Mr. Carr has disclosed that he has served on speakers bureaus CareFusion in 2013 and Becton Dickinson in 2014 providing lectures on vascular access. He received a grant from CareFusion to attend a scientific meeting and a part-funded Scholarship from Becton Dickinson to support research activities.
VC: Tell me a bit about yourself and your background/calling to vascular access.
PC: I'm Irish which by default means I come from the most beautiful country in the world. However, I live in Perth, WA - the second most beautiful part of the world. If I want, I can cycle to work almost every day as the weather is super. I can even wear shorts in winter so what’s not to like!?
My professional interest in vascular access began in 2006 when I joined a European Working Time Directive initiative “IV Team”. A team of nurses and staff from the phlebotomy department provided peripheral intravenous cannulation to inpatients in Galway University Hospital; a teaching hospital in Ireland. While the service was disbanded due to the economic downturn, I had become motivated to research vascular access. My wife and I wanted a new adventure, a new challenge, to up skill clinically and academically so we departed the Emerald Isle taking a career leave from the Irish health service.
At that time the intention was to return and bring new knowledge/clinical methods back home. We have now been living “down under” for over 5 years and it looks like Australia is now our home and we appreciate the opportunity WA health have given us.
As a way of giving back to Australia, I am the current vice-president for the Australian Vascular Access Society and Scientific Chair for our 2nd Scientific Meeting. I am the Australian Global representative for World Congress on Vascular Access (WoCoVA) and lead the Western Australian Chapter of the AVATAR group. I won't be in these roles forever and the baton will be passed on in due course as change is a good thing (except for PIVCs!!).
VC: Tell me about your ongoing research work, interests and collaborators.
PC: I'm currently researching a clinical prediction model for first-time insertion success. This is focussed on appropriate insertion of peripheral cannulae on the first attempt in an anatomical location that will have greater dwell (and therefore reduce subsequent attempts ) by a clinician who is confident to do so.
It is part of my PhD and is co-supervised by a leading ultrasound expert and Emergency physician James Rippey. If clinicians/health care service providers are unable to succeed with traditional attempts then the appropriate use of ultrasound will be a superior method. For my research it is important to be with a clinical and academic expert in this area as James is.
I found the world leading researcher in vascular access in Prof Claire Rickard of Griffith University. Claire had the only vascular access research group that I could find in the world. There is nothing like working and learning from the best. Myself James, Prof Marie Cooke, Dr Niall Higgins and Gabor Mihala are a great team. I contribute to the AVATAR group with some of the most passionate scientific minds who focus on making positive vascular access experiences for patients and eliminating complications using scientific methods. In a word, AVATAR is an inspiration. I am so lucky to be involved with it. I am busy with a Cochrane systematic review title and would love for a few RCT’s on specialist teams for successful device insertion and prevention of failure. So if any of your readers have a clinical trial registration, protocol and RCT on this subject, please feel free to send it my way.
VC: You have always believed that insertion skills matter most? Why so?
PC: Well, insertion skill matters to the patient who receives the cannula, no? As clinicians we can be so focussed on trying not to miss and undertake repeated attempts without considering the feelings of the patient who is on the receiving end of the PIVC. Nothing beats genuine empathy. It is important for our colleagues to also understand that while insertion skill is critical, using the least appropriate device could result in a high failure rate on the first attempt or lead to a high post insertion failure. This requires us to be skilled in the assessment phase of the procedure and skilled in selecting the right devices suited to the patient.
I have seen and heard many comments such as “I can cannulate the small vein on your baby finger”. Well, find me a compos mentis adult who wants the PIVC in their pinky?
VC: So why has this issue not received more attention?
PC: Because PIVC is so frequently performed by a range of professionals, no one owns the insertion skill and this results in fragmentation in expertise. Some get protected proctoring by the worst possible mentors and very few get the best. It’s the classic bystander effect in clinical care, someone else will teach it, someone else will sort out the infection, the difficult patient and so on.
Inserting invasive devices into patient's anatomy is a unique relationship between provider and patient and we need to accept that we can always do better. People who we are privileged to look after are not getting good enough outcomes; at best 70-86% (note, not a 100%) first-time insertion success; is this acceptable in 2016? What about the other 30%.
Even with the use of ultrasound, you won't get a first pass success publication over 85%. This is what the scientific literature is telling us. Last week I gave a local presentation about PIVC evidence for an ultrasound PIVC workshop. When I told the audience the effectiveness of USG PIVC (based on randomised trials) was no better than traditional attempts it was like I stole the goose that laid the golden egg. But it's not a personal opinion but what the evidence is telling us! The latest systematic review (one of 5) on USG PIVC by Shannon Parker and colleagues from Canada sheds some perspectives on this.
The fact is after insertion 25%-50% (note, not 0%) can fail because of avoidable complications. I love the “getting to zero literature for CLASBI OR CRBSI” and applaud the clinical champions involved in this work but wonder why can't we get to down to 1 attempt? Behind each percent, each number, is our core business; human life; people in need of help. Imagine you are in a hospital bed, tired from chemo on your 5th PIVC insertion in 6 days (bear in mind you’ve had 8 attempts between the last two) and your thinking about your life, your kids, dog and you are finally getting some clarity before you hear the occlusion alarm on your infusion pump indicating another failure. This means another attempt and possibly more unsuccessful ones at that.
This is happening 24/7 around the world and it is going unnoticed as it is unrecognised or deemed to be of less importance amongst the array of competing healthcare issues. My hope is for our research to contribute to improving the insertion skills of clinicians today and in the future.
VC: So how do you propose to measure the skill of the inserter?
PC:We are working on a possible concept that we hope will attract funding (if you are a philanthropic reader, drop me a Tweet!). We (read as a generic term for Healthcare) poorly use data and poorly understand the relationship between data and vascular access regarding outcomes. One of those is the clinician's skill.
Let's say you had two medical/nursing inserters in the ED or Surgical ward, and on this occasion had to send 1 for mandatory PIVC training. Who would you send? (of course, some of your readers know this is a highly unlikely scenario… mandatory vascular access training that is) How would you pick the 1? The skill of the inserter is important, but they should want to be measured as a hospital mandate. Otherwise, we will continue with the keep trying until you get it approach; let's all have 2 attempts; call the anaesthetic to insert the PIVC or the local vein whisperer when all else fails.
Some clinicians reading this think they know how good they are, some might know how good they think they are, but what is their actual, factual data… if one of the aforementioned could say ”I put 50 PIVCs in this month; 44 traditional on the first needle puncture; 6 USG PIVCs on the first attempt. My outcomes are: 1 failed by accidental dislodgment, 29 remain insitu and 20 no longer needed and 0 infection/occlusion/thrombus. The category of patient was well spread between easy to difficult ones."
