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Deep Vein Thrombosis

​Step 1: Review PICC Related DVT Data to Identify Areas for Improvement

Review identified PICC-related DVT cases
Element
Key Institutional Partners
  • Review PICC Related DVT cases using the following tools to assess if the correct device and/or number of lumens was appropriate
    • MAGIC guidelines
    • Michigan Risk Score (MRS) – Predicts Risk of DVT in Patients with a PICC
QI Team, Vascular Access Team
  • Identify which units or types of units (i.e. ICU vs non-ICU) that have the highest rates of PICC-related DVT. Subsequent interventions in this toolkit should be focused on these patient care areas
QI Team, Vascular Access Team
Resources/Tools
Audit tool to review PICC-DVT cases 
​
Decision Tools: 
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
  • The Michigan MAGIC, PICC Appropriateness & Mindful Medicine
  • ImprovePICC MAGIC App
  • How to use the MAGIC App
Badge Card for Peripherally Compatible Infusates
Michigan Risk Score (MRS) to Predict risk of DVT in Patients with a PIC
  • MRS Online Calculator
  • MRS Pocket Card 
  • MRS Educational Video
Infusion Therapy Standards of Practice 2016 (Paid)
Intermountain Medical Center Algorithm for IV Access 
Vascular Access Dashboard (PICC Excellence)
WOCOVA Difficult Intravenous Access Pathway (DIVA)- Slides
Tools to Assist with Determining Potential Vesicants:  
  • INS List of Noncytotoxic vesicant list
  • Cincinnati Children’s List of Venous Infusion Extravasation Risk
  • Intermountain Medical Center Irritants and Vesicants Guide 
  • Michigan Medicine List of Medications with Irritant or Vesicant Properties ​
Articles/References
Winters JP, et al. Central venous catheters and upper extremity deep vein thrombosis in medical inpatients: the Medical Inpatients and Thrombosis (MITH) Study. Journal of Thrombosis and Haemostasis 2015
  • Upper extremity deep vein thrombosis (UEDVT) is a relevant complication affecting medical inpatients, accounting for half of hospital-acquired DVTs. Use of central venous catheters (CVCs) was strongly associated with risk of UEDVT with the highest number of events in patients with PICCs
Chopra V, et al. The Michigan Risk Score to predict peripherally inserted central catheter-associated thrombosis. Journal of Thrombosis and Haemostasis 2017 
  • Multiple lumens, multiple CVC’s present at time of PICC placement, WBC >12.0, history of VTE and active cancer are associated with increased risk of catheter associated VTE
Chopra V, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of Internal Medicine 2015
  • Criteria for the use of PICCs was developed, adopting the RAND/UCLA Appropriateness Method. After a review of 665 scenarios, 43% of PICCs were flagged as inappropriate. Applying these criteria as a guide can help decrease the likelihood of an inappropriate catheter, improve care, and inform quality improvement efforts
Validation Survey
DVT Step 1 Validation - Review DVT Data.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress. 
​Perform an assessment of potential cost savings from preventing PICC-related DVT 
Element
Key Institutional Partners
  • Perform an assessment of potential cost savings from preventing PICC-related DVT 
QI Team, Hospital Leadership
Resources/Tools
Decision Tools:
PICC-Safety and Cost Calculator
Articles/References
Ratz D, et al. Limiting the number of lumens in peripherally inserted central catheters to improve outcomes and reduce cost:  A simulation study. Infection Control & Hospital Epidemiology 2016
  • Increases in single lumen PICC use resulted in monetary savings and decreases in PICC-associated CLABSI and PICC-associated DVT
Validation Survey
DVT Step 1 Validation - Perform an Assessment of Potential Cost Savings.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress. 

