The Picc Conundrum: To Picc Or Not To Picc?

Mehta, Bijal

THE PICC CONUNDRUM: TO PICC OR NOT TO PICC?

Ankita Patel, MD, MBA, MA¹, Sabeen Ahmed², Priya Mehta², Purav Patel², Valerie Allusson, MD, SFHM², Bijal Mehta, MD, FACP², ¹Hackensack University Medical Center Mountainside Hospital, Edison, NJ; ²Hackensack University Medical Center Mountainside Hospital

Meeting: Hospital Medicine 2018; April 8-11; Orlando, Fla.

Abstract Number: 257

Category: Research

Sub-Category: Quality Improvement

Keywords:

Background: Peripherally inserted central catheter (PICC) lines are placed in inpatients often without weighing the risk of complications such as infection, thrombosis and vein damage. It is reported that there is a nationwide problem of inappropriate PICCs being placed in patients for antibiotics that can be given via alternative routes like oral or intramuscularly. In patients with a GFR <44 (chronic kidney disease stage 3b or greater), the AV fistula First Breakthrough Initiative National Coalition recommends that a small bore internal jugular (SBIJ) catheter be placed in lieu of a PICC. SBIJ is associated with less risk of thrombosis while maintaining vein patency for future arteriovenous fistula placement if the patient’s CKD progresses to requiring hemodialysis. The purpose of this investigation was to review all PICCs placed between January 2015 and September 2015, to look at the patient’s medical history, reason for PICC placement and GFR at time of placement, and to see how many PICCs were inappropriately placed. Inappropriate PICC placement compromises patient safety and the delivery of quality care.

Methods: A retrospective chart review was conducted: age, sex, ethnicity, BMI, GFR at time of PICC insertion, diabetes, hypertension, congestive heart failure, chronic kidney disease and stage, peripheral vascular disease, coronary artery disease, smoking history, thrombus history, pulmonary embolus history, deep vein thrombosis history, trauma history, transplant history, and cancer history. Medication list was reviewed to see the intravenous medications patients received. The study separated patients with a GFR less than 44 (Chronic Kidney Disease stage 3b or higher) from those patients with a GFR>44. The number of patients with chronic medical problems was calculated. The PICC indication was reviewed to see if there were alternative routes of administration.

Results: Twenty one percent of the patients (44/206) who received a PICC had a GFR <44 and 7 out of the 44 were already ESRD on hemodialysis. Forty three percent of patients (89/204) had two or more comorbid medical conditions, placing them at a higher risk for complications. The common antibiotics for PICC placement were vancomycin 20% (42/206) and ceftriaxone 14% (29/206).

Conclusions: A PICC was placed for antibiotics where alternative routes of administration were available. PICC lines were placed in patients with two or more comorbid medical conditions. PICC lines were placed despite patients having CKD Stage 3b or greater. When ordering a PICC, special care must be given especially to those patients who have a GFR<44 in order to maintain vein patency for future fistula placement.