These data can help the manager allocate who they want to send for training. It's frustrating when people think they have data on the issue when they really don't. Because they have done the 2-4 hours mannequin venipuncture and cannulation training day and got someone to sign off on 20 insertions (if they got 20), they are ready for cannulation.
Do you think the patient should know what the success of the inserter is before he/she attempts one? Would you like your mother, father, brother sister, wife, husband, son, daughter to be the human simulator? We know (or at least I know) having observed 1,400 insertions in 2 large tertiary EDs with a variety of clinicians inserting that practice varies; training varies and success varies.
VC: Your research focuses a lot on the emergency department. Why did you choose this site as a venue for your study?
PC: It is the front door of the hospital and the first exposure that most patients (notwithstanding pre-hospital attempts) have with invasive devices. In Australia, we have a national target to get patient assessed, admitted, transferred or discharged within 4 hours. PIVC insertion is ever present in ED admitted patients.
My clinical background is also in ED and my experience in vascular access have contributed to the concepts my research seeks to evaluate. ED is where vessel health and preservation should commence. In my opinion (but biased by my studies!) insertion practice is no different on the ward when compared to ED. Clinical practice should be no different, it should be as per policy.
Insertion skill is the final act in a long process of critical clinical decision making; this can happen in seconds or much longer. Not to get too deep into cognitive psychology, but this is where Type 1 and 2 of thinking is evident. It could happen very quickly with some and be influenced by their Gestalt or others may take time with a procedure.
We are about to finish analysis on a data set that looks at which provider we could resource to certain veins based on their confidence. My clinical academic colleague James Rippey is fascinated by the influence of clinician gestalt on first-time insertion success. We have a paper in press in Emergency Medicine Australia.
Simply put, we hope to test an application of rules in future to resource the least experienced with the best veins so they amass consistent insertion success, increase their confidence and continue to develop successful procedural consistency and experience with patients with the fewest visible veins.
VC: How can one get better at inserting peripheral IVs? Is there a course or training you would recommend?
PC: It is a skill, an art and practice one can make permanent. You must know your product "intima"tely (pardon the pun) well. Your product target is a vein.
Jack LeDonne is a great friend and mentor, and he has a great saying “Feel is our fluoro” (this is the best advice he has told me). He’s right, though. The evidence to date is a visible palpable vessel is a strong predictor of insertion success. Don't set yourself up to fail; assessment is key. Once you can see and feel that vessel you approach it text book like (Aseptic-Sterile). You must be confident. Patient rapport and trust is important. Make them feel safe in your presence. Simple, really.
However, clinicians need to follow their outcomes. Imagine you’re the clinician who was at the pin of their collar so to speak, and got the PIVC in only for the device to fail by occlusion on the ward 6hrs later? Now the patient has the duty anaesthetist who has to make an extra attempt at an extra cost. These are modifiable and avoidable outcomes.
There are many courses one can take locally, online and many scientific meetings have pre-conference workshops. Seek out the local health care professionals whose paid role is to provide such training and mentorship. Ensure they actually perform clinical PIVC insertion themselves; I know may vascular access educators who insert vascular access devices in mannequins but not patients. That's a concern. Find the person who you think is the go-to person in your hospital, ask for mentorship/proctoring. Reflect on your performance.
VC: A lot of this comes back to having a dedicated group of providers to insert peripheral IVs? Is that your recommendation?
PC: You ask an excellent question Vineet. Yes it most certainly does, and in my opinion not just for PIVCs but for all peripheral and central vascular access devices. I have been grounded into defending my answers where possible with an evidence base. We just don't have the evidence for dedicated groups though; by evidence I mean many RCTs- followed by Systematic appraisal and meta–analysis of the data proving this is the case.
By dedicated groups, we don't know if nursing vascular access team exclusively are better than a mixed healthcare professional model (nurses, doctors, RTs, PA’s) versus the general inserters. We have a Cochrane review coming out soon, and there is not one published RCT that randomises the patient (or indeed a registered protocol for one at the time of typing this) that suggests a dedicated group of providers is superior when compared to the current combination of medical, nursing, technician provision. There is an obvious evidence gap.
Of course, there is evidence that local single centre initiatives prove teams are associated with good outcomes, but no causal data. This comes back to clinical confidence and procedural competency not defaulting to a technology. If you were to run against Usain Bolt in the morning who would win the 100m sprint? If you were to compare a vascular access team member with an HCP who focuses on less frequent insertion, who may you think will have better outcomes? We can’t all get the gold medal, but I’m willing to take a bet that we can have improved and sustained insertion success and a huge reduction in failure and waste with a process that uses a dedicated group of providers. Then patients will have a gold standard.
VC: What types of policies need to be enacted in Australia to ensure consistent practice on a local/regional/national scale?
PC: That is a tough one. As someone who has contributed to policy and guideline development, I respect the efforts that are made in writing them. However, based on current evidence I read daily, Australia needs an exclusive national vascular access device standard to include:
1. Better evidence-based assessment tools so we promote appropriate placement by appropriately trained professionals;
2. Device registries in hospitals and better use of technology to capture data and report all outcomes, not just infection related. For example, alerts on previous line history, whether it was difficult or not. Some great work is being done with renal patients in this area in Australia;
3. But the answer is in one word - consistent. Right now our first-time insertion success is “consistent” with 70-80% and post insertion failure is “consistent” 45%. Australia needs to continue to improve toward maintaining acceptable clinical outcomes for patients and aim for: “Consistent Practice” that reflects 100% first-time insertion success, 0% bloodstream infections, 0% complications through device failure.
In my opinion, the team approach to vascular access science is the biggest priority, and large metropolitan hospitals should have the professional entity that is “consistent” with practice approach. Otherwise, clinical decision-making will be underpinned by authority; let everyone have a go, rather than evidence.
Finally, with the development of our national society “AVAS”, we have ignited a flame for vascular access device practice and research to be promoted. That flame will continue to burn brightly next May in Perth with what we hope will be a cracking scientific meeting that will engage clinical practice with science, supported by the patient narrative. Toward better patient and hospital outcomes for Australia and afar.
VC: Prof. Antonio LaGreca is a surgeon at Catholic University in Rome. We recently held an Open Discussion regarding the MAGIC recommendations at WoCoVA. Our exchange led to a number of important points, many of which pertain not only to the contrarian point of view with respect to PICCs but also nuances regarding vascular access devices. I therefore invited him to consider submitting a blog for ImprovePICC.
Dr. LaGreca has indicated the following conflicts of interest with respect to this blog: "I am a member of the Italian Study Group on Vascular Access (GAVeCeLT). This a non-profit association aimed at deepening and spreading knowledge and practice on vascular access."
VC: Your views regarding the safety of PICCs differ from mine. Tell my why?