​Step 2: Insertion

​Appropriate device choice and insertion - only use a PICC if necessary AND only use in populations at low risk of DVT
Element
Key Institutional Partners
  • Use MAGIC or another validated decision tool to guide your decision for PICCs – Indications
Hospital Leadership, HMS PICC Team, QI Department
  • Evaluate who is determining appropriateness/number of lumens
    • Consider if another clinician type should be involved (i.e. Vascular Access Teams)
    • Ensure those identified as most appropriate to determine appropriateness/number of lumens are educated on appropriate device choice/insertion
Hospital Leadership, HMS PICC Team, QI Department
  • Make MAGIC app available to providers/inserters  
Hospital Leadership, Providers, IR, Vascular Access Team
  • Consider integrating use of the MAGIC app into your policy so that providers cannot order a PICC line unless unless it is first deemed appropriate through the app
Hospital Leadership, Providers, IR, Vascular Access Team
  • Design electronic order sets that map to MAGIC criteria
Hospital Leadership, Providers, IR, Vascular Access Team
  • Only use a central line, including a PICC, if central venous access is necessary; avoid use of PICCs for patients with difficult venous access only
Providers, IR, Vascular Access Team
  • Place the minimum number of lumens 
Providers, IR, Vascular Access Team
Resources/Tools
Assessment/Decision Tools
The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
  • Video- The Michigan MAGIC, PICC Appropriateness & Mindful Medicine
  • App- ImprovePICC MAGIC App
  • Video – How to use the MAGIC App
Badge Card for Peripherally Compatible Infusates - Ascension Genesys Hospital
Infusion Therapy Standards of Practice 2016 (Paid)
Vascular Access Dashboard (PICC Excellence)
Tools to Assist with Determining Potential Vesicants:
INS List of Noncytotoxic vesicant list
Cincinnati Children’s List of Venous Infusion Extravasation Risk
Intermountain Medical Center Irritants and Vesicants Guide 
Michigan Medicine List of Medications with Irritant or Vesicant Properties 
Example Inpatient PICC Order Set Criteria 
Articles/References
The SIP Protocol- A GAVeCeLT bundle for the safe implantation of PICCs
Winters JP, et al. Central venous catheters and upper extremity deep vein thrombosis in medical inpatients: the Medical Inpatients and Thrombosis (MITH) Study. Journal of Thrombosis and Haemostasis 2015
  • Upper extremity deep vein thrombosis (UEDVT) is a relevant complication affecting medical inpatients, accounting for half of hospital-acquired DVTs. Use of central venous catheters (CVCs) was strongly associated with risk of UEDVT
Moureau N, et al. Making the MAGIC: Guiding vascular access selection for intensive care - a summary of Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). ICU Management & Practice 2016
  • MAGIC provides guidance on assessing the appropriateness of PICCs and other vascular access devices for the intensive care patient. Application of MAGIC by clinicians and providers within intensive care areas may assist hospitals in establishing reliable access, improving outcomes, achieving infection prevention goals and reducing burden of thrombosis
Ratz D, et al. Limiting the Number of PICC Lumens to Improve Outcomes and Reduce Cost: A Simulation Study. Infection Control & Hospital Epidemiology 2016
  • Every 5% increase in single-lumen PICC use would prevent 0.5 PICC-related central line-associated bloodstream infections and 0.5 PICC-related deep vein thrombosis events, while saving $23,500
Swaminathan L, et al. Improving PICC use and outcomes in hospitalized patients:  An interrupted time series study using MAGIC criteria. BMJ Quality & Safety 2018
  • A multi-modal intervention based on MAGIC resulted in a modest decrease in inappropriate PICC use
Validation Survey
DVT Step 2 Validation - Appropriate Device Choice and Insertion.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress. 
Always place a PICC with the smallest size catheter/least number of lumens possible
Element
Key Institutional Partners
  • Default to single lumen PICC when possible
Hospital Leadership, Vascular Team, QI Department
  • Develop criteria for multi-lumen PICCs
Hospital Leadership, Vascular Team, QI Department
​Resources/Tools
Articles/References
Example Inpatient PICC Order Set Criteria - Michigan Medicine
PICC Tier 1 Resources and Tools ​
​Zehnder J, et al. Catheter-related upper extremity venous thrombosis. Up To Date. 2018 
  • Intravenous catheters cause endothelial trauma and inflammation that often progresses to venous thrombosis. Three-quarters of thrombotic events occurring in veins of the upper extremity are due to the presence of intravenous catheters. This article provides a detailed summary of the available evidence for detecting, identifying, and treating upper extremity deep vein thrombosis
Bozaan D, et al. Less lumens-less risk:  A pilot intervention to increase the use of single-lumen peripherally inserted central catheters. Journal of Hospital Medicine 2019
  • An intervention involving setting PICC default orders to single-lumen devices, establishing criteria of when multi-lumen PICCs are appropriate, and provider, nursing, and pharmacy education resulted in significant decrease in inappropriate PICC use as well as an overall increase in single lumen PICC use 
Lam PW, et al. Impact of defaulting to single-lumen peripherally inserted central catheters on patient outcomes:  An interrupted timeseries study. Clinical Infectious Diseases 2018
  • Defaulting non-ICU PICC orders to single-lumen devices resulted in a sustained decrease in PICC-associated complications
Validation Survey
DVT Step 2 Validation - Smallest Gauge/Least Lumens.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress. 
Avoid PICCs in patients with a higher risk of DVT
Element
Key Institutional Partners
  • Provide education on the MRS score to Providers and/or PICC Inserters at your facility
Vascular Access Team
  • Use the Michigan Risk Score to Predict Risk of DVT prior to selecting a PICC

