Use Of Peripherally Inserted Central Catheters Research Articles

Risk of deep venous thrombosis associated with peripherally inserted central catheter: A retrospective cohort study of 11.588 catheters in Brazil.

Deep Venous Thrombosis (DVT) due to Peripherally Inserted Central Catheter (PICC) is one of the most threatening complications after device insertion. To assess the rate of PICC-associated DVT and analyze the risk factors associated with this event in cancer and critically ill patients. We conducted a descriptive, retrospective cohort study with 11,588 PICCs from December 2014 to December 2019. Patients ≥ 18 years receiving a PICC were included. Pre-and post-puncture variables were collected and a logistic regression was used to identify the independent factors associated with the risk of DVT. The DVT prevalence was 1.8% (n = 213). The median length of PICC use was 15.3 days. The median age was 75 years (18; 107) and 52% were men, 53.5% were critically ill and 29.1% oncological patients. The most common indications for PICC's were intravenous antibiotics (79.1%). Notably, 91.5% of PICC showed a catheter-to-vein ratio of no more than 33%. The tip location method with intracavitary electrocardiogram was used in 43%. Most catheters (67.9%) were electively removed at the end of intravenous therapy. After adjusting for cancer profile ou chemotherapy, regression anaysis revealed that age (OR 1.011; 95% CI 1.002-1.020), previous DVT (OR 1.96; 95% CI 1.12-3.44) and obstruction of the device (OR 1.60; 95% CI 1.05-2.42) were independent factors associated with PICC-associated DVT, whereas the use of an anticoagulant regimen was a protective variable (OR 0.73; 95% CI 0.54-0.99). PICC is a safe and suitable intravenous device for medium and long-term therapy, with low rates of DVT even in a cohort of critically ill and cancer patients.

Improving Appropriate Use of Peripherally Inserted Central Catheters Through a Statewide Collaborative Hospital Initiative: A Cost-Effectiveness Analysis

Quality improvement (QI) programs require significant financial investment. The authors evaluated the cost-effectiveness of a physician-led, performance-incentivized, QI intervention that increased appropriate peripherally inserted central catheter (PICC) use. The authors used an economic evaluation from a health care sector perspective. Implementation costs included incentive payments to hospitals and costs for data abstractors and the coordinating center. Effectiveness was calculated from propensity score-matched observations across two time periods for complications (venous thromboembolism [VTE], central line-associated bloodstream infection [CLABSI], and catheter occlusion): preintervention period (January 2015 through December 2016) and intervention period (January 2017 through December 2021). Cost-effectiveness was presented as the cost-offset per averted complication, reflecting the health care costs avoided due to having lower complication rates. Across 35 hospitals, this study sampled 17,418 PICCs placed preintervention and 26,004 placed during the intervention period. PICC complications decreased significantly following the intervention. CLABSIs decreased from 2.1% to 1.5%, VTEs from 3.2% to 2.3%, and catheter occlusions from 10.8% to 7.0% (all p < 0.01). Estimated number of complications prevented included 871 CLABSIs, 2,535 VTEs, and 8,743 catheter occlusions. Project implementation costs were $31.8 million, and the cost-offset related to avoided complications was $64.4 million. Each participating hospital averaged $932,073 in cost-offset over seven years, and the average cost-offset per complication averted was $2,614 (95% CI [confidence interval] $2,314-$3,003). A large-scale, multihospital QI initiative to improve appropriate PICC use yielded substantial return on investment from cost-offset of prevented complications.

Incidence and clinical progression of asymptomatic peripherally inserted central catheter–related thrombosis in solid neoplasm patients: ultrasound insights from a prospective cohort study

BackgroundManaging central venous catheters in patients with neoplasms is challenging, and peripherally inserted central catheter PORT (PICC-PORT) has emerged as a promising option for safety and efficacy. However, understanding the clinical progression of catheter-related thrombosis (CRT) in cancer patients with central venous catheters remains limited, especially in certain neoplasm types associated with a higher risk of venous thrombosis. ObjectivesThis study aims to assess the effectiveness of ultrasound-guided management in detecting and treating asymptomatic CRT in cancer patients with PICC. MethodsIn this prospective cohort study of 120 patients with solid neoplasms receiving chemotherapy, we investigated the incidence of isolated upper-extremity superficial vein thrombosis, upper-extremity deep vein thrombosis, and fibrin sheath formation through ultrasound follow-up at 30 and 90 days after catheter insertion. We analyzed risk factors associated with CRT and compared incidence rates between PICC-PORT and traditional PICC. ResultsAmong the cohort, 69 patients (57.5%) had high-risk thromboembolic neoplasm, and 31 cases (25.8%) of CRT were observed, mostly within 30 days, with only 7 cases (22.6%) showing symptoms. Traditional PICC use (odds ratio, 5.86; 95% CI, 1.14-30) and high-risk thromboembolic neoplasm (odds ratio, 4.46; 95% CI, 1.26-15.81) were identified as independent risk factors for CRT. ConclusionThe majority of CRT present asymptomatically within the first 30 days of venous catheter insertion in patients with solid neoplasms. Ultrasound follow-up is valuable for detecting asymptomatic CRT. The risk of CRT was lower with PICC-PORT than with PICC. Additionally, the risk of CRT was found to be higher in patients with high-risk thromboembolic neoplasms. It is crucial for larger studies to confirm the utility of treating asymptomatic thromboses and isolated superficial thrombosis.