AG: I tried to underline that, from a conceptual point of view, PICCs are not something different from CICCs (centrally inserted central catheters) or FICCs (femoral inserted central catheters), as we like to classify central VADs. The difference lies in the approach, not in the vascular access device (VAD), and the approach makes a big difference. If we look back to the genesis of PICCs, they were born as second choice devices. When placed at the elbow, their clinical performance was so unsatisfying (early massive thrombophlebitis as high as 70% at 3 days, mechanical problems such as dislocation, rupture, occlusion, high failure rates at insertion) that they could not be considered a first line approach. After introducing the mid arm approach under ultrasound guidance, a revolution occurred: success rates improved, indications widened, and the ability to obtain a CENTRAL line without facing potentially life-threatening complications of a cervical or thoracic approach (e.g., pneumothorax, vessel injury, etc.) extended the range of operators that could feel (or try to feel) confident with the procedure.
VC: Interesting - how do you think this influenced the adoption of PICCs?
AG: The culture of patient safety in the field of vascular access has always grown with the introduction of new and enthusiastic operators involved in insertion and management of new devices. This was true for central venous catheters, and in todays era, we have to thank PICCs for this.
VC: So are there no problems, in your opinion, when it comes to PICCs?
AG: Well, PICCs have faced several technical and procedural problems in the recent past. Some of these problems have been overcome thanks to a huge cultural and technical effort by clinicians and companies.
Technical problems may be summarized as follows:
Procedural problems include correct indications and choice of device for each patient, wise proactive vascular planning, standardization of safe and effective insertion techniques.
In this context, numbers without wisdom can make the difference. If operators dealing with a new procedure increase, numbers may increase irrespective of actual needs and benefits, safe insertion and care procedures and cost-effectiveness. This may harm patients and health systems as well. I use to present a brief paradoxical example of what can happen if we consider the same issue from two different points of view: I call it "the rule of the numerator”…
In 2010, the vascular team of a small hospital inserts 100 PICCs, with a global complication rate of 10%. In 2013, the same team is able to insert 1000 PICCs with a global complications rate of 5%. The absolute percentage of complications looks much better in 2013, but if we look at the actual numbers of patients harmed - we had 10 complications in 2010 as compared to 50 in 2013. If the average complication costs 25,000 euros (as it happens for a single CR-BSI), we are facing a global cost of 1,250,000 Euros in 2013, as compared to 250,000 Euros in 2010. Is this balanced by an actual increase in patients outcomes and/or reduction in other expense sections such as procedural costs, operators’ workload etc.?
VC: I see - what about major problems like bloodstream infection?
AG: In the middle between technical and procedural problems, catheter related blood-stream infections are still a concern, related to numbers as well as correct indications, care protocols and use of supporting devices (dressings, sutureless devices, etc.). In this field we have good quality evidence and devices, but still need to better incorporate these data into practice. This is especially relevant in the case of PICCs given the wider adoption of these devices and the growing availability of dedicated operators and staff to maintain them.
VC: So how to move this forward so that everyone inserts and cares for PICCs safely, much like you do in in Rome?
AG: A huge cultural effort by clinicians and technological effort by companies could further improve results as follows:
These are all avoidable in my opinion, as follows: first we need to define and adopt an evidence-based, but comprehensive algorithm for choosing the right device in each patient. We are proposing our hospital algorithm throughout the country: it includes indications and contraindications, and provides a reasonable approach to the problem. Maybe an international approach, one that began with the MAGIC paper that can be further modified and integrated to the local context could work even better.
VC: What do you see as the major challenges in the field today?
AG: There are several important issues that need resolution:
VC: Your thoughts are very interesting. What final words of wisdom do you have for our readers?
AG: I told you in Lisbon that I see myself as a good clinician, not as a researcher: so tell me what do and I will do it the best I can. I haven’t got answers yet, but only some ideas. One of these is, if one of the major concerns is thrombosis, we need a big multicenter study with a very homogenous insertion protocol throughout the centers, including a strict indication for catheter-to-vein ratio. This is feasible and will give a definitive answer as concerns pathogenesis of catheter related thrombosis and related consequences on practice. Also, we need better cost-effectiveness studies and data regarding empiric outcomes. The field should work on a simple, but effective algorithm for indication and choice of vascular access devices to be spread all over the world of operators. I hope we can work together to provide answers and conduct these types of studies.
I just returned from WoCoVa 2016 in Lisbon. What a meeting! Representatives from over 60 countries, 1000 participants and so much interest in improving all aspects of device safety - from selection, insertion, care and maintenance. My heartiest congratulations to the organizers for arranging such a fantastic scientific session.
On a personal note - it was also nice to finally meet many of the people I have corresponded with via email, putting faces to names and shaking hands after all these years. I also appreciated the many different aspects of vascular access in the world. It's fascinating to me how the same device is often inserted by different people, cared for in different ways, and viewed upon variably based upon these and other factors. For those of you that have never been to WoCoVa, I highly encourage it -- it is refreshing and opens your eyes to important differences in our practice.
One of the highlights of the meeting for me was debates with key leaders regarding the evidence. At many sessions that I attended, there was a palpable anxiety regarding the evidence base and whether or not it applies to current practice. Most notably, I heard the revered Drs. Pittiruti and Lamberti (both of whom I have tremendous respect for), speak about systematic reviews and meta-analysis and the limitations of current data. While I understood their concerns, I also was vexed regarding their interpretation of these studies that have been published in top-tier journals. In particular, they discussed our recent meta-analysis regarding PICC DVT published in the Lancet. I had the opportunity to challenge some of their assertions in an unscripted mini-debate. Here, in summary, are the key issues brought forward and my responses:
1. Meta-analyses of observational data is not appropriate or valid.
Response: This is simply not accurate. There is a robust science regarding how to use data from observational studies in meta-analyses, including guidelines and a checklist of best practices. Meta-analyses of observational data are responsible for key learnings, including those of global climate change and it's effect on species, the association between tobacco use and cancer, as well as the recent and Zika virus outbreak by the World Health Organization. These analyses are also extremely hard to do - much harder than analyses of randomized trials. And it's not as if RCTs are the silver bullet to solve all of our problems -- in fact, quite the opposite, as so nicely outlined by this author. They are therefore KEY to understanding and improving our knowledge about key scientific questions. Top tier journals, including the Lancet, understand this and have very stringent requirements to ensure such studies are well done and adhere to the highest standards of practice. In fact, our review was independently reviewed and met stringent scientific criteria to be included by DARE, an organization that reviews the quality of systematic reviews.