Providers, IR, Vascular Access Team
  • Avoid PICC use in the ICU for durations <14 days 
    • PICCs placed in critically ill patients have 2.5 higher risk of thrombosis when compared to non-tunneled acute CVCs placed in the IJ, subclavian or femoral veins
    • If a PICC is used in the ICU, prefer use of single or double lumen catheters over triple lumen devices
Providers, IR, Vascular Access Team
  • Avoid PICC use in patients with cancer 
    • Patients with solid malignancies have the greatest risk of thrombosis
    • If a PICC is used in a patient with cancer, use the smallest size catheter possible
Providers, IR, Vascular Access Team
  • Avoid or limit multi-lumen PICC use for blood transfusion 
    • Red blood cell delivery through multi-lumen PICCs is associated with a greater risk of thrombosis than a peripheral catheter
Providers, IR, Vascular Access Team
  • If a patient is at high risk of DVT, consider advanced approaches (i.e. Endexo coated catheters) to device insertion or use of another device 
​Providers, IR, Vascular Access Team
  • If you are using a PICC: 
    • Avoid triple lumen (6Fr or greater) PICCs
    • Do not place a PICC in a patient who has had VTE (lower or upper extremity) within the past 30-days
    • Do not use PICCs in patients recently diagnosed with or admitted for treatment of cancer
    • If a patient is at high risk of DVT, consider advanced approaches to device insertion or use of another device
Providers, IR, Vascular Access Team
​Resources/Tools
Decision Tools:
Michigan Risk Score (MRS) to Predict risk of DVT in Patients with a PICC
  • Online Calculator
  • Pocket Card 
  • Educational Video
Patient education tool on DVT risk 

