Making PICCs Safer What We Know; What We Don t Know; What We Need to Know

Transcription

1 Making PICCs Safer What We Know; What We Don t Know; What We Need to Know Jamie Bowen Santolucito, RN,CRNI,VA-BC Vascular Access Specialist/Educator Vibra Specialty Hospital Portland, Oregon

2 Disclosures Speaker Bureau: Bard Access Systems There is no corporate support for this lecture

3 Lecture Objectives Compare contemporary complication rates of PICCs to acute CICCs. Explore the evidence and, in some cases, lack of evidence behind current practices, techniques and technologies designed to reduce risks associated with PICCs. Identify evidence-based interventions shown to overwhelmingly reduce risks associated with PICCs even among select high-risk patient populations.

4 Be Picky About PICCs American College of Physicians Hospitalists, 2013 Don t Place or Leave in Place PICCs for Patient or Provider Convenience Society of General Internal Medicine Choosing Wisely Campaign, 2013 The PICC Myth Commonly Used Catheters (PICCs) Pose Significant Risks for Infection, Thrombosis and other Complications Patient Safety Tip of the Week, Jan 21, 2014 The Truax Group, Patient Safety Solutions and Healthcare Consulting PICCs May Be the New Cardiac Stress Test American College of Physicians, 2012 PICCs Double Risk of Blood Clots in ICU and Cancer Patients Infection Control Today, 2013 Serious Risks from PICCs mean Doctors Should Choose Carefully Science Daily, March 20, 2015 Commonly Used Catheter s Safety Tied to Patient Population Study Shows PICCs Have Similar CLABSI Risk in Vulnerable Patients SHEA, 2013 The Problem with Peripherally Inserted Central Catheters Physicians Should Exercise Restraint in the Decision to Place PICCs JAMA, 2012

5 Making PICCs Safer What We Know Insertion Risk PICCs are unquestionably superior to CICCs in minimizing serious insertionrelated complications Insertion risk must be included in overall risk assessment when comparing PICCs to CICCs Contemporary CICC insertion-related complications Occur at significant rates Associated with increased risk for HACs, length of stay and costs Significant portion are reportable and non-reimbursable

6 Parienti, J.J., et al. (2015) N Engl J Med Multicenter RCT to evaluate patient risk by CICC insertion site 2532 catheters randomly assigned to IJ, SCV or femoral vein 1.4% 0.7% 2.1% * *National Cancer Institute s Criteria for Adverse Events

7 Empower Vascular Access Specialists to Perform CICC Insertion Specialized dedicated vascular access teams using recommended technology High volume greater experience/proficiency reduced complications Designate only trained personnel to insert/maintain CVCs (IA) Currently possess expert-level knowledge and skills Use of real-time ultrasound guidance Vascular anatomy of the upper extremity, neck and thorax Use of dilators, wires, introducers Catheter navigation, confirmation systems and/or radiographic assessment to ensure proper catheter tip position Provide crucial resource to patients, staff nurses and physicians Lack of proficient, available medical staff to insert CICCs Contributes to suboptimal VAD selection/placement Jeopardizes patient outcomes and life-sustaining options for future vascular access O Grady, N.P., et al (2011) Guidelines for the prevention of intravascular catheter-related infections.

8 OSBN Interpretative Statement DRAFT The RN or LPN Who Participates in Vascular and Non- Vascular Access and Infusion Therapy

9 Making PICCs Safer What We Know Infection Risk PICCs pose similar infection risk when compared to acute CICCs in hospitalized patients Do not use a PICC as an infection prevention strategy Chopra, V., et al. (2013) Infect Cont and Hosp Epidemiol. Marschall, J., et al. (2014) Infect Control Hosp Epidemiol. Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN.

10 CLABSI Reduction What We Know CDC HAI Progress Report, % reduction in CLABSI between 2008 and 2014 No change in overall CAUTIs 17% reduction in SSIs 8% reduction in C. diff infections 13% reduction in MRSA bacteremias Proposed 2020 targets from the Department of HHS Road Map to Eliminate HAI advocate 50% reduction from 2015 baseline Opportunities for improvement still exist Centers for Disease Control and Prevention (2016) Healthcare-associated infections (HAI) progress report.

