Background: Growing use of peripherally inserted central catheters (PICCs) in hospitalized patients has led to the recognition that they are associated with important complications. Defining when use of PICCs and related vascular access devices (VADs) is appropriate (such that benefits outweigh risks) is thus important. We sought to develop evidence-based appropriateness criteria to guide the use of PICCs and related VADs in hospitalized patients.
Methods: A multidisciplinary panel of 15 experts representing a variety of specialties was convened in Ann Arbor, Michigan in May 2014. Using the RAND/UCLA Appropriateness Method, we systematically reviewed the literature to develop scenarios related to insertion, maintenance, and removal of PICCs and related VADs. Scenarios were structured to represent reasons for use of these devices according to patient population (general hospitalized, critically ill, cancer, special patients [e.g., cystic fibrosis, short-gut syndrome]); duration of use (< 5 days, 6-14 days, 15-30 days or > 30 days); and indication (frequent phlebotomy, infusion of vesicants or irritants, hemodynamic monitoring, venous access). In a two-round modified Delphi approach, panelists rated appropriateness of each scenario using a 1-9 numerical scale. Ratings were categorized by median score and level of agreement as (a) inappropriate (score: 1-3), (b) appropriate (score: 7-9) or (c) neutral/uncertain (score of 3.5-6.5 or ratings with disagreement [at least 5 panelists rated an indication as appropriate and 5 as inappropriate]).
Results: A total of 665 scenarios were rated to develop the Ann Arbor Vascular Access Appropriateness Criteria. Within these scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. In general, PICC use was judged inappropriate if the proposed duration of venous access was < 5 days. In these situations, alternative VADs such as ultrasound-guided/long peripheral intravenous catheters were rated as being more appropriate. Substantial variation in the appropriateness of PICC use based on patient population was noted. For example, non-tunneled central venous catheters were preferred to PICCs in critically ill patients; however, in patients with cancer, PICCs were rated as appropriate devices for short-term vesicant or irritant infusion while ports were felt more appropriate for episodic chemotherapy. PICCs were also considered appropriate for hospitalized patients who needed frequent blood draws or challenging venous access provided that this requirement was likely to last > 7 days. PICC placement was rated inappropriate in patients with advanced (Stage IIIb or greater) kidney disease or special populations who are likely to require life-long venous access (e.g., sickle cell disease or short-gut syndrome).
Conclusions: Through synthesis of existing evidence and the structured use of expert opinion, we developed a list of appropriate, neutral/uncertain and inappropriate indications for use of PICCs and related VADs in hospitalized patients. These novel criteria can inform quality improvement efforts that advance safety and improve vascular access outcomes for hospitalized adults.