Articles/References
Chopra V, et al. The Michigan Risk Score to predict peripherally inserted central catheter-associated thrombosis. Journal of Thrombosis and Haemostasis 2017 
  • Multiple lumens, multiple CVC’s present at time of PICC placement, WBC >12.0, history of VTE and active cancer are associated with increased risk of catheter associated VTE
Zehnder J, et al. Catheter-related upper extremity venous thrombosis. Up To Date. 2018 
  • Intravenous catheters cause endothelial trauma and inflammation that often progresses to venous thrombosis. Three-quarters of thrombotic events occurring in veins of the upper extremity are due to the presence of intravenous catheters. This article provides a detailed summary of the available evidence for detecting, identifying, and treating upper extremity deep vein thrombosis
Rogers MAM, et al. Association between delivery methods for red blood cell transfusion and the risk of venous thromboembolism: a longitudinal study. The Lancet Haemotology 2016
  • Red blood cell delivery through a multi-lumen PICC is associated with a greater risk of thrombosis than transfusion through a peripheral intravenous catheter. Careful monitoring for venous thromboembolism when transfusing red blood cells through multi-lumen PICCs is prudent
Evans S, et al. Reduction of Peripherally Inserted Central Catheter-Associated DVT. Chest 2013
  • Use of single-lumen PICCs and smaller gauge (french) resulted in decreased rate of PICC-associated DVT
Sriskandarajah P, et al. Retrospective cohort analysis comparing the incidence of deep vein thromboses between peripherally-inserted and long-term skin tunneled venous catheters in hemato-oncology patients. Thrombosis Journal 2015
  • Incidence of thrombotic events in hemato-oncology patients was significantly lower in those who had a long-term skin tunneled venous catheter compared to PICC line 
Validation Survey
​
​DVT Step 2 Validation - Avoid PICCs in Patients with Higher Risk of DVT.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress. ​
Use ultrasound and measure catheter to vein ratio
Element
Key Institutional Partners
  • Use Ultrasound to map arm veins
Providers, IR, Vascular Team, Hospital Leadership 
  • Use the Zone Insertion Method
Providers, IR, Vascular Team, Hospital Leadership 
  • Keep catheter to vein ratio (CVR) < 45%
Providers, IR, Vascular Team, Hospital Leadership 
  • Use the CVR app to help determine appropriate catheter to vein ratio (CVR)
    • Download and provide all inserters with the CVR App or Tool in iOS or Android, or use the pocket card
    • Document CVR in the chart
Providers, IR, Vascular Team, Hospital Leadership 
  • Audit CVR documentation, especially among patients that develop DVT 
PICC Team, Data Abstractor, QI Department
​Resources/Tools
Badge card for appropriate catheter to vein ratios  
App on iOS or Android CVR app
  • iOS
  • Android
Articles/References
​Hughes ME. PICC related thrombosis: pathophysiology, incidence, morbidity and the effect of ultrasound-guided placement technique on occurrence in cancer patients. Journal of the Association for Vascular Access 2011
  • The use of ultrasound devices to place PICCs leads to a reduction in the incidence of catheter-related thrombosis
Dawson RB, et al. PICC Zone Insertion MethodTM (ZIMTM): A systematic approach to determine the ideal insertion site for PICCs in the upper arm. Journal of the Association for Vascular Access 2011
  • The author details a color-coded diagram of the upper arm, including risk factors related to site selection for an ultrasound guided PICC insertion. Thrombosis cannot be underestimated as it limits the chance for future vascular access (potentially life-saving)
Spencer T, et al. Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio. Journal of Thrombosis and Thrombolysis 2017
  • Increasing the understanding and utilization of CVRs will lead to a safer, more consistent approach to device placement, with potential thrombosis reduction strategies
Simcock L. No going back: advantages of ultrasound-guided upper arm PICC placement. Journal of the Association for Vascular Access 2008
  • Upper arm placement increased insertion success rate and line longevity, while reducing exit site infection, thrombosis and catheter migration
Validation Survey
​DVT Step 2 Validation - Catheter to Vein Ratio.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
​Ensure that the Catheter Tip is Located in the Lower 1/3rd of the Superior Vena Cava (SVC), Cavoatrial Junction (CAJ) or in the Right Atrium at the Time of PICC Placement
Element
Key Institutional Partners
  • ECG and Fluoroscopy preferred over X-Ray to determine catheter tip position
Providers, IR, Vascular Team, Hospital Leadership
  • Catheter malposition is associated with significant risk of DVT
    • Consider auditing catheter tip positions when DVT occurs
    • Check catheter tip positions following CT injection
Providers, IR, Vascular Team, Hospital Leadership
Articles/References
​Zehnder J, et al. Catheter-related upper extremity venous thrombosis. Up To Date 2018 
  • Intravenous catheters cause endothelial trauma and inflammation that often progresses to venous thrombosis. Three-quarters of thrombotic events occurring in veins of the upper extremity are due to the presence of intravenous catheters. This article provides a detailed summary of the available evidence for detecting, identifying, and treating upper extremity deep vein thrombosis
Lum P. A new formula-based measurement guide for optimal positioning of central venous catheters. Journal of the Association for Vascular Access 2004
  • The “tailored fit” formula to individual patient height is a reliable tool to predict CVC length. Appropriate catheter length can greatly reduce the guesswork and possibility of complications related to tip malposition
Orme RM, et al. Fatal cardiac tamponade as a result of a peripherally inserted central venous catheter: a case report and review of the literature. British Journal of Anaesthesia 2007
  • Details the proper tip location (Zone A, B & C)
Lee J, et al. Displacement of a power-injectable PICC following computed tomography pulmonary angiogram. Radiology Case Report 2017
  • Case report and literature review related to PICC displacement or migration after contrast injection for radiologic study recommending review of catheter tip position following CT
Validation Survey
​
DVT Step 2 Validation - Final Insertion Validation.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.