Safety and Efficacy of Midline vs Peripherally Inserted Central Catheters Among Adults Receiving IV Therapy

Midline catheters (MCs) are widely used, but safety and efficacy compared with peripherally inserted central catheters (PICCs) has not been adequately evaluated. To compare the safety and efficacy of MCs with PICCs among adult patients with an anticipated intravenous therapy lasting from 5 to 28 days. This parallel, 2-group, open-label, randomized clinical trial (RCT) was conducted in Denmark from October 2018 to February 2022 at a single academic tertiary care center. Adult inpatients and outpatients were consecutively randomized. Patients were randomized in a 1:1 ratio to either the MC group or the PICC control group. The primary outcome was catheter-related bloodstream infection (CRBSI), analyzed using the Fisher exact test. Secondary outcomes were symptomatic catheter-related thrombosis and catheter failure, including mechanical cause, phlebitis, infiltration, pain in relation to drug or fluid administration, and leaking from the puncture site. Incidence rate ratios (IRRs) were calculated to assess between-group failure rates over device dwell time using Poisson regression. An intention-to-treat analysis was performed. A total of 304 patients (mean [SD] age, 64.6 [13.5] years; 130 [42.8%] female) were included in the analysis, and 152 patients were allocated to each catheter group. The incidence of CRBSI was low, with 0 in the MC group and 1 in the PICC control group (P > .99). The MC group had a higher catheter-related complication rate (20 [13.2%] vs 11 [7.2%]), and an IRR of 2.37 (95% CI, 1.12-5.02; P = .02) for complications compared with the PICC control group. In a post hoc analysis stratified by catheter dwell time, no significant difference in complication rate (IRR, 1.16; 95% CI, 0.50-2.68; P = .73) was found between the 2 groups for catheters used less than 16 days. In this RCT with patients who received medium- to long-term intravenous therapy, the incidence of CRBSI was low, with no difference between MCs and PICCs. The use of MCs resulted in a higher incidence of catheter-related complications compared with use of PICCs. This finding should be balanced in the decision of type of catheter used at the individual patient level. ClinicalTrials.gov Identifier: NCT04140916.

Impact of a midline catheter prioritization initiative on device utilization and central line-associated bloodstream infections at an urban safety-net community hospital.

Overuse of peripherally inserted central catheters (PICCs) can lead to idle central line (CL) days and increased risk for CL-associated bloodstream infections (CLABSIs). We established a midline prioritization initiative at a safety-net community hospital. This initiative led to possible CLABSI avoidance and a decline in PICC use.

The role of hospital-based vascular access teams and implications for patient safety: A multi-methods study.

Peripherally inserted central catheters (PICCs) and midline catheters are often placed by nurse-led vascular access teams (VATs). While some data regarding the effectiveness of these teams exists, less is known about their structure and function. To examine the roles, functions, and composition of VATs related to the use and management of PICC and midline catheters. A descriptive, multi-method study that included an online survey of 62 hospitals participating in a quality improvement consortium and qualitative interviews with 74 hospital-based clinicians in 10 sites. Interviews were recorded, transcribed, and analyzed using a rapid analysis and matrix approach. The survey, which contained closed-ended, categorical questions, was analyzed using frequencies and percentages. More than 77% (n = 48) of hospitals had an on-site VAT. The average team size was seven nurses; their primary function was device insertion. Interview findings revealed that teams varied in characteristics and functions. Interviewees described the broad role that teams play in device insertion, care and removal, and in educating/training hospital staff. However, we found that teams' role in decision making, particularly related to appropriate device selection, was limited and, in some cases, met with physician resistance. To realize the full benefit of VATs, changes in hospital culture, along with an increased willingness from physicians to integrate VAT nurses in decision making, may be needed. Future interventions aimed at engaging and empowering teams appear necessary.

Peripherally Inserted Central Catheter Safety and Efficacy in Acute Lymphoblastic Leukemias: A 16-Years Monocentric Experience

