Less Lumens-Less Risk: A Pilot Intervention to Increase the Use of Single-Lumen Peripherally Inserted Central Catheters
To reduce risk of complications, existing guidelines recommend use of peripherally inserted central catheters (PICCs) with the minimal number of lumens. This recommendation, however, is difficult to implement in practice. We conducted a pilot study to increase the use of single-lumen PICCs in hospitalized patients. The intervention included (1) education for physicians, pharmacists, and nurses; (2) changes to the electronic PICC order-set that set single lumen PICCs as default; and (3) criteria defining when use of multilumen PICCs is appropriate. The intervention was supported by real-time monitoring and feedback. Among 226 consecutive PICCs, 64.7% of preintervention devices were single lumen versus 93.6% postintervention (P < .001). The proportion of PICCs with an inappropriate number of lumens decreased from 25.6% preintervention to 2.2% postintervention (P < .001). No cases suggesting inadequate venous access or orders for the placement of a second PICC were observed. Implementing a single-lumen PICC default and providing education and indications for multilumen devices improved PICC appropriateness.
© 2019 Society of Hospital Medicine
Vascular access is a cornerstone of safe and effective medical care. The use of peripherally inserted central catheters (PICCs) to meet vascular access needs has recently increased.1,2 PICCs offer several advantages over other central venous catheters. These advantages include increased reliability over intermediate to long-term use and reductions in complication rates during insertion.3,4
Multiple studies have suggested a strong association between the number of PICC lumens and risk of complications, such as central-line associated bloodstream infection (CLABSI), venous thrombosis, and catheter occlusion.5-8,9,10-12 These complications may lead to device failure, interrupt therapy, prolonged length of stay, and increased healthcare costs.13-15 Thus, available guidelines recommend using PICCs with the least clinically necessary number of lumens.1,16 Quality improvement strategies that have targeted decreasing the number of PICC lumens have reduced complications and healthcare costs.17-19 However, variability exists in the selection of the number of PICC lumens, and many providers request multilumen devices “just in case” additional lumens are needed.20,21 Such variation in device selection may stem from the paucity of information that defines the appropriate indications for the use of single- versus multi-lumen PICCs.
Therefore, to ensure appropriateness of PICC use, we designed an intervention to improve selection of the number of PICC lumens.
METHODS
We conducted this pre–post quasi-experimental study in accordance with SQUIRE guidelines.22 Details regarding clinical parameters associated with the decision to place a PICC, patient characteristics, comorbidities, complications, and laboratory values were collected from the medical records of patients. All PICCs were placed by the Vascular Access Service Team (VAST) during the study period.
Intervention
The intervention consisted of three components: first, all hospitalists, pharmacists, and VAST nurses received education in the form of a CME lecture that emphasized use of the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).1 These criteria define when use of a PICC is appropriate and emphasize how best to select the most appropriate device characteristics such as lumens and catheter gauge. Next, a multidisciplinary task force that consisted of hospitalists, VAST nurses, and pharmacists developed a list of indications specifying when use of a multilumen PICC was appropriate.1 Third, the order for a PICC in our electronic medical record (EMR) system was modified to set single-lumen PICCs as default. If a multilumen PICC was requested, text-based justification from the ordering clinician was required.
As an additional safeguard, a VAST nurse reviewed the number of lumens and clinical scenario for each PICC order prior to insertion. If the number of lumens ordered was considered inappropriate on the basis of the developed list of MAGIC recommendations, the case was referred to a pharmacist for additional review. The pharmacist then reviewed active and anticipated medications, explored options for adjusting the medication delivery plan, and discussed these options with the ordering clinician to determine the most appropriate number of lumens.