2. The studies put together are extremely heterogeneous, do not reflect current practice.
Response: It is true that the studies included in our analysis span over 50 years and practice with PICCs has changed considerably. For instance, Drs. Pittiruti and Lamberti cite use of ultrasound as a key advancement that influences safety. While I understand these concerns, there are important caveats. First, the key to a well-done systematic review is the use of an explicit protocol that includes all, not some of the evidence. Including only a few studies or focusing on those that (in the readers assertion) are the most representative (which is what they chose to do) is the key to introducing selection bias, the very thing systematic reviews were designed to counteract. Second, it is important to remember that systematic reviews cannot, by definition, improve upon the quality of the evidence. They are a representation of what is out there - and well done reviews are an important clue to a "signal" as to what current evidence suggests. Finally, it is always important to look at evidence holistically, not just from a single studies point of view. In this context, it is worth noting that the signal that PICCs might be more thrombogenic than other devices was not simply suggested by our review - but also by those of Saber and colleagues, Pikwer and colleagues, and also by Johanssen and colleagues. Is it possible that all of these are flawed. Possibly. But I doubt it.
3. The data do not support greater risk of thrombosis associated with PICCs than central venous catheters.
Response: This assertion, unfortunately, occurred with some misrepresentation of the data from our studies and those of others. First, only certain studies from our analysis of 62 were picked and chosen to fit the bill for this argument based on ultrasound use, a modern era of PICC placement, etc. Asides from the huge concerns regarding selection bias here, I think it is wrong to pick studies only because insertion practices were better. I realize this is very important when it comes to thrombosis, but ultrasound represents but a fraction of time for a PICC. What about the rest of the life of the device? We know that PICCs are more likely to develop malposition than other devices (this was conceded by the speakers as well), and since tip malposition is a key factor for thrombosis - how does an ultrasound at insertion at the time prevent this in the future? Second, none of the numbers presented had confidence intervals around them. Confidence intervals are the key to understanding effect sizes -- in fact, in meta-analysis, they are FAR more important than the actual point estimate. When you actually look at the confidence intervals of the data points used by the speakers, they completely overlap those of the conclusion of the study. Third, concerns regarding including asymptomatic and symptomatic thrombosis and inclusion of both of these data were not correct -- we understood these are separate entities and did separate them in subgroup analysis, only to come up with the same conclusion. I will add that there are several new studies that suggest PICCs might be more thrombogenic, including a recently published RCT, a large study of DVT in medical patients, and a study from Italy by Dr. Bertoglio who also spoke at the conference. Again, remembering the totality of the evidence -- is it possible that these are all wrong? Maybe, but again - I doubt it.
1. Please note that I am obviously conflicted being the writer of this document and of the Lancet paper. I am also an empiricist, not a rationalist (more on this topic here). I believe good science requires data and that all decisions must be made taking this data into consideration. This was not what was happening at this session, prompting me to take on two leaders in our field whom I have learned much from. I think it is important to respect the evidence we have. In a field that struggles to find any type of evidence, we simply cannot afford to throw out the baby with the bathwater. There are patients in all of these studies that might have been hurt by the choices we providers made when placing PICCs. It is simply not right to assume all of the data is inaccurate given this important pretext. Absence of evidence is not evidence of absence.
2. I do not want you to walk away from this seeing this post as more rhetoric and verbal jousting. Rather, regardless of our differences, I share with Drs. Pittiruti and Lamperti the need for better data in helping make this assertion. Given the effect sizes and numbers involved, only a large, likely international, multi-site trial can give us the answers we need when it comes to thrombosis risk between these devices. I see our role in leading just such a study, not arguing over the data. I was happy that we agreed on this -- and that we will work towards such a study in the years to come.
3. In the end, we agreed to disagree. But everyone reading this should know that this was a huge win for our field. This type of debate - by people who are passionate, knowledgeable and able to communicate in a non-defensive, conflict-free way - is precisely what vascular access needs. At the end of the day - the specialty won. And that, my friends, is what is most important.
I look forward to your thoughts regarding the session (if you were there) or this post.
Dr. Claire Rickard is a PhD nurse investigator affiliated with Griffith University in Brisbane, Australia. An accomplished researcher who has published in top-tier journals and is internationally recognized as a leader in vascular access, she also oversees the Alliance for Vascular Alliance Teaching and Research Group (known widely as AVATAR). AVATAR and it's members have conducted some of the most influential trials in vascular access, including the recent routine vs. clinically warranted replacement of peripheral IVs (PIV) published in the Lancet.
Dr. Rickard was kind enough to sit down with us and answers some questions about vascular access and her research in this field. She has filled the ICJME form and has disclosed the following conflicts of interest: grants and other from 3M, grants and other from BBRAUN, grants and other from BD, grants from CAREFUSION, grants from COOK, grants from ENTROTECH, grants from BAXTER, grants from HOSPIRA, other from BARD, grants and other from TELEFLEX, outside the submitted work.
VC: Please tell us a bit about yourself and how you got interested in vascular access?
CR: I’m a Registered Nurse from Brisbane, Australia. I worked in medical and cardiac surgical wards (floors) and then in ICU for many years. I was always intrigued about all the variation in how we cared for vascular access devices between different hospitals. So, later I did (was almost forced to!) complete a research methods subject as I completed an ICU Graduate Diploma. It wasn' too longer afterwards that I could see how research just might be a good tool to sort out some of that care variation. And the rest, as they say, is history
VC: Your research group, AVATAR, is well-known for producing high quality research. How did the group come to be and tell us a bit about your focus?
CR: AVATAR came about quite organically over 20 years. When I say organically, I mean that it just sort of happened from the ground up - there was never some type of "master plan" to develop a research group focused on vascular access. At first it was just me and a couple of colleagues who shared this passion and interest. But then, as we were able to win larger research grants we met other researchers passionate about vascular access and just enjoyed learning from and spurring each other on. And so -AVATAR was born. Now keep in mind, AVATAR is a voluntary group - we don’t receive any ongoing funding from any of the hospitals or universities. But somehow we have managed to survive and thrive - speaking to the power of passionate individuals coming together to advance science that they truly care about.
VC: Tell us about some of your ongoing research projects, especially those that relate to PICCs?
CR: We have about 70 research projects active right at this minute. Our bigger PICC projects at the moment are the RSVP Trial which is randomising patients to have 4 day or 7 day routine replacement of their IV tubing, and the PISCES Trial which is another multi-centre randomised trial comparing methods of dressing and securement that prevent infection, dislodgment and thrombosis.
VC: Is much of AVATARs research has focused on peripheral IVs? If so, can you share with us why you chose this device in particular?
CR: Well actually this is a common misconception. As a former ICU nurse (in Australia we rarely see PIVs in ICU) I was initially far more focussed on central and arterial device issues. Later on, I could see the commonality of the problems across all vascular access devices, and realised that although there were pockets of research activity in central lines in particular, the poor old PIVs were almost totally ignored. Looking at the bigger picture made me realise that improving PIV care was actually going to benefit a huge majority of the population, due to the numbers used.
VC: What have some of the surprises been in your research journey?