Background: Acute lymphoblastic leukemia (ALL) is a cancer of lymphoid cells and organs that requires immunochemotherapy combined with hematopoietic stem cell transplantation (HSCT) according to minimal residual disease. Recently, cell therapy and targeted drugs have been added to the treatment algorithm. Supportive care, and local treatment such as intrathecal chemotherapy are also recommended due to complications related to disease and therapy. Introduction: The Peripherally Inserted Central Catheters (PICC )may be a safe and useful tool for the treatment of ALL patients because it is easier to implant with a lower risk of complications than Centrally Inserted Central Catheters (CICC), and is effective in outpatient settings. Methods: Since its introduction in our medical oncology department, a PICC team consisting of a hematology physician and three dedicated nurses has conducted a prospective study to evaluate the efficacy and complication rate of the PICC system in inpatients and outpatients ALL. Inclusion criteria included all ALL patients who required chemotherapy, supportive care, or HSCT, regardless of white blood cell (WBC) count. A platelet count (PLT) greater than 20000/mm 3 and normal coagulation tests were required for implantation. In all patients, the vascular anatomy of the arms was previously examined by ultrasound. All implantations were performed under ultrasound control, followed by radiographic control. Results: From March 2007 to April 2023, 87 PICC implantations were performed in 75 patients, including 39 men and 36 women. The mean age was 44 years (range 15-80). The majority of implantations were performed in hospitalized ALL patients (81-93%). Seventy-one PICCs (82%) were used for chemotherapy, eleven (13%) for supportive care, two (2%) for autologous HSCT, 4 (5%) for allogeneic HSCT. No PICC was lost to follow-up. At the time of this analysis, only one PICC (1%) was still in situ and in use. Total PICC survival was 13683 days (median, 121; range, 1-1257). The reasons for removal are listed in Table1. Of note, most PICCs were removed because of end of therapy (61%) and exitus (17%), and only 1 in 3 (33%) had suspected catheter-related bloodstream infection confirmed by microbiological testing. Complications recorded in the overall populations are described in the Table.2 No complications occurred in 68% of PICCs. There were 16 episodes of confirmed PICC-related systemic infection recorded (18%; 1.1/1000 days/PICC). The pathogens isolated in blood cultures and in analysis of PICC spikes were: Staphylococcus Epidermidis, Staphylococcus Hominis, Pseudomonas Aeruginosa, Escherichia Coli, Enterococcus Faecium, Klebsiella Pneumoniae, Candida spp. Only 1 of 16 confirmed PICC-related systemic infections (6%) required removal of the devices, whereas in the other 15 cases (94%), PICC were allowed to remain after resolution of the infection with systemic antibiotic therapy. No cases of symptomatic thrombotic complications associated with PICC were recorded. Conclusions: These data suggest that the use of PICC can be considered the device of choice in the treatment of ALL patients because it is easy to insert, safe to use, durable, and associated with a low complication rate, even in the case of PICC-related systemic infections.

Venous Thromboembolism in Hematopoietic Stem Cell Transplantation

Background: Venous thromboembolism (VTE) is an underappreciated complication seen amongst allogeneic and autologous hematopoietic stem cell transplant (HSCT) patients and a major cause of morbidity and mortality. Despite these challenges, VTE in HSCT remains understudied, with a paucity of established guidelines on thrombosis surveillance, prevention, and treatment. Balancing risk of bleeding and thrombosis is particularly challenging as HSCT patients are concurrently pancytopenic and coagulopathic. We aimed to describe the incidence, predictors, and adverse events of VTE amongst patients at 90 days post-HSCT. Methods: We conducted a retrospective cohort study of adult patients, age &amp;gt;18-years-old, who underwent HSCT for a hematological malignancy between January 1, 2011 and December 31, 2021 at a tertiary care centre in Canada. Patients were followed from transplant until Day 90 post-transplant, or death. Baseline, transplant, laboratory, and cancer characteristics were analyzed. Results: Four Hundred and Seventy Six (476) HSCT patients were included (age range 18 - 74), 285 (59.9%) of our patients were male, and 191 (40.1%) were female. Three Hundred and Seventeen (317) (66.6%) patients underwent autologous transplant, and 159 (33.4%) patients underwent allogeneic transplant ( Table 1). Forty Seven (47) patients (9.8%) suffered from VTE within 90 days post-HSCT; 74.5% were catheter related. 9.43% of allogeneic, versus 10.09% autologous patients were diagnosed with VTE (p=0.820). 11.9% of allogeneic, versus 4.1% of autologous patients (p=0.001) suffered from bleed unrelated to anticoagulation. There was significant association of VTE post-HSCT with history of unprovoked DVT (p = 0.026), previous treatment with steroids (p = 0.032), infectious complications (including bacteremia (p = 0.025), and skin and soft tissue infection (p &amp;lt; 0.001)), use of peripherally-inserted central catheters (PICCs (p &amp;lt;0.001), left-sided CVC placement (p = 0.007), second central venous line insertion (due to complications from the first) (p &amp;lt; 0.001), and blocked or malfunctioning central venous catheter (p = 0.003). There was no significant association of VTE post-HSCT with transplant graft (autologous versus allogeneic), underlying hematological malignancy, age, BMI, or sex. Mortality rate at 90 days amongst VTE patients was 14.89%, versus 3.27% in non-VTE patients (p &amp;lt; 0.001) ( Figure 1). Conclusion: The majority of VTE post-HSCT were catheter-related and were more frequently associated with use of PICCs. VTE post-HSCT was associated with higher mortality. VTE prophylaxis or active surveillance could be considered in patients with the above-mentioned risk factors balancing the risk of bleeding, particularly in allogeneic stem cell transplant patients, and those who are concurrently thrombocytopenic.

