Abstract
Imagine a set of assumptions that proves entirely incorrect. You order a peripherally inserted central catheter (PICC) for your hospitalized patient. False assumption 1: This is a PICC team procedure, and physicians do not really need to give this order much thought. The PICC team will figure out the largest catheter that can be safely inserted. At most, you will specify whether you want a single-, double-, or triple-lumen catheter. If unsure, order double lumen rather than single lumen or order triple lumen rather than double lumen; after all, to minimize the number of procedures, it is better to err on having more rather than fewer sites to infuse medications, blood products, and nutritional support. Eventually, the PICC will stop working. Its duration of function is mostly a matter of luck. The catheter may thrombose, but this is a minor problem. False assumption 2: An upper-extremity line-associated DVT is nothing more than a nuisance. It adds hardly a blip to the length of hospital stay and barely registers on the radar screen for incremental cost of hospitalization. If one studied the evidence and decided that current ingrained PICC practices are outmoded and should be radically reformed, false assumption 3 would label this goal as “wishful thinking” and “not achievable.” After all, the PICC is simply not a hot topic. Will issues surrounding the lowly PICC generate enough passion to schedule a series of 7:00 am interdisciplinary committee meetings that further tilt the imbalance toward work life over family life? The contemporary PICC story demolishes ingrained dogma. The new approach has begun with mechanical and mathematical modeling by Nifong and McDevitt,1Nifong TP McDevitt TJ The effect of catheter to vein ratio on blood flow rates in a simulated model of peripherally inserted central venous catheters.Chest. 2011; 140: 48-53Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar who have forced us to ponder the competing three issues of blood and fluid flow, catheter size, and vein size. Their work compels us to consider ordering smaller-lumen PICCs to prevent physiologic or anatomic central obstruction, which in turn could lead to PICC-associated DVT. In a previous observational study, Evans and colleagues2Evans RS Sharp JH Linford LH et al.Risk of symptomatic DVT associated with peripherally inserted central catheters.Chest. 2010; 138: 803-810Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar from Intermountain Healthcare found that increasing PICC diameter is a risk factor for upper-extremity DVT. On all counts, they dismantle our assumptions about PICCs and set us straight with their important and timely article in this issue of CHEST (see page 627).3Evans RS Sharp JH Linford LH et al.Reduction of peripherally inserted central catheter-associated DVT.Chest. 2013; 143: 627-633Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar Their approach to optimizing PICC lumen size is illuminating and inspiring from many viewpoints. The hospital-based physician must work closely with the PICC team and quality control teams to optimize PICC policies and procedures. It seems counterintuitive, but a smaller lumen size is safer than a larger one, and single-lumen catheters will lead to fewer complications than double-lumen catheters, which in turn will lead to fewer complications than triple-lumen catheters. Working collaboratively with clinicians and hospital administration, Intermountain Healthcare changed its PICC procurement policy. Beginning in 2010, only 5F triple-lumen catheters were stocked, compared with 6F in 2008 and 2009. This seemingly simple and straightforward change was associated with a plummeting of the PICC-associated DVT rate. The percentage of PICC procedures with single-lumen, 4F PICCs increased from 17% in 2008 to 26% in 2010. A widespread educational campaign was undertaken. As a consequence, the percentage of triple-lumen PICC procedures decreased from 8% in 2008 to 4% in 2010. Intermountain Healthcare is blessed by having some of the best medical informatics in the world. The numbers tell what happened next. PICC insertions associated with DVT decreased from 3.0% to 1.9%. PICC-associated DVT per 1,000 PICC days decreased from 4.0 in 2008 to 2.7 in 2010. By the way, the impression that PICC-associated DVT has minimal impact on health-care costs and morbidity is a myth. At Intermountain Healthcare, the average cost and length of stay attributable to a single PICC-associated DVT was $15,973 and 4.6 days. We have a lot to learn from the PICC reforms undertaken at Intermountain Healthcare. The authors have translated mathematical modeling theory, clinical evidence, and commitment to quality improvement to score a victory for their patients.
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