CR: Well in Australia until recently we had no vascular access society (now we have avas.org.au), and IV/PICC teams continue to be rare, although brilliant when we have them. So I was actually unaware that there was this whole specialty out there called vascular access or infusion nursing until many years after I started research in the area. Now I’m so happy and energised to be connected with this international community of practitioners and researchers. The other thing that surprises me constantly is how content healthcare professionals can be with using and implementing new devices and care procedures, that have little to zero evidence that they actually work. That’s very frustrating.
VC: Your team focuses on systematic reviews and trials? Why these two types of research methods?
CR: Well we only have so many hours in this life! and we know that we need ‘Level 1 Evidence’, like Cochrane systematic reviews, and randomised clinical trials, if we want to understand ‘cause and effect’ relationships and identify those policies and products that really do prevent complications. It’s hard yakka (that's Australian for hard work btw) to do research so we think we should focus our limited time and money on providing the most valid and reliable research results for implementing in practice.
VC: What advice do you have for vascular access nurses interested in starting a research project?
CR: I would say go for it! But in reality you’re going to need some friends in the form of supportive clinical colleagues, and some experienced researchers who you can go to for advice. They don’t need to be vascular access researchers necessarily, you might have clinical trial nurses attached to the cancer or renal service for example, who would have heaps of knowledge about all the processes and paperwork. It would also help to find a mentor, either an academic nurse or doctor, but check they have published clinically focussed research themselves. I’d always suggest doing a randomised trial, not a pre and post study. It is actually no harder and your results will have so much more power. Even if you study a small number of patients, it’s very valuable data and can also then be included by authors of systematic reviews on the topic.
VC: You’ve discussed creating a “Center of Excellence” for vascular access. Tell us a bit more about this.
CR: We’d like to formalise what we have been doing in AVATAR for some time now. We are seeking government and philanthropic funds that would give us 5 years surety of funding. This money allows us to hire clinical nurses or doctors as researchers, so they can get that experience, and similarly fund Masters and PhD research scholarships so we can grow the global capacity for research. We plan to focus these research programs in three areas: (i) Insertion (assessment, procedure, devices), (ii) the Function phase (dressings and securement, flushing and blood sampling, connectors), and (iii) Removal (this one is a no-brainer - ongoing assessment and getting devices out when no longer needed). Some of this work will be clinical research but a whole other arm will focus on the Implementation/uptake of knowledge from research results.
VC: In your opinion, what are the three most important questions remaining to be answered in vascular access? How can we go about getting these addressed? What barriers, if any, remain in effectively answering these issues?
CR: Wow, ok. Here we go:
#1: We know 25-50% of vascular access devices have complications that lead to the device becoming non-functional, but how do we set up public benchmarking, so that hospitals take this seriously, and practitioners are more aware of this? We plan to set up a Vascular Access Registry to help with this, but that will still need to find ways to be championed throughout the Quality, Nursing and Hospitalist worlds in particular, to make this successful.
#2: In recent years, our research has shown that PIVs do not need to be routinely removed every 72-96 ours. They are licensed for up to 30 days use and with continued policies of clinical monitoring, can be safely used until there is a clinical reason for removal. We also know thanks to Dr Chopra and colleagues that PICCs have complications more similar to CVCs, so we are now taking that decision to place a PICC more seriously. So there is now this huge ‘middle ground’ – which patients/treatments can we use PIVs for (including new longer PIVs and mid-lines), and avoid the need for a PICC?
#3. Occlusion is the big ticket item, it’s the number one complication across most device types, not phlebitis or infection as many people think. In terms of picking the ‘low hanging fruit’ – what can we do with better care practices ?flushing ?dressings ?connectors etc to help there. If we could even bring occlusion down by 10% in PIV and central lines, that would be a massive cost saving and patient benefit across the system.
The barriers are simple: lack of funded research nurse positions within the health services, and lack of awareness across the broader health system about the catastrophe of vascular access complications occurring every day.
VC: If there were one thing you wish you could have done differently in your research journey, who would it have been and why?
CR: I would have perhaps done less individual research studies and spent more time on promoting implementation of results. It’s a tough call though, as I always have a lot of exciting new ideas I want to pursue. A decade ago, we thought once we’d published, as researchers our job was done and we could move on to the next topic. Now, we know it takes a lot of effort to get the health system to change and take on new policies. I’m not saying it’s necessarily the researcher’s job to do this, but they can help a lot as the various societies update their guidelines for example.
Dr. Hugo Sax (front, right) is the Head of Infection Control, Hospital Epidemiology and a Consultant in Infectious Diseases at the University Hospital of Zurich in Switzerland. A human-factors engineering and implementation scientist, Dr. Sax is perhaps most well known for creating the "Five Moments of Hand Hygiene" which has been adopted by the World Health Organization as the prototypical way of improving hand hygiene.
Dr. Sax recently visited Ann Arbor and our research team (picture). He was kind enough to sit down with me and share his wisdom regarding hand hygiene for the vascular access community. Of note, Dr. Sax completed the ICJME form and disclosed research support from Ecolab for the evaluation of an alcohol-based hand sanitizer product in a previously published study.
VC: Why did you choose hand hygiene as your area of research?
HS: I really didn’t' choose it: rather, it chose me. I had the opportunity to organize a nationwide hand hygiene promotion campaign in Switzerland in 2005 and after this I was hooked. Plus, it exemplifies THE challenge in infection prevention, no? Germs are invisible and infection always happen later. This makes hand hygiene operate in a system that basically never gives feedback to your behavior. Such systems are bad teachers: how do we keep doing hand hygiene when nothing perceivable happens when we don’t? So we need to better rely on mental models, as we discuss in this paper.
VC: Why is hand hygiene so important? What data suggests that it helps prevent infection?
HS: This is indeed a crucial question! Rather than go into all the data, I wonder if we could do a little survey here? Here is my email: email@example.com. If you don’t mind, please send me a few words on the exact mechanism by which you think hand hygiene prevents a patient from getting any of the big 4 healthcare-associated infections (primary bloodstream infection, urinary tract infection, pneumonia, or surgical site infection). For example, you may think about how central line infections are thought to come about and in what step exactly hand hygiene would intervene to prevent them. Plus, if you feel comfortable, tell me what went on in your head while you were thinking about this. In return for participating, not only will I answer each email personally, I will also send you the overall result of the survey and a signed reprint of our ‘Five Moments’ paper. We know very little about vascular access providers and hand hygiene so this will be a new and important project I think. Please note: I will treat your answers as absolutely confidential.
VC: Can you tell us a bit about the WHO "My 5 moments of hand hygiene" campaign?
HS: When organizing the Swiss Hand Hygiene campaign in 2005, we decided to measure hand hygiene performance before and after the campaign in over 100 hospitals at the same time. That needed a robust concept, one easy to understand, train, and monitor hand hygiene in a broad range of healthcare settings. So we tried a lot of different approaches, did a lot of videotaping and drawing, showed it to various people to tap into what I call their mental models -- that is, how they picture the world around them. Finally, we came up with the idea of five fingers, five moments: thus, making it ‘sticky’ with respect to memory and translation of the concept. But actually, the central piece of the concept is the patient zone, comprising the patient skin and immediate environment, which is colonized with the patient’s microbiome. The goal of this step is simple: no germs in, no germs out.