Peripherally Inserted Central Catheter Safety and Efficacy in Acute Myeloid Leukemia: A Monocentric Experience from the Hematology of Cagliari

Background: Acute myeloid leukemia (AML) is a cancer of the blood and bone marrow cells that requires intensive chemotherapy combined with hematopoietic stem cell transplantation in fit patients and less intensive treatment in elderly patients. Supportive care is also advised due to disease and therapy-related cytopenia that can lead to life-threatening systemic infections, bleeding, and hypoxemia. Introduction: The Peripherally Inserted Central Catheter (PICC) may be a safe and useful tool for the treatment of AML patients because it is easier to implant and has a lower rate of infectious complications than the Centrally Inserted Central Catheters (CICC). Methods: Since its establishment in our medical oncology department, a PICC team consisting of a hematology physician and three dedicated nurses has conducted a prospective study to evaluate the efficacy and complication rate of the PICC device in inpatient and outpatient AML patients. Inclusion criteria included all AML patients who required chemotherapy, supportive care, and HSCT, regardless of white blood cell (WBC) count. A platelet count greater than 20000/mm 3 and normal coagulation tests were required for implantation. In all patients, the vascular anatomy of the arms was previously examined by ultrasound. All implantations were performed under ultrasound guidance followed by radiographic control. Results: From March 2007 to April 2023, 216 PICC implantations were performed in 186 patients (110 men and 76 women), including 13 patients with acute promyelocytic leukemia, after the conclusion of the induction phase. Median age 60 years (range 22-79). The majority of implantations were performed in hospitalized AML patients (193 - 89%). One hundred ninety-three PICCs (81%) were used for chemotherapy, thirty (14%) for supportive care, four (2%) for autologous HSCT, five (3%) for allogeneic HSCT. Only two PICCs were lost to follow-up in the AML population. Therefore, the analysis of duration and complications was performed on 214 devices. At the time of this analysis, 13 of 214 PICCs (6%) are still in situ and in use. The total duration of PICC life was 26289 days (median, 103; range, 0-959). The reasons for removal in the two populations are shown in Table1. Of note, most PICCs were removed because of end of therapy (40%) and exitus (31%), and only one in five (20%) had suspected catheter-related bloodstream infection confirmed by microbiological testing. Complications recorded in the global populations are described in the Table.2 No complications occurred in 68% of PICCs. There were 34 episodes of confirmed PICC-related septicemia recorded (16%; 1.3/1000 days/PICC). The pathogens isolated in blood cultures and PICC tip analysis were: Staphylococcus Epidermidis, Staphylococcus Hominis, Staphylococcus Warneri, Pseudomonas Aeruginosa, Escherichia Coli, Enterococcus Faecium, Enterococcus Fecalis, Stenotrophomonas Maltophila, Bacillus Cereus, Klebsiella Pneumoniae, Candida spp. In only 11 of 34 confirmed PICC-related septicemias (32%) did the devices need to be removed, whereas in the other 23 cases (68%), PICC were left in place after the infection resolved with systemic antibiotic therapy. There were only 4 (2%; 0.15/1000 days/PICC) cases of symptomatic thrombotic complications related to PICC without the need for removal. Conclusions: These data indicate that the use of PICC can be considered a safe and useful tool in the treatment of AML patients because it is easy to insert, safe to use, long lasting, and has a low complication rate, even in the case of PICC-related systemic infections.

Use and safety of peripherally inserted central catheters and midline catheters in palliative care cancer patients: a retrospective review

PurposeSome cancer patients in palliative care require intravenous administration of symptom relieving drugs. Peripherally inserted central catheters (PICCs) and midline catheters (MCs) provide easy and accessible intravenous access. However, limited evidence supports the use of these devices in palliative care. The aim was to assess the use, safety, and efficacy of PICC and MC in this patient population.MethodsA retrospective study of all palliative care cancer patients who received PICC or MC at the Department of Palliative Medicine at Akershus University Hospital between 2020 and 2022.ResultsA total of 374 patients were included; 239 patients received a PICC and 135 an MC with a total catheterization duration of 11,698 days. The catheters remained in place until death in 91% of patients, with a median catheter dwell time of 21 days for PICCs and 2 days for MCs. The complication rate was 3.3 per 1000 catheter days, with minor bleeding and accidental dislocation as the most common. The catheters were utilized primarily for opioids and other symptom directed treatments, and 89% of patients received a patient or nurse-controlled analgesia pump. Patients with PICC or MC discharged to home or nursing homes spent 81% of their time out of hospital.ConclusionPICC and MC provide safe parenteral access for palliative care cancer patients where intravenous symptom treatment is indicated. Their use can facilitate intravenous symptom treatment beyond the confines of a hospital and supplement the traditional practice relying on subcutaneous administration.