Step 3: Care and Maintenance

Step 3 involves a four month audit of dressing and securement. Step 6 requires a four month audit of line necessity. To facilitate both of these audits during a single four-month time frame, we recommend using the below audit form. 
  • Catheter Dressing/Securement & Line Necessity Audit Form
​Securement: if a PICC is in place, appropriate care/maintenance must be in place
Element
Key Institutional Partners
  • Dressing audits should be performed to examine whether site is clean, dry, intact and the catheter is appropriately secured
    • Movement of the catheter at the exit site (“pistoning”) can induce endothelial injury and promote phlebitis which can cause thrombosis
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Ensure competencies of nursing staff are up-to-date for catheter care and maintenance
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Measure external catheter length and document in chart
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Review periodicity and compliance via audit of charts of patients with and without thrombosis
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Consider use of advanced securement devices
    • StatLock
    • Secureacath
    • Sorbaview
    • Other adhesive or advanced devices
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
​Resources/Tools
I-DECIDED PICC Assessment and Decision Tool for Nurses
Catheter Dressing and Securement Audit Form
Care and Maintenance Handout for Nurses
Articles/References
​Zehnder J, et al. Catheter-related upper extremity venous thrombosis. Up To Date 2018 
  • Intravenous catheters cause endothelial trauma and inflammation that often progresses to venous thrombosis. Three-quarters of thrombotic events occurring in veins of the upper extremity are due to the presence of intravenous catheters. This article provides a detailed summary of the available evidence for detecting, identifying, and treating upper extremity deep vein thrombosis
Validation Survey
DVT Step 3 Validation - Care and Maintenance - Securement.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
Use of systemic anticoagulants for prophylaxis is not recommended to prevent PICC related upper extremity (UE) DVT
Element
Key Institutional Partners
  • Use of systemic anticoagulation at prophylactic doses (e.g., low-molecular weight heparin [LMWH] or Heparin VTE prophylaxis) does not lower risk of PICC-related thrombosis
Providers
  • Do not use or expect systemic anticoagulation to reduce risk of DVT
Providers
  • The role of aspirin in preventing catheter-related thrombosis (CRT) is not clear
Providers
  • Limit/Avoid Blood Transfusion via PICC
Providers, IR, Vascular Team
Articles/References
​
Zehnder J, et al. Catheter-related upper extremity venous thrombosis. Up To Date 2018 
  • Intravenous catheters cause endothelial trauma and inflammation that often progresses to venous thrombosis. Three-quarters of thrombotic events occurring in veins of the upper extremity are due to the presence of intravenous catheters. This article provides a detailed summary of the available evidence for detecting, identifying, and treating upper extremity deep vein thrombosis​
Rogers MAM, et al. Association between delivery methods for red blood cell transfusion and the risk of venous thromboembolism: a longitudinal study. The Lancet Haemotology 2016
  • Red blood cell delivery through a multi-lumen PICC is associated with a greater risk of thrombosis than transfusion through a peripheral intravenous catheter. Careful monitoring for venous thromboembolism when transfusing red blood cells through multi-lumen PICCs seems necessary
​Patient Education regarding care and maintenance of PICC line 
Element
Key Institutional Partners
  • Educate patients regarding precautions they need to take while the PICC line is in place including no lifting heavy weights, no contact sports, avoid lifting the arm above your head, and monitor the catheter length on the skin
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Educate patients on PICC care
  • Evaluate when patients are being educated and ensure that education occurs at a minimum prior to/upon PICC insertion and upon discharge if the patient is being discharged with a PICC
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
​Resources/Tools
​I-DECIDED PICC Assessment and Decision Tool for NursesPatient Education Tool on Protecting the Arm and PICC
Patient Education Tool on Caring for PICC  
Patient Education Care & Maintenance Guide: “Your Peripherally Inserted Central Catheter”
Giving Medication by IV Push Home Care Handout
myIV.com
Validation Survey
​
DVT Step 3 Validation - Patient Education.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.

Step 4: Advanced Approaches/Targeted Technology Solutions

Advanced Approaches/ Targeted Technology Solution
Element
Key Institutional Partners
  • Consider antithrombotic catheters in patients at high risk of DVT
    • Endexo PICCs (e.g., BioFlo)
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
  • Reversed taper catheters have conflicting data – the HMS Coordinating center does not recommend using these as a strategy to reduce rates of PICC DVT in view of the lack of evidence for these devices
Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership
Articles/References
​Ullman AJ, et al. Antithrombogenic peripherally inserted central catheters:  Overview of efficacy and safety. Taylor & Francis Online 2018
  • A review of published and unpublished laboratory and clinical studies was performed to evaluate the effectiveness, efficiency, and safety of antithrombogenic PICCs. Early studies show promise, however furthers trials are needed to establish results
Validation Survey
DVT Step 4 Validation - Advanced Approaches/Targeted Technology Solutions.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.

