanders.

Administrative, technical, or material support: Chopra, Flanders.

Study supervision: Chopra, Bernstein, Flanders.

Conflict of Interest Disclosures: Dr Flanders reported being a consultant for the Institute for Healthcare Improvement and the Society of Hospital Medicine; reported receiving royalties from Wiley Publishing; honoraria for various talks at hospitals as a visiting professor; grants from CDC Foundation, Agency for Healthcare Research and Quality (AHRQ), Blue Cross Blue Shield of Michigan, and Michigan Hospital Association; and reported receiving compensation for expert witness testimony. Dr Bernstein reported being a consultant for Blue Care Network and the Michigan Department of Community Health, and reported receiving grants from Blue Cross Blue Shield of Michigan, Michigan Health and Hospital Association, Department of Veterans Affairs, National Institutes of Health, and the Agency for Healthcare Research and Quality (AHRQ). Dr Kaatz reported receiving speaker honorarium from Janssen, Boehringer-Ingelheim, Bristol Myer Squibb/Pfizer, CSL Behring, Daiichi Sankyo, and reported being a board membership for Thrombosis and Hemostasis Societies of North America, AC Forum, National Certification Board of Anticoagulation Providers, National Blood Clot Alliance Medical and Scientific Advisory Board.

Funding/Support: Support for the Michigan Hospital Medicine Safety Consortium (HMS) is provided by Blue Cross and Blue Shield of Michigan and Blue Care Network as part of the BCBSM Value Partnerships program. Dr Chopra is supported by a career development award from the AHRQ (1-K08-HS022835-01).

Role of the Funder/Sponsor: Blue Cross/Blue Shield of Michigan and Blue Care Network supported data collection at each participating site and funded the data coordinating center but had no role in study concept, interpretation of findings, or in the preparation, final approval or decision to submit the manuscript.

Disclaimer: Although Blue Cross Blue Shield of Michigan and HMS work collaboratively, the opinions, beliefs and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees.

References
1.
O’Brien  J, Paquet  F, Lindsay  R, Valenti  D.  Insertion of PICCs with minimum number of lumens reduces complications and costs.  J Am Coll Radiol. 2013;10(11):864-868.PubMedGoogle ScholarCrossref
2.
Gibson  C, Connolly  BL, Moineddin  R, Mahant  S, Filipescu  D, Amaral  JG.  Peripherally inserted central catheters: use at a tertiary care pediatric center.  J Vasc Interv Radiol. 2013;24(9):1323-1331.PubMedGoogle ScholarCrossref
3.
Chopra  V, Flanders  SA, Saint  S.  The problem with peripherally inserted central catheters.  JAMA. 2012;308(15):1527-1528.PubMedGoogle ScholarCrossref
4.
Greene  MT, Flanders  SA, Woller  SC, Bernstein  SJ, Chopra  V.  The association between PICC use and venous thromboembolism in upper and lower extremities.  Am J Med. 2015;128(9):986-93.e1.PubMedGoogle ScholarCrossref
5.
Flanders  SA, Greene  MT, Grant  P,  et al.  Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study.  JAMA Intern Med. 2014;174(10):1577-1584.PubMedGoogle ScholarCrossref
6.
Chopra  V, Flanders  SA, Saint  S,  et al; Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) Panel.  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. PubMedGoogle ScholarCrossref
7.
Fitch  K, Bernstein  SJ, Aguilar  MD,  et al.  The RAND/UCLA Appropriateness Method User’s Manual. Santa Monica, CA: RAND Corp; 2001.
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