11 What We Know Everyday a PICC is in place the risk for CLABSI increases Using PICCs only when medically necessary and removing promptly when no longer essential is a crucial infection prevention strategy (IA) O Grady, N.P., et al (2011) Accessed at Society of General Internal Medicine Choosing Wisely Campaign (2013).

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13 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 PICC Usage per Patient Days Data from Vibra Specialty Hospital, Portland, Oregon 60% 50% 40% 30% 20% 10% Patients with PICCs Average before Intervention Average after Intervention 0%. Wallace, C.K., Santolucito, J.B., et al. (2015) Society of Hospital Medicine Annual Meeting, National Harbor, MD.

14 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 CLABSI Events Data from Vibra Specialty Hospital, Portland, Oregon /mo CLABSIs per Month Average before Intervention Average after Intervention /mo Wallace, C.K., Santolucito, J.B., et al. (2015) Society of Hospital Medicine Annual Meeting, National Harbor, MD.

15 Society of General Internal Medicine Choosing Wisely Campaign (2013). American Society of Nephrology Choosing Wisely Campaign (2012). Society of Hospital Medicine Choosing Wisely Campaign (2013).

16 Additional Strategies to Reduce Unnecessary PICC Usage Recognize that staff/patients may not be motivated to remove PICCs Designate VA specialist to perform QOD rounds on all patients with PICCs to justify ongoing usage with low tolerance for idle PICC days Abx, parenteral nutrition, vasopressors, inotropes, chemotherapy justified PICC use Blood sampling, narcotics, antiemetics, IVF generally do not justify continued PICC use Antimicrobial stewardship and antibiotic timeout As soon as clinically feasible transition to oral equivalent medications Discourage the use of PICCs for administration of empiric anti-infective agents Use PIVs or midlines until central access is clearly warranted

17 Ultrasound-Guided Midlines to Reduce CVAD Usage/Days Deutsch, G.B., et al. (2013) Journal of Surgical Research. Pathak, R, et al. (2015) Infectious Diseases in Clinical Practice. Moureau, N. et al. (2015) JAVA.

18 Midline Outcomes Data from Vibra Specialty Hospital, Portland, OR 100 midlines in 87 patients Indications Anti-infective agents 14 days Hydration Pain mgmt/comfort care Antiemetics Blood products Dwell times ranged from 3-57 days Average dwell time = 9.8 days Failure rate = 13% (PIV failure rate=35-50%) 1 No clinical s/s of CRBSI/UE edema 2% 11% 9% Indication for Midline Removal 9% Completed IVT Kinking/occlusion/leakage Pain/phlebitis Transferred/expired 69% Required CVAD 1 Helm, et all (2015) JIN.

19 Considerations for Midlines Standard 33. Site Preparation and Device Placement o Consider the use of maximum sterile barrier precautions with midline catheter insertion (V) MST vs. new generation midlines? Use labels to differentiate midlines from PICCs Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN.

20 Optimal PICC Insertion Site What We Know Whenever possible select mid-upper arm exit site away from axilla and AC Lower rates of skin colonization, dressing disruption, catheter movement Consider tunneling for high-risk insertion sites Moureau, N.L. (2014) Berlin, Germany Santolucito, J.B. (2007) JAVA Toh, L., et al. (2013) JVIR

21 Real-Time Navigation/Confirmation Systems What We Know Real-time navigation/ confirmation systems dramatically reduce the need to manipulate catheters post-insertion and consequently provide an important infection prevention strategy Endorsed by INS as more accurate, time efficient and costeffective compared to CXR Pittiruti, M., et al. (2008) JAVA Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN.

22 What We Know PICC insertion requires two clinicians When things go poorly, technique is jeopardized We can t always predict difficult insertions Checklist should be completed by someone other than the inserter who is an educated healthcare clinician Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN. Marschall, J., et al. (2014) Infect Control Hosp Epidemiol.