Application of peripherally inserted central catheter in immune tolerance induction treatment of children with hemophilia A and accompanying inhibitors in China

ABSTRACTObjective:To explore the feasibility, safety and cost effectiveness of the use of peripherally inserted central catheter (PICC) in children with hemophilia A and inhibitors who underwent ITI treatment.Method:This retrospective cohort study evaluated the effect of PICC placement and ITI on bleeding rates, costs, and parents’ satisfaction before and within 6 months after PICC placement in children with hemophilia A and inhibitors.Results:A total of 20 children with hemophilia A and high-titer inhibitors were included, with a success rate for PICC placement of 100%, at a cost of ¥6730.50. Parents’ satisfaction with PICC was 100%, and the total length of catheter indwelling was 6055 days. In terms of curative effect, the success rate of ITI treatment was 75%, and the annualized bleeding rate was decreased from 10.90 ± 12.16 times before placement to 2.10 ± 3.32 times (p < 0.05). The transportation expense for children and their parents to the clinic decreased from ¥20,920 ± 32,274.57 before catheter placement to ¥2915 ± 2195.99 (p < 0.05). Time of children missed school and their parents missed work decreased from 10.85 ± 22.36 days to 1.90 ± 3.58 (p < 0.05) days and 40.33 ± 46.11 days to 3.83 ± 7.11 days (p < 0.05), respectively.Conclusion:The use of PICC for ITI treatment in children with hemophilia A and accompanying inhibitors in developing countries (e.g. China) can ensure the effect of ITI, reducing expense and improving the quality of life without obvious side effects.

Peripherally inserted central venous catheter for pediatric acute leukemia: A retrospective 11-year single-center experience.

Peripherally inserted central catheters (PICCs) are successfully increasingly used in children in onco-hematologic setting. PICC insertion, especially in oncologic patients, can be associated with adverse events (thrombosis, mechanical complications, and infections). Data regarding the use of PICC, as long-term access in pediatric patients with severe hematologic diseases, are still limited. We retrospectively evaluated the safety and efficacy of 196 PICC, inserted in 129 pediatric patients with acute leukemia diagnosed and treated at Pediatric Hematology Unit, Sapienza University of Rome. The 196 PICC analyzed were in situ for a median dwell time of 190 days (range 12-898). In 42 children, PICC was inserted twice and in 10, three times or more due to hematopoietic stem cell transplant, disease recurrence, or PICC-related complications. The overall complication rate was 34%: catheter-related bloodstream infections (CRBSI) occurred in 22% of cases after a median time of 97 days; a catheter-related thrombosis (CRT) in 3.5% and mechanical complications in 9% of cases. Premature removal for complications occurred in 30% of PICC. One death from CRBSI was observed. To our knowledge, this study represents the largest cohort of pediatric patients who have inserted the PICC for acute leukemia. In our experience, PICC was a cheap, safe, and reliable device for long-term intravenous access in children with acute leukemia. This has been possible with the help of dedicated PICC team.

Nudging to select single-lumen over multiple-lumen peripherally inserted central catheters (PICCs) in a large safety net system.

Peripherally inserted central catheters (PICCs) are increasingly used for vascular access in inpatient settings. Compared to multilumen PICCs, single-lumen PICCs carry a lower rate of complications, including central-line-associated bloodstream infection and thrombosis. Despite this, multilumen PICCs are still overused. This quality improvement initiative was implemented across 11 hospitals at New York City Health + Hospitals safety net system. The electronic health record (EHR) interventional radiology or vascular access team consultation orders were modified to allow for lumen choice, with default selection to a single-lumen PICC. Average single-lumen PICC utilization increased by 25.5%, from 44.4% to 69.9% (P < .001). CLABSI rates had a nonsignificant reduction by 26.7% from 2.44 to 1.79 infections per month (P = .255). Among provider types in the postintervention period, single-lumen PICC utilization ranged from 67.7% for advanced practice providers to 82.4%-94.6% for physicians. Among provider specialties, utilization ranged from 31.8% for neurology to 97.7% for orthopedics. Additionally, there was large variation in pre- and postintervention differences in utilization by hospital. We successfully increased single-lumen PICC utilization across all 11 safety net hospitals. This expands on previous work on improving single-lumen PICC use and use of default nudges in large, resource-limited settings. Further study is needed to examine variation among provider types, specialties, and hospitals.

Symptomatic Deep Vein Thrombosis Associated With Peripherally Inserted Central Catheters of Different Diameters: A Systematic Review and Meta-Analysis.

We assessed the relationship between peripherally inserted central catheter (PICC) diameters and symptomatic deep vein thrombosis (DVT) rates. We conducted a systematic search for articles published between 2010 and 2021 reporting DVT incidence by catheter diameter in patients who had a PICC, followed by meta-analyses for DVT risk in each diameter group. Pooled DVT rates were incorporated into an economic model. Of 1627 abstracts screened, 47 studies were included. The primary meta-analysis of 40 studies demonstrated the incidence of DVT was 0.89%, 3.26%, 5.46%, and 10.66% for 3, 4, 5, and 6 French (Fr) PICCs (P = .01 between 4 and 5 Fr). Rates of DVT were not significantly different between oncology and nononcology patients (P = .065 for 4 Fr and P = .99 for 5 Fr). The DVT rate was 5.08% for ICU patients and 4.58% for non-ICU patients (P = .65). The economic model demonstrated an annual, incremental cost savings of US$114 053 for every 5% absolute reduction in 6 Fr PICCs use. Using the smallest PICC that meets the patients' clinical needs may help to mitigate risks and confer savings.