VC: When inserting vascular catheters, variation in how we perform hand hygiene exists. Some use alcohol-based rubs, other chlorhexidine scrubs or antimicrobial soap with water, etc. Which is best?
HS: Alcohol-based handrub is certainly the quickest and most effective way to get rid of the transient hand flora, if the hands are visibly clean. If the hands are soiled, then best to use soap and water.
VC: In your opinion, what are the greatest problems or barriers in performing hand hygiene?
HS: I think the biggest problem is cognitive overload - that is, clinicians are often busy doing all sorts of things in the day from thinking about patients to delivering treatments and interventions. Given all of this, its not hard to see how hand hygiene can "slip" out of focus - especially when approaching a patient. The other problem is lack of feedback that occurs if/when you skip hand hygiene. If you don't know you made a mistake, how can you fix it?
One way of solving this problem is to develop what I call "muscle memory" and "cues to action." For example, in Europe, we drive mostly stick shift cars and when we pull up to a red traffic light our hand automatically grabs the stick and shifts it into 1st gear, otherwise we feel uneasy. This happens unconsciously while watching people cross the street or listening to a radio program. Hand hygiene should be the same - an unconscious act that actually puts us at ease.
VC: How has human factors research influenced your approach to studying hand hygiene?
HS: I believe that everyone takes genuine pleasure in organized, streamlined work flow. This translates well into my studies of hand hygiene. For instance, it is always a good idea to place dispensers conveniently where they are visible, accessible and can be used. It also makes sense to make sure that people fall in love with the experience of using them – a bit like car makers purposefully design the sound and feel of a shutting door of an expansive sports vehicle to be an addictive experience. I view hand hygiene much the same way - a safety component that can be designed such that it is easy, accessible and enjoyable for all those that useit.
VC: If there was one thing you hoped people would know about hand hygiene, what would that be?
HS: That our hands are meant to heal!
Please do take the time to email Dr. Sax regarding his hand hygiene survey by emailing him here. Dr. Sax will keep all replies confidential and will reply to your emails individually.
Sheila Inwood is a vascular access specialist who was among one of the first nurses to place central catheters in the UK and the first to surgically place an implantable port. She has worked with industry, academia and clinicians to improve the care of patients that need vascular access in her NHS hospital. Ms. Inwood has served as Keynote Speaker at a number of international meetings including WoCoVa and the Association of Vascular Access.
Ms. Inwood has completed the ICMJE disclosure form and has indicated no current conflicts of interest. She has served as the Director of International Medical Affairs and Clinical Affairs for CareFusion and has been a CVC faculty member for Teleflex Inc. in the past.
VC: Tell us a bit about yourself, where you work, what you do and how you came to be where you are?
SI: I work in an 800-bed general hospital. My background in nursing is in the critical care, cardiothoracic area. I established the first IV nutrition nurse post at the hospital in 1987. The primary objective of the position was to enable IV nutrition to be administered around the general hospital, not just in ICU. A huge amount of my time was spent finding someone / anyone to insert a cuffed tunnelled central catheter. This was the only way intravenous nutrition was given (such a long time ago!)
Needless to say the variety of expertise, and knowledge that I encountered during those years as a nutrition nurse was extremely broad. There was no standardised method, level of expertise or equipment for inserting catheters. The supposed level of expertise was firmly in the hands of the anaesthesia department. Failing their support, it was very common to have patients waiting for a catheter to be surgically inserted by a surgeon.
Hand in hand with a visionary anaesthetist, we established a comprehensive vascular access service (VAS) in 1993 providing this to all areas of the hospital. I should clarify when I say that ours was a service that could insert all types of vascular catheters: Traditional, cuffed tunnelled, acute CVC, PICC, dialysis. It truly brought vascular access to the patient in a way that didn't happen before.
VC: I sense the passion in your response, but tell me why you chose the field of vascular access nursing as a career choice? What is it that excites you the most about this work?
SI: I found I could really make a difference. Part of the service delivery was that catheters were placed at the bedside -- when the patient required it. Rather than the patient being moved around the hospital to suit the location of the inserter, the service was delivered to the patient wherever they might be which I found very powerful
I also think vascular access may seem quite simple and straightforward to some, but it has a breadth and depth that never seems to end. It may appear at first glance to be a repetitive process but the one variable that constantly changes are the patients that require your service and expertise. Add to this changes in the accompanying technology (the female version of boys with their toys) and expertise that only grows with time.
VC: What are some of the biggest problems you face on a daily basis as a vascular access specialist?
SI: One problem is that everything thinks they are an “expert” when it comes to vascular access, from peripheral to central lines. I believe this is because in many settings no one particular group “owns” this field. Subsequently, I often get referrals for a PICC, not a vascular access assessment or evaluation to determine what a patient may need. My way of dealing with this problem is to always accept the referral, but explain that I will review the patient and make a decision as to what would be the most appropriate access for their needs. This is a long-term education / culture change process that never ends. I would add that this philosophy only functions if a vascular access specialist such as myself can offer all the choices of vascular access. Meaning if I assess a patient and determine they require a CVC and not a PICC, I need to be able to place it for the patient and the referring provider. If you hold the title of vascular access specialist, you need to have the experience and skill set that justify the title across all devices.
VC: So given this issue, what do you think are the biggest challenges facing the field of vascular access access today and how do we move the field forward?
SI: I think one of the biggest challenges is on our end. For instance, I am not 100% certain that PICC teams are vascular access specialists. Rather, they need to understand their limitations and push to be able to place all types of devices - so that the patient gets what is best for them, not what is available.
Another challenge and area for innovation is a manufacturer’s / industry’s ability to keep up with the appropriate / safest products, technology. There is a real illusion that industry works hand in hand with practitioners; in my opinion, this is not always true. Rather, practice, technology is driven (sadly) by marketing. There needs to be a lot more collaborative cooperation particularly at the R&D stage. Industry needs to work in sync with clinicians so that the needs identified by us can be met by emerging technology.
VC: If there were one vascular access policy change you could make, what may it be and why?
SI: That's easy. All patients should be referred to a vascular access specialist, who is an expert and competent in all areas of vascular access. Just as a patient that may need surgery is referred for a surgical consult, vascular access should be a speciality in its own right. Last I checked we didn’t ask the surgeon to come down to the ER and do an appendectomy now, did we?
Context is everything when it comes to scientific enquiry. The right questions, the right approach and an answer that appears balanced, logical and reasonable are keys to credibility.
Despite this truism,we know well that context is a moving target. And in order to be right on topic - we believe it's important to listen to the voices of many in the Vascular Access Community.