23 Maintaining Catheter Patency What We Know; What We Don t Know Maintaining catheter patency is a crucial strategy in prevention of intraluminal colonization Non-antibiotic, antibacterial, anticoagulant lock solutions. Optimal dosing for thrombolytic agent for catheter clearance? Infusion Nurses Society (2016) Infusion Therapy Standards of Practice. JIN. Pittiruti, M., et al. (2016) Jour Vasc Access.

24 Sapienza, S.P., Ciaschini, D.R. (2015) Intraluminal volume dose alteplase for the clearance of occluded peripherally inserted central catheter lines at a long-term acute care hospital; efficacy and economic impact. Hosp Pharm. Study Purpose: Conducted 3 month trial of 270 PICC occlusions to evaluate the efficacy of intraluminal volume (1mg/1mL) vs. standard (2mg/2mL ) dosing 96% 94% 92% 90% Intraluminal Volume vs. Standard Alteplase Dosing 93.30% 94.40% Intraluminal volume of most PICCs is < 0.8 ml Potentially over half of each standard dose is wasted with significant cost to institutions 88% 86% 84% 82% 85.60% 87.20% 1mg/1mL 2mg/2mL 80% Patency after 1 st dose Patency after 2 cd dose Conclusions: No difference in the efficacy of intraluminal vs. standard dose alteplase No difference in the mean number of reocclusions or the mean time to reocclusion Intraluminal volume dose alteplase was found to be significantly more cost-effective

25 Additional CLABSI Prevention Strategies What We Know; What We Don t Know CHG impregnated sponges/dressings Daily CHG bathing Passive disinfection caps Antimicrobial impregnated catheters O Grady, N.P., et al (2011) Retrieved from Ling, M.L., et al. (2016) Antimicrobial Resistance and Infection Control. DeVries, M., et al. (2014) JAVA. Lai, N.M., et al. (2013) Cochrane Data Base of Systematic Reviews.

26 Cochrane Collaboration Recognized as the benchmark for healthcare research 56 studies representing 16,512 catheters 11 types of antimicrobial impregnations Conclusions Benefit varied according to study setting Convincing reductions in ICU setting but not in oncology or long-term TPN pts No significant benefit shown in reducing sepsis and mortality rates Lai, N.M., et al. (2013) Cochrane Data Base Syst Rev.

27 Implications for future research Whether antimicrobial impregnated catheters reduce overall rates of sepsis and mortality is now the critical research question Lai, N.M., et al. (2013) Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Data Base Syst Rev.

28 Systematic review and meta-analysis of 8 studies 12,879 patients Minocycline/rifampin (5) CHG (3) Results Pooled CLABSI rate of 0.2 % with antimicrobial PICCs vs. 5.3 % with standard PICCs 0.3/1000 CD with antimicrobial PICCs 2.4/1000 CD with standard PICCs Conclusions: Antimicrobial PICCs associated with clinically substantial and statistically significant reduction in CLABSI Greater use of antimicrobial PICCs in specific settings may be warranted RCTs needed Study limitations: Failure to capture sepsis and mortality rates No supportive RCTs

29 First RCT to examine antimicrobial and antithrombogenic benefits of CHG-impregnated PICCs to standard PICCs 167 high-risk patients Conclusions: No differences noted in the development of CLABSI and VTE between the CHG and non-chg groups. Post-insertion bleeding was more frequent in the CHG group. Additional multicenter RCTs are warranted. Storey, S., et al. (2016) Amer Jour of Infection Control.

30 Management of Confirmed PICC-Related BSI Whenever possible provide a "line-free" interval to ensure clearance of bacteremia Continued treatment using the affected PICC, guidewire exchange, or placement of a new device in the contralateral arm without documented clearance of infection was rated as inappropriate After a line-free interval (typically 48 to 72 hours) and negative blood cultures, panelists rated placement of a PICC or other acute CVC as appropriate only if CVAD is warranted Chopra, V., et al. (2015) Annals of Internal Medicine

31 Making PICCs Safer What We Know Thrombosis Risk Current research suggests that PICCs pose an increased risk for DVT when compared to CICCs especially in critically-ill and cancer patients Chopra, V., et al. (2013) Lancet.