1664. Impact of a Midline Catheter Prioritization Project on Central Venous Access and Central Line Associated Bloodstream Infections at an Urban Safety-net Community Hospital

Abstract Background The use of peripherally inserted central catheters (PICCs) has increased in the past decade. PICCs are central lines (CLs) commonly used for venous access. Midline catheters (MLs) can provide access when the need for a CL, such as vasopressors, is no longer present. MLs have a lower rate of BSI compared to PICCs and CLs, while providing dwell times comparable to PICCs. We established a project prioritizing ML use. Methods This is a quasi-experimental study in a 151-bed safety net community hospital. The pre-intervention period was January-December 2018 and post period was January 2019-December 2021. MLs were prioritized when new PICCs are requested without CL indications, such as total parenteral nutrition, hyperosmolar solutions and vasopressors. PICCs and CLs are transitioned to a ML once indications are no longer met and peripheral IVs are not feasible. Data on utilization and complications, such as deep venous thrombus (DVT) and BSIs, were reviewed and compared. Results A total of 63 peripherally inserted lines occurred prior to the intervention, of which 55 (87%) were PICC and 8 (13%) were ML (Figure 1). Post-intervention, 76 lines were placed the first year, of which 48 were ML (63%). This upward trend was sustained throughout the pandemic, with 116 lines in 2020 (80% ML) and 96 in 2021 (88% ML). No BSIs occurred during the pre-intervention and first post-intervention year. During the pandemic, 8 BSIs in MLs and 3 in PICCs occurred. The most common organism was Candida (Figure 2). The majority had COVID-19 (72%) and all (100%) BSIs were in the setting of shock. Case review demonstrated suspected secondary sources other than central venous catheters (CVCs). All BSIs with ML would have met NHSN criteria if CL present. No upper extremity DVTs were found. Conclusion A midline prioritization project was successfully implemented and sustained during the COVID-19 pandemic. The decline of PICC use from 87% to 12% suggests use for access without CL needs. High acuity during the pandemic led to BSIs that were likely secondary to shock and complications of COVID-19. All cases would have met NHSN criteria for CLABSI. The cost of a CLABSI is estimated at $48,108. Thus, this midline prioritization project may have led to CLABSI avoidance and an estimated cost savings of $384,864. Disclosures All Authors: No reported disclosures.

Self-injecting non-prescribed substances into vascular access devices: a case study of one health system’s ongoing journey from clinical concern to practice and policy response

BackgroundOverdose-associated deaths and morbidity related to substance use is a global public health emergency with devastating social and economic costs. Complications of substance use are most pronounced among people who inject drugs (PWID), particularly infections, resulting in increased risk of hospitalization. PWID often require intravenous access for medical treatments such as antibiotics; however, vascular access may be limited due to the impacts of long-term self-venipuncture. While vascular access devices including peripherally inserted central catheters (PICCs) allow reliable and sustained routes of administration for indicated therapies, the use of PICCs among PWID presents unique challenges. The incidence and risks associated with self-injecting non-prescribed substances into vascular access devices (SIVAD) is one such concern for which there is limited evidence and absence of formal practice guidance.Case presentationWe report the experience of a multidisciplinary team at a health organization in Vancouver, Canada, working to characterize the incidence, patient and healthcare provider perspectives, and overall impact of SIVAD. The case study of SIVAD begins with a patient’s perspective, including patient rationale for SIVAD, understanding of risks and the varying responses given by healthcare providers following disclosure of SIVAD. Using the limited literature available on the subject, we summarize the intersection of SIVAD and substance use and outline known and anticipated health risks. The case study is further contextualized by experience from a Vancouver in-hospital Overdose Prevention Site (OPS), where 37% of all individual visits involve SIVAD. The case study concludes by describing the systematic process by which local clinical guidance for SIVAD harm reduction was developed with stakeholder engagement, medical ethics consultation, expert consensus guideline development and implementation with staff education and planned research evaluation.ConclusionSIVAD is encountered with enough frequency in an urban healthcare setting in Vancouver, Canada, to warrant an organizational approach. This case study aims to enhance appreciation of SIVAD as a common and complex clinical issue with anticipated health risks. The authors conclude that using a harm reduction lens for SIVAD policy and research can provide benefit to clinicians and patients by offering a clear and a consistent healthcare response to this common issue.

Does the antimicrobial-impregnated peripherally inserted central catheter decrease the CLABSI rate in neonates? Results from a retrospective cohort study.