So, new to the website this year - we are adding "Guest Blogs" from invited hosts. These blogs will be authored by pioneers whose voices, work, achievements and opinions matter to all of us in the field. But no free passes here - we will ask them tough questions about context, relevance and the challenges ahead for the field, perhaps some that are uncomfortable or controversial as well.
We've got a star studded cast lined up for the first few posts and plan to bring you these refreshing perspectives every so often in 2016. In keeping with ImprovePICCs goal to remain bias-free, please note that this isn't a megaphone for industry or those with substantial conflicts of interest. All bloggers are required to submit the ICMJE conflict of interest form and these will be reported with their post. The decision to post something is reserved by us and will be based on myriad factors, including suitability and perceived conflict of interest.
This isn't just a club for the elite, though. We do want to hear from those of you in the front lines who have something important and relevant to tell the vascular access community. If you're up to it - draft us a brief outline of a blog you want to write and send us a note using the Contact Us page. We would love to hear from you! Remember the rules regarding Conflicts of Interest and the fact that the decision to post is reserved by us based on content, scope, interest, etc.
And even if you're not interested in writing a blog, tell us what you think by commenting on this or the other guest blog posts. We will be watching these with interest!
Dr. Sanjay Saint is the George Dock Professor of Medicine at the University of Michigan. He is my Primary Research Mentor and has influenced me profoundly when it comes to how best to prevent healthcare-associated infections. I invited him to talk about his recent work on mandating influenza vaccination for healthcare workers here on the ImprovePICC blog site. This is a topic that clearly affects all vascular access nurses, physicians and providers that work in hospitals or inpatient care facilities. He was kind enough to agree.
VC: Tell me about the controversy related to your recent research paper on influenza vaccination.
SS: There has been quite a bit of controversy related to mandating influenza vaccination for healthcare workers. Much of the discussion has appeared on the important blog “Controversies in Hospital Infection Prevention” hosted by infectious disease specialists Drs. Eli Perencevich, Mike Edmond, and Dan Diekema of the University of Iowa. I respond on the blog itself to these issues and am happy to do so here for the vascular access and nursing community.
Our recent editorial in The Wall Street Journal on mandatory flu vaccination for healthcare workers elicited strong opinions, especially on social media. The impetus for our editorial was a recent paper published in Infection Control and Hospital Epidemiology in which we found through a national survey of lead infection preventionists that 42.7% of nonfederal hospitals had a policy mandating flu vaccinations for healthcare workers while only 1.3% of VA hospitals did.
In a 22 December 2015 blog post, Dr. Perencevich clarified his position by writing that he is “in favor of mandating influenza vaccination of healthcare workers (for now)”. I am in agreement. While the data supporting mandatory healthcare worker flu vaccination is perhaps not as robust as researchers would like – when is it? – in my opinion, it is compelling enough to move forward unless new data emerge that reveal the mandate to be unnecessary or ineffective.
VC: Can you tell me a bit about the most compelling studies supporting mandatory vaccinations?
SS: The first is a systematic review from Faruque Ahmed, PhD -- a senior scientist in the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention (CDC) – and four other CDC researchers. Here are the verbatim Results and Conclusions from their abstract:
Results. We identified 4 cluster randomized trials and 4 observational studies conducted in long-term care or hospital settings. Pooled risk ratios across trials for all-cause mortality and influenza-like illness were 0.71 (95% confidence interval [CI], .59–.85) and 0.58 (95% CI, .46–.73), respectively; pooled estimates for all-cause hospitalization and laboratory-confirmed influenza were not statistically significant. The cohort and case-control studies indicated significant protective associations for influenza-like illness and laboratory-confirmed influenza. No studies reported harms to patients. Using GRADE, the quality of the evidence for the effect of HCP vaccination on mortality and influenza cases in patients was moderate and low, respectively. The evidence quality for the effect of HCP vaccination on patient hospitalization was low. The overall evidence quality was moderate.
Conclusions. The quality of evidence is higher for mortality than for other outcomes. HCP influenza vaccination can enhance patient safety.
VC: But how may influenza vaccination reduce all-cause mortality?
SS: I am not sure. But previous studies have found influenza vaccination reduces cardiovascular events and venous thromboembolism. How vaccination may affect these outcomes is also not known - but it isn't irrational to also include all-cause mortality as an outcome given the myriad benefits of influenza vaccination in the literature.
VC: What about the other studies you mention?
SS: The second study (not included in the aforementioned systematic review, but mentioned in the postscript), is a cluster randomized trial of hospitalized patients in the Netherlands published in June 2013. Here's the abstract:
Nosocomial influenza is a large burden in hospitals. Despite recommendations from the World Health Organization to vaccinate healthcare workers against influenza, vaccine uptake remains low in most European countries. We performed a pragmatic cluster randomised controlled trial in order to assess the effects of implementing a multi-faceted influenza immunisation programme on vaccine coverage in hospital healthcare workers (HCWs) and on in-patient morbidity. We included hospital HCWs of three intervention and three control University Medical Centers (UMCs), and 3,367 patients. An implementation programme was offered to the intervention UMCs to assess the effects on both vaccine uptake among hospital staff and patient morbidity. In 2009/10, the coverage of seasonal, the first and second dose of pandemic influenza vaccine as well as seasonal vaccine in 2010/11 was higher in intervention UMCs than control UMCs (all p<0.05). At the internal medicine departments of the intervention group with higher vaccine coverage compared to the control group, nosocomial influenza and/or pneumonia was recorded in 3.9% and 9.7% of patients of intervention and control UMCs, respectively (p=0.015). Though potential bias could not be completely ruled out, an increase in vaccine coverage was associated with decreased patient in-hospital morbidity from influenza and/or pneumonia.
A third study (from another group in the Netherlands) used decision-analytic modeling to estimate the effects of healthcare worker influenza vaccination in the hospital setting. The abstract is below:
Nowadays health care worker (HCW) vaccination is widely recommended. Although the benefits of this strategy have been demonstrated in long-term care settings, no studies have been performed in regular hospital departments. We adapt a previously developed model of influenza transmission in a long-term care nursing home department to study the effects of HCW vaccination in hospital wards. We study both the effectiveness and efficiency in reducing the hazard rates of influenza virus infection for patients. Most scenarios under study show a similar or higher impact of hospital HCW vaccination than has been predicted for the long-term care nursing home department. Therefore, it seems justified to extend the recommendations for HCW vaccination, based on results in the long-term care setting, to short-term care settings as well.
VC: So where does the controversy stand now?
SS: Dr. Perencevich recently wrote: “There is no data supporting the benefits of healthcare worker vaccination in acute care hospital settings…We are basing acute-care hospital policy on one observational study.” I would thus modify this by stating we are basing acute-care hospital policy on a cluster randomized trial done in a hospital setting, an observational study performed in a hospital setting, a decision analytic model explicitly focusing on an acute-care setting, and 4 randomized studies from long-term care settings as part of a well-done systematic review.