​Step 5: Line Necessity/Removal

Each day with a PICC increases the risk of thrombosis; daily multidisciplinary rounds for device use/necessity is recommended
Element
Key Institutional Partners
  • Daily audits of lines to determine clinical necessity of the device
    • Rounds should be multi-disciplinary, including physician and nursing leadership at the unit-level whenever possible
Providers, IR, Vascular Access Team, Hospital Leadership/Nursing Leadership, QI Department
  • De-escalate devices to peripheral access whenever possible
    • If a line has not been used for >24 hours, consider targeting it for removal
    • Daily labs are not an indication for a central venous catheter or a PICC unless the frequency of lab draws is >3 times per day
    • If a line has not been used >48 hours, it should be considered idle and removed
Providers, IR, Vascular Access Team, Hospital Leadership/Nursing Leadership, QI Department
  • PICCs that are placed in the ICU setting should be reviewed prior to patient transitioning out of the ICU
    • If not necessary, remove and secure peripheral access
    • If necessary, determine and document date of removal and ensure process for removal is in place
Providers, IR, Vascular Access Team, Hospital Leadership/Nursing Leadership, QI Department
​Resources/Tools
I-DECIDED PICC Assessment and Decision Tool for Nurses
Line Necessity and De-Escalation Rounding and Auditing Tool
Care and Maintenance Handout for Nurses
Articles/References
​McDonald EG, & Lee, TC. Venous catheter use in medical inpatients through regular physician audits using an online tool. JAMA Internal Medicine 2015
  • Use of an online audit tool by Physicians focused on re-evaluating CVC appropriateness resulted in a 46.6% reduction in use of CVCs 
Aufricht G, et al. Analysis of central venous catheter utilization at a quaternary care hospital. Baylor University Medical Center Proceedings 2019
  • Audit and feedback regarding appropriateness of central lines resulted in a decrease of 65% of central venous catheters that were not clinically indicated
Lederle FA, et al. The idle intravenous catheter. Annals of Internal Medicine 1992 
  • Twenty percent of all patient-days of IV catheter use were idle. Efforts should focus on reducing unnecessary use
Parenti CM, et al. Reduction of unnecessary intravenous catheter use. Internal medicine house staff participate in a successful quality improvement project. Archives of Internal Medicine 1994 
  • Idle IV catheter episodes decreased significantly after a house staff-led intervention. House staff proved critical to successful quality improvement and should be further included to improve patient care and enhance education of quality improvement processes
Validation Survey
​DVT Step 5 Validation - Line Necessity/Removal.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.

​Step 6: Appropriate Testing

Testing for PICC DVT should only be performed in the setting of patient symptoms; screening for DVT in asympotmatic patients is not recommended as the utility is not clear.
Element
Key Institutional Partners
  • Use compression ultrasonography to examine arm veins for thrombosis
Providers
  • Avoid routine “4-limb” screens in patients with fever
Providers
  • Consider CT Angiography for chest/central thrombosis
    • CT Venography is the gold standard for diagnosing catheter-related deep vein thrombosis
Providers
​Resources/Tools
Decision Tools
  • Michigan Risk Score (MRS) to Predict risk of DVT in Patients with a PICC
    • Online Calculator
    • Pocket Card 
    • Educational Video
Articles/References
​Chopra, V et al. Risk of Venous Thromboembolism Associated with Peripherally Inserted Central Catheters: A Systematic Review and Meta-Analysis. LANCET 2013
  • PICCs are associated with a higher risk of deep vein thrombosis than CVCs, especially in patients who are critically ill or those with a malignancy. The decision to insert PICCs should be guided by weighing the risk of thrombosis against the benefit provided by these devices.  
Evans, RS et al. Risk of Symptomatic DVT Associated with Peripherally Inserted Central Catheters. CHEST 2010
  • This article examines risk factors for PICC-associated DVT. They concluded that prior DVT and surgery lasting >1 hour put  patients at increased risk for PICC-associated DVT. Increasing catheter size is also associated with increased risk.  

Evans, RS et al. Reduction of Peripherally Inserted Central Catheter-Associated DVT. CHEST 2013
  • Reduction in PICC-associated DVT can be impacted by increased insertion education and training, persistent DVT surveillance and reporting, and judicious PICC diameter selection.  

Kearon, C et al. Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012
  • This article provides a detailed summary of the evidence-based medicine recommendations for avoiding and treating thrombosis. 
Validation Survey
DVT Step 6 Validation - Final Validation.
  • This document includes all of the validation questions associated with this content area to help with collaboration on responses for your hospital. Responses to the validation questions should be entered in to the linked document and recorded to monitor progress.
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