Background: Peripherally inserted central catheters (PICCs) are increasingly used for vascular access in hospitalized patients due to convenience and long term viability. PICC lines are known to have complications such as deep venous thromboses and central line associated bloodstream infections (CLABSI). According to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), there are few appropriate indications for PICC. The Michael E DeBakey VA Medical Center in Houston has seen a rise in CLABSIs and analysis indicated that the majority of those CLABSIs were in PICCs. To improve patient safety, a multidisciplinary team was formed to implement a hospital-wide intervention to reduce the number of unnecessary PICCs and CLABSIs.

Methods: The multidisciplinary team included representatives from infection control, vascular access nurses, and internal medicine and critical care physicians. Data was collected via our electronic medical record to determine the number of consults placed for PICCs, ultrasound guided IV, and midlines as well as the number of CLABSIs and the type of line that was involved. The outcome measure was an overall reduction in the number of PICC lines placed. Noting the high number of PICC lines places, the initial cycle began with the introduction of midline capabilities within the vascular access team. During the first PDSA cycle, there was still a number of PICCs and CLABSIs noted so we implemented MAGIC protocol to reduce the indications for PICC lines, reduce the number of lumens for each PICC line placed, and measurement of vein to catheter ratio of all PICCs. Education still appeared an issue so the most recent PDSA cycle included resident education via morning talks as well as introduction of the MAGIC app and utilization of the app prior to MD ordering PICCs. Results were analyzed using XmR charts and line graphs.

Results: The introduction of midlines in July 2017 reduced the number of PICCs from 56 to 32. With the implementation of the second cycle of change, the number of PICCs was further reduced from 32 to 24. After resident education, the number was noted to increase from 24 to 28, but there has not been enough time to analyze if this is statistically significant. With the overall reduction in number of PICCs, we have noted a decrease in the number of CLABSIs related to PICC lines by about 25%. Unfortunately, we now have seen an increase in CLABSIs related to dialysis catheters.

Conclusions: Inappropriate vascular access choices can lead to patient harm. Using the MAGIC protocol as well as resident education and introduction of midline access, we have decreased the number of inappropriate PICCs and in turn, reduced the number of CLABSIs. The team plans to introduce a more specific order set in our electronic medical record that includes the indications and contraindications for each type of vascular access device. We are also in a trial phase of utilizing chlorhexidine impregnated wipes to clean our central lines ports.

IMAGE 1: PICC Data