The use of antimicrobial-impregnated peripherally inserted central catheters (PICCs) has been introduced in the last few years to neonatal units aiming to reduce central line-associated bloodstream infection (CLABSI). This retrospective observational study aimed to compare the CLABSI rates and other catheter-related parameters including the insertion success rates and catheter-related complications in the antimicrobial-impregnated and conventional (ordinary) PICCs in NICU between 2017 and 2020. Our dedicated PICC team including physicians and nurses inserted 1,242 conventional (PremiCath and NutriLine) and 791 antimicrobial-impregnated PICCs (PremiStar) over the study period from 2017 to 2020. Of those 1,242 conventional PICCs, 1,171 (94.3%) were 1 Fr single lumen and only 71 (5.7%) were 2 Fr double lumen. The mean ± SD [median (IQR)] for the birth weight in all babies who had a PICC line was 1,343.3 ± 686.75 [1,200 (900, 1,500)] g, while the mean ± SD for the gestational age was 29.6 ± 4.03 [29 (27, 31)] weeks. The mean ± SD [median (IQR)] age at the time of insertion for all catheters was 9.3 ± 21.47 [2 (1, 9)] days, while the mean ± SD [median (IQR)] dwell time was 15.7 ± 14.03 [12 (8, 17)] days. The overall success rate of the PICC insertion is 1,815/2,033 (89.3%), while the first attempt success rate is 1,290/2,033 (63.5%). The mean ± SD [median (IQR)] gestational age, birth weight, age at catheter insertion, and catheter dwell time were 28.8 ± 3.24 [29, (26, 31)] weeks, 1,192.1 ± 410.3 [1,150, (900, 1,450)] g, 6.3 ± 10.85 [2, (1, 8)] days, and 17.73 ± 17.532 [13, (9, 18)] days in the antimicrobial-impregnated catheter compared with 30.1 ± 4.39 [29, (27, 32)] weeks (P < 0.001), 1,439.5 ± 800.8 [1,240, (920, 1,520)] g (P < 0.001), 11.1 ± 25.9 [1, (1, 9)] days (P < 0.001), and 14.30 ± 10.964 [12, (8, 17)] days (P < 0.001), respectively, in the conventional PICCs. The use of the antimicrobial-impregnated catheter was not associated with any significant reduction in the CLABSI rate (per 1,000 days dwell time), either the overall [P = 0.11, risk ratio (RR) (95% CI): 0.60 (0.32, 1.13)] or the yearly CLABSI rates. The use of miconazole and rifampicin-impregnated PICCs did not reduce the CLABSI rate in neonates compared with conventional PICCs. However, it has a higher overall rate of elective removal after completion of therapy and less extravasation/infiltration, occlusion, and phlebitis compared with the conventional PICCs. Further large RCTs are recommended to enrich the current paucity of evidence and to reduce the risk of bias. Neonatal PICCs impregnation by other antimicrobials is a recommendation for vascular access device manufacturers.

A Risk Score for Single-Lumen Peripherally Inserted Central Catheter (PICC)-Related Venous Thrombosis in Cancer Patients Undergoing Ambulatory Chemotherapy

Introduction The extended use of peripherally inserted central catheters (PICCs) in cancer patients have simplified the management of the treatment, but also represent an important risk factor of upper limbs thrombosis in a population specially predisposed to thrombotic events. Given the clinical significance of PICC-related venous thrombosis (VT) in cancer patients, a predictive risk model could be helpful. Methods Retrospective unicentric study in which patients with single-lumen PICCs, placed by using ultrasound guidance by a trained nursing team at our centre from January 2015 to May 2019 were included. Inclusion criteria were age ≥18 years-old, histologically confirmed diagnosis of cancer and treatment with ambulatory chemotherapy regimen. The presence of symptomatic PICC-related VT confirmed by ultrasounds, variables regarding PICC (placement, use and removal) and the main clinical and biological characteristics of the patients were recorded. For further analysis, sites of cancer were categorized into "very high risk", those with VT rates of 2-fold or higher than the median risk of the group (lung, testicular, bladder), "high risk", those with rates higher than average (gastric, pancreatic, breast, head and neck), and low risk, those with rates at or below average (colorectal, prostate, lymphoma, gynecologic, and others). The predictive accuracy of the model was assessed: discrimination was evaluated using the c-statistic representing the AUC (area under the receiver-operating characteristic), the Hosmer-Lemeshow test was used to assess model calibration and a bootstrap internal validation procedure with 1000 bootstrap resamples was performed. Results Seventy (6%) of 1170 patients who received PICCs, with a median time of use of 108.5 days [2-525], developed symptomatic, image-confirmed PICC-related VT. Moreover, 10 of the 70 had associated pulmonary embolism. The main characteristics of the patients with and without PICC-VT are summarized in table 1. The median time between PICC placement and thrombosis was 25.5 [1-458] days and VT was more probable on the first 100 days after placement (p=0.002). In univariable analyses, the following variables were significantly associated with the development of symptomatic PICC-VT: primary site of cancer, pre-chemotherapy platelet count ≥350 x109/L and supradiaphragmatic radiotherapy concomitant to PICC use. In addition, PICC tip placement next to the right atrium (in the right atrium or at the lower third of the superior vena cava) is associated with a lower incidence of VT. PICC tip position only could be checked in 447 patients by chest radiography. In the final multivariable logistic regression model (table 2), three variables emerged as risk factors independently associated with PICC-VT: primary site of cancer (very high risk or high risk), pre-chemotherapy platelet count ≥350 x109/L and supradiaphragmatic radiotherapy concomitant to PICC use. PICC tip placement was not considered in the multivariable analysis, since it is a correctable variable. To create the risk score, we assigned points to each of the three variables based on their regression coefficients (table 2). Patients were assigned to one of three risk groups based on cumulative total points: low (score 0), intermediate (score 1), and high (score ≥2). Observed PICC-related VT rates were 3.1% for the low-risk group, 6.4% for the intermediate-risk group and 12.4% for the high-risk group. In a logistic regression model with risk group as a categorical predictor, the risk classification rule was significantly associated with PICC-VT (p <0.001), with odds ratios of 2.136 (95% CI, 1.137-4.011) and 4.456 (95% CI, 2.387-8.320) for intermediate-risk and high-risk groups vs. low-risk group, respectively. C statistic was 0.662 (95%CI 0.598-0.727). Conclusions Primary site of cancer, pre-chemotherapy platelet count and supradiaphragmatic radiotherapy concomitant to the PICC use are independent risk factors for single-lumen PICC-related venous thrombosis in cancer patients undergoing ambulatory chemotherapy. The score proposed herein could be a helpful tool to predict the risk of PICC-related VT. PICC tip placement proximal to the right atrium could reduce the risk of VT. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