32 Largest meta-analysis to date 64 studies including 29,503 patients 52 non-comparative studies 12 comparative studies Conclusions PICCs were associated with 2.5 fold increased risk of DVT compared to CICCs Highest risk in critically-ill and cancer patients INS Standard 26. VAD Planning Use a PICC with caution in patients who have cancer or are critically-ill due to venous thrombosis and infection risk (III) MAGIC Consensus Statement CICC preferred to PICC for < 14 days in critically-ill patients Chopra, V., et al. (2013) Lancet. Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN. Chopra, V., et al. (2015) Annals of Internal Medicine.

33 Contemporary Rates of Symptomatic PICC DVT Following Implementation of an Effective DVT Prevention Bundle Meyers, % DeLemos, 2011 (Neuro) 3% Pittiruti, 2012 (ICU) 3.1% Cotogni, 2013 (Hem-onc) 0% Evans, % Mermis, 2014 (CF; 4FR only) 0% Pittiruti, 2014 (Hem-onc) 0.5% Wilson, % Cotogni, 2015 (Hem-onc) 1.1% Dupont, % Average rate of symptomatic PICC DVT = 1.5% Pittiruti, M. (2015) AVA Scientific Meeting, Dallas, Tx.

34 Reducing PICC-Associated Thrombosis Risk What We Know Remove PICCs as soon as they are no longer clinically essential (IA) Designate vascular access specialist to ensure prompt PICC removal.

35 Retrospective cohort study Purpose: Compare contemporary rates of CLABSI and VTE associated with PICCs vs. CICCs in the ICU 5 & 6 FR PICCs Upper arm US-guidance 3:1 vein-to-catheter ratio PICCs (5&6 FR) (N=200) CICCs (N=200) Indwelling days Median Indwelling ICU Catheter Days No significant difference in indwelling ICU days Symptomatic CRDVT 2% 1% No significant difference in DVT rates P=0.685 Nolan, M.E., et al. (2016) Jour Crit Care CLABSI 0 0

36 When followed until DC DVT rate was 4% for PICCs 1% for CICCs PICCs dwelled 2.7 x longer than CICCs Conclusions: PICC days = 1730 CICC days = 637 PICCs carry a small but definite risk of serious thrombotic complications and as with any CVC placed in the ICU they should be aggressively discontinued when no longer absolutely needed Nolan, M.E., et al. (2016) Jour of Crit Care.

37 Reducing PICC-Associated Thrombosis Risk What We Know Ensure adequate vein-to-catheter ratio For each increase in FR size there is a 9 times increased risk for DVT Implement 3 or 4 FR PICC as default catheter size Require clinical justification for 5 FR catheters Avoid 6 FR catheters Evans,R.S., (2013) CHEST Sharp, R., et al. (2015) International Jour of Nurs Studies. Meyers, B.M. (2011) JAVA. Pittiruti, M. (2015) Presented at the 29 th AVA Scientific Meeting, Dallas, TX. Mermis, J.D., et al. (2014) Annals of American Thoracic Surg. Nolan, M.E., et al. (2016) Jour of Critical Care.