VC: Have professional societies weighed in on a mandatory influenza policy?
SS: While the opinion of professional societies may not always be correct, I am impressed by the strong support in the scientific community for mandatory influenza vaccination for healthcare workers. The list of societies that support mandatory influenza vaccination for healthcare personnel includes: American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Hospital Association, American Public Health Association, Association for Professionals in Infection Control and Epidemiology, Infectious Diseases Society of America, National Patient Safety Foundation, and Society for Healthcare Epidemiology for America.
VC: Is it ethical to mandate flu vaccine for healthcare workers?
SS: For guidance, I turn to Arthur L. Caplan, PhD, one of the country’s foremost medical ethicists and whose opinion about white coats on work you and I are doing was recently highlighted on “Controversies in Hospital Infection Prevention”. Writing in 2013, Professor Caplan states:
“The moral case for limiting health care workers' choice concerning influenza vaccination rests on 4 principles: the professional duty to put patients' interests first, the obligation to do no harm, the requirement to protect those who cannot protect themselves, and the obligation to set a good example for the public. It is hard to see how the invocation of personal liberty claimed by some health care workers who oppose mandates could overcome this powerful “four-legged” moral case in support of an influenza vaccination mandate…Mandating vaccination is consistent with professional ethics; benefits many, some of whom must rely on health care workers to protect them; and sets an example that permits honest engagement with the public in educating them to do the right thing about all recommended vaccines.”
This year has been an incredibly productive year for us at ImprovePICC.
We've celebrated many successes, including the funding of a large AHRQ grant that will allow us to continue to develop devices that sense the presence, rationale and nature of catheters; the addition of bright, new research and project management staff; and unparalleled productivity in terms of peer-reviewed papers, lectures and seminars.
We've also increased our international presence, punctuated by a deepening partnership with the AVATAR group that led to a substantial Australian NHRMC Grant examining PICC securement and dressing (the PISCES Trial). And with the publication of the first evidence-based "guideline" for when to use a range of IV devices, MAGIC, well...its not hyperbole to say it's been an amazing year.
So as I look ahead to 2016, I cannot help but worry given the strong benchmark we've set! Can we possibly continue to keep up the pace that we have so aptly held this year? What projects will we take on and how will we get these funded so as to ensure success? Will our new staff and faculty soar? Is our success perhaps our greatest enemy?
I know that these thoughts plague many of us in the knowledge and discovery arena, but I am reassured by several facts. First, our mission, vision and values remain strong and our focus on improving the use of PICCs in hospitalized medical patients has never been as laser-like as it is now . Second, we know that important questions regarding the use of vascular devices remain to be answered - a thought that is always good for job security (and grant funding in these tight times). Third, I sense we will begin to make the shift from "observing" practice to "implementing" change given all of the efforts we and others have done that continually show room for improving practice. This last thought is perhaps the most exciting for us at ImprovePICC, because we will now begin to influence the care of patients with PICCs in a real and tangible way through our quality improvement partners across Michigan.
So, we close 2015 in a strong way. We already have ten (yes, 10) research and innovation abstracts submitted to a scientific meeting from our partnership with HMS. We have several papers in press and a few that remain under review. We continue to write grants that focus on translating our research into practice. These important contributions will undoubtedly allow us to keep up our cadence.
I have a feeling 2016 will be a good year. Thank you for being part of our journey. Onwards...
Our first post is a big one -- and sets the bar high because it begins with a conversation regarding our landmark product: The Michigan Appropriateness Guide to Intravenous Catheters (MAGIC). Here's excerpts of our thoughts regarding this project.
Q: What motivated this project?
A: Vascular access is literally the most common procedure performed in hospitalized patients. It is invasive, costly, can lead to finite harm -- and yet the research behind it has not been well organized. When you begin to look at practice, you realize people are acting in very different ways with respect to who gets an IV, who gets a central line, who gets a PICC. This variation brought our attention to the topic.
Q: How do you think current use compares to what was deemed appropriate by the panel?
A: A big problem is defining what current use is. We now have 47 hospitals across Michigan working collaboratively to collect data regarding use of PICCs and outcomes. This experience - now one year old - shows large gaps between what is deemed appropriate and current practice. A classic example: one of the recommendations deemed appropriate by the panel was [to] not place PICCs for durations of less than 5 days, unless you need to give an irritant or a vesicant. Yet in data encompassing over 5,000 PICCs, about 25% are removed within 5 days. It's over 1,000 devices when you do the math. It's astonishing.
Q: Were you surprised by any of the conclusions the panel came to?
A: The surprise wasn't so much the conclusions, as much as the process. It was incredible how extremely collaborative it was. I was also surprised by the intense debate that transpired in specific areas—especially on when and which device to use. The evidence in this area is fragmented and much of it has been generated by nurses, interventional radiology and others. As you can imagine, with the cultural shifts between nursing and physicians, there's lots of disagreement about what device, when and why.
Q: What were the biggest areas of disagreement among the participants?
A: One of the disagreements we had early on was the use of PICCs for short-term periods in patients who had veins that were difficult to access or needed frequent blood draws. The evidence here isn't clear. Ultimately the panel agreed devices other than PICCs may be safer and could achieve these goals. But the process of discussion and deliberation was intense.
Q: How do you get these recommendations into practice?
A: We want to start testing MAGIC in our real-world laboratory, the Hospital Medicine Safety Consortium, which now consists of 47 hospitals in Michigan. We want to figure out what works, what doesn't and why. What we ideally would like to do is create a toolkit, "Here are the top 5 recommendations from this panel of ways to improve your practice around venous access and PICCs," and actually make it simple. Hospitalists can choose 1, 2, 3, maybe all 5 of these recommendations and then track the impact of these changes.
Q: Do you see appropriateness of PICCs eventually being a quality measure?
A: Yes - not just PICCs but venous access in general. What we would like to do, especially for our collaborative, is give hospitals a dashboard. We have started doing this for benchmarking purposes … feeding back things like the number of PICCs that were placed for less than 5 days, how many PICCs developed CLABSI [central line-associated bloodstream infection], how many developed VTE [venous thromboembolism].
Q: Do you think these recommendations will change much based on future research?
A: I sincerely hope so. This is an important first step, but it's just that, a first step. There are going to be newer devices that come out that we haven't even thought about or included. There will be new evidence regarding harm and benefit, and if and when evidence suggesting one device may be better than another, then we should look back on MAGIC and modify recommendations. MAGIC is a great way of organizing what we know, but I sincerely hope it's a living document. Only then will it serve to best take care of our patients.
Blogs written and edited by Vineet Chopra unless otherwise stated in the header. Guest blogs are identified accordingly.