"They Just Assume That We're All Going to Do the Wrong Thing With It. It's Just Not True": Stakeholder Perspectives About Peripherally Inserted Central Catheters in People Who Inject Drugs.

BackgroundIn the absence of adequate harm reduction opportunities, people who inject drugs (PWID) are at increased risk for serious infections. Infectious diseases guidelines recommend extended periods of intravenous antibiotic treatment through peripherally inserted central catheters (PICCs), but PWID are often deemed unsuitable for this treatment. We conducted semi-structured interviews and focus groups to understand the perspectives and opinions of patients and clinicians on the use of PICCs for PWID.MethodsWe approached patients and clinicians (doctors, nurses, PICC nurses, social workers, and case workers) involved in patient care at Tufts Medical Center (Boston, Massachusetts) between August 2019 and April 2020 for semi-structured interviews and focus groups.ResultsEleven of 14 (79%) patients agreed to participate in an in-depth interview, and 5 role-specific clinician focus groups (1 group consisting of infectious diseases, internal medicine, and addiction psychiatry doctors, 2 separate groups of floor nurses, 1 group of PICC nurses, and 1 group of social workers) were completed. Emergent themes included the overall agreement that PICCs improve healthcare, patients’ feelings that their stage of recovery from addiction was not taken into consideration, and clinicians’ anecdotal negative experiences driving decisions on PICCs.ConclusionsWhen analyzed together, the experiences of PWID and clinicians shed light on ways the healthcare system can improve the quality of care for PWID hospitalized for infections. Further research is needed to develop a system of person-centered care for PWID that meets the specific needs of patients and improves the relationship between them and the healthcare system.

Patterns of use and outcomes of peripherally inserted central catheters in hospitalized patients with solid tumors: A multicenter study.

The risk of peripherally inserted central catheter (PICC)-related complications in patients hospitalized with solid tumors remains unclear. Existing studies are limited by single-center, outpatient designs and include heterogenous patients. A retrospective cohort study was designed and included adult patients with solid organ cancers who were admitted to a general medicine ward or intensive care unit and received a PICC. Data were collected from November 2013 to December 2019 at 50 Michigan hospitals. Major complications were defined as central line-associated bloodstream infection, deep vein thrombosis, pulmonary embolism, and catheter occlusion. Hospital variation in PICC use and outcomes was examined. Data included 3235 hospitalized patients with solid tumors who had PICCs placed for 51,047 catheter days. Most catheters were double-lumen devices (57.0%). Notably, 17.5% of patients had another central venous catheter at the time of PICC insertion. The most common indications for PICC use were antibiotics (34.5%) and difficult access or blood draws (21.6%); chemotherapy was the primary indication in only 15.7% of patients. A major PICC-related complication occurred in 491 patients (15.2%); catheter occlusion was the most prevalent complication (n=322; 10.0%) followed by deep vein thrombosis (n=116; 3.6%), central line-associated bloodstream infection (n=82; 2.5%), and pulmonary embolism (n=20; 0.6%). Significant variation in indications for PICC use, device characteristics, and frequency of major complications across hospitals was observed (p < .001). PICCs were associated with significant complications in hospitalized patients who had solid malignancies and were often used for reasons other than chemotherapy. Policies and guidance for the appropriate use of PICCs in oncologic patients appear necessary. Peripherally inserted central catheters (PICCs) are devices placed in peripheral veins to deliver medication to large veins near the heart. PICCs are used frequently in oncology. The objective of this report was to describe PICC-associated complications in hospitalized patients with solid tumors. This study was performed across 50 Michigan hospitals and included 3235 patients with solid tumor cancers and who had a PICC. Overall, 15.2% of patients experienced a complication, including central line-associated bloodstream infections, deep vein thrombosis, pulmonary embolism, or catheter occlusion. Complication rates varied across hospitals. PICCs are associated with substantial complications in hospitalized patients with solid tumors.