38 Recommendations for Minimum Vein Diameter for PICCs Catheter Size* Vein diameter 2 x s the catheter size 1 Minimum Vein Diameter (Native State) Catheter-to-vein ratio 45% 2,3 Vein diameter 3 x s the catheter size 4,5 3 FR / 20 g 2 mm 2.1 mm 3 mm 4 FR / 18 g 2.6 mm 2.7 mm 4 mm 5 FR / 16 g 3.3 mm 3.5 mm 5 mm 6 FR / 14 g** 4 mm 4.2 mm 6 mm 1 Meyers, B.M. (2011) Managing Peripherally Inserted Central Catheter Thrombosis Risk: A Guide for Clinical Best Practice. JAVA. 16(3): Infusion Nurses Society (2016) Infusion Therapy Standards of Practice. Jour of Infusion Nurs. 39(1S):S Sharp, R., et al. (2015) The catheter to vein ratio and rates of symptomatic thromboembolism in patients with a PICC: a prospective cohort study. International Jour of Nurs Studies 4 Pittiruti, M. (2015) What the world needs now is an insertion bundle to prevent catheter-related thrombosis. Presented at the 29 th AVA Scientific Meeting, Dallas, TX. 5 Nolan, M.E., et al. (2016) Complication rates among peripherally inserted central venous catheters and centrally inserted central catheters in the medical intensive care unit. Jour of Critical Care. *Use smallest size catheter and fewest number of lumens to accommodate therapy **The use of 6 FR PICCs have shown to significantly increase the risk of venous thrombosis and should be avoided

39 Reducing PICC-Associated Thrombosis Risk What We Know Appropriate vein/site selection Select mid upper arm Avoid thrombosed/stenosed veins Right vs. left side approach? Limited evidence indicates laterality is not a predictor for PICC DVT Basilic vein generally largest, but not always Brachial or cephalic veins reported to be largest in 45% of patients Assess all three veins bilaterally Chopra, V., et al. (2014) Jour of Thrombosis and Haemostasis Sharp, R., et al (2015) International Jour of Nurs Studies Sperry, B.W., et al. (2012) Jour of Vasc Access Marnejon, T. (2012) Jour of Vasc Access Sharp, R. (2016) JAVA

40 Reducing PICC-Associated Thrombosis Risk What We Know Thorough patient assessment Determine that a CVAD is warranted and ensure that a PICC is the best CVAD Past and present medical history Assess for CKD stage 3b or greater Avoid extremity affected by axillary node dissection, reduced mobility due to neurologic or orthopedic conditions Relevant laboratory values BUN, creatinine, GFR WBC and recent culture results Severe coagulopathies Relevant radiographic studies

41 MC-PP-769

42 12.5 cm

43 Reducing PICC-Associated Thrombosis Risk What We Know Minimize trauma during catheter insertion Number of attempts/traumatic insertion has shown to be a risk factor for PICC-associated DVT Expert practitioners using real-time US/navigation/confirmation systems Proper catheter tip position on insertion and thereafter

44 Redefining Guidelines for Optimal PICC Tip Position? INS Standard Malposition defined as tip position deep in the RA > 2cm below the CAJ MAGIC Consensus Statement Adjustment of PICC tips that reside in the lower one third of the superior vena cava, cavoatrial junction, or right atrium is inappropriate Only adjust PICCs that terminate in the upper or mid one third of the superior vena cava or right ventricle Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN Chopra, V., et al. (2015) Chopra, V., et al. (2015) Annals of Internal Medicine.

45 Non-Central Catheter Tip Locations Suboptimal INS Standard 23. CVAD Tip Location Avoid CVAD tip locations in veins distal to the SVC or IVC d/t higher rates of complications (e.g., BCV, SCV, external or common iliac veins) May be clinically indicated in rare cases d/t anatomic or pathophysiologic changes INS Standard 53. CVAD Malposition Manage malposition depending on Location of the CVAD Continued need for infusion therapy Acuity of patient

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47 Management of Confirmed PICC-Related DVT What We Know Catheter removal with replacement at a new site is associated with an 86% risk of a new UEDVT Do not remove a PICC in the presence of DVT when the catheter is clinically necessary, correctly positioned, functioning properly and there is no evidence of infection Provide systemic anticoagulation in the absence of contraindications Kearon, C. et al. (2012) Chest. Crawford, J.D., et al. (2016) Jour of Vasc Surg: Venous and Lymphatic Disorders. Infusion Nursing Society. (2016) Infusion Therapy Standards of Practice. JIN. Chopra, V., et al. (2015) Chopra, V., et al. (2015) Annals of Internal Medicine.

48 Success is moving from failure to failure with continued exuberance. Winston Churchill