Step 1: Review PICC Related DVT Data to Identify Areas for Improvement
Review identified PICC-related DVT cases
Element |
Key Institutional Partners |
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QI Team, Vascular Access Team |
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QI Team, Vascular Access Team |
Resources/Tools
Audit tool to review PICC-DVT cases
Decision Tools: Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
Michigan Risk Score (MRS) to Predict risk of DVT in Patients with a PIC 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: |
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
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Validation Survey
DVT Step 1 Validation - Review DVT Data.
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 |
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QI Team, Hospital Leadership |
Resources/Tools
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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
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Validation Survey
DVT Step 1 Validation - Perform an Assessment of Potential Cost Savings.
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 |
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Hospital Leadership, HMS PICC Team, QI Department |
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Hospital Leadership, HMS PICC Team, QI Department |
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Hospital Leadership, Providers, IR, Vascular Access Team |
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Hospital Leadership, Providers, IR, Vascular Access Team |
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Hospital Leadership, Providers, IR, Vascular Access Team |
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Providers, IR, Vascular Access Team |
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Providers, IR, Vascular Access Team |
Resources/Tools
Assessment/Decision Tools
The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
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
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Validation Survey
DVT Step 2 Validation - Appropriate Device Choice and Insertion.
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 |
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Hospital Leadership, Vascular Team, QI Department |
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Hospital Leadership, Vascular Team, QI Department |
Resources/Tools
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Articles/References
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Zehnder J, et al. Catheter-related upper extremity venous thrombosis. Up To Date. 2018
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Validation Survey
DVT Step 2 Validation - Smallest Gauge/Least Lumens.
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 |
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Vascular Access Team |
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Providers, IR, Vascular Access Team |
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Providers, IR, Vascular Access Team |
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Providers, IR, Vascular Access Team |
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Providers, IR, Vascular Access Team |
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Providers, IR, Vascular Access Team |
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Providers, IR, Vascular Access Team |
Resources/Tools
Decision Tools: Michigan Risk Score (MRS) to Predict risk of DVT in Patients with a PICC 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
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Validation Survey
DVT Step 2 Validation - Avoid PICCs in Patients with Higher Risk of DVT.
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 |
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Providers, IR, Vascular Team, Hospital Leadership |
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Providers, IR, Vascular Team, Hospital Leadership |
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Providers, IR, Vascular Team, Hospital Leadership |
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Providers, IR, Vascular Team, Hospital Leadership |
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PICC Team, Data Abstractor, QI Department |
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
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Validation Survey
DVT Step 2 Validation - Catheter to Vein Ratio.
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 |
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Providers, IR, Vascular Team, Hospital Leadership |
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Providers, IR, Vascular Team, Hospital Leadership |
Articles/References
Zehnder J, et al. Catheter-related upper extremity venous thrombosis. Up To Date 2018
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
- 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
- Details the proper tip location (Zone A, B & C)
- 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.
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.
Securement: if a PICC is in place, appropriate care/maintenance must be in place
Element |
Key Institutional Partners |
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Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership |
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Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership |
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Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership |
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Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership |
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Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership |
Articles/References
Zehnder J, et al. Catheter-related upper extremity venous thrombosis. Up To Date 2018
|
Validation Survey
DVT Step 3 Validation - Care and Maintenance - Securement.
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 |
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Providers |
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Providers |
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Providers |
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Providers, IR, Vascular Team |
Articles/References
Zehnder J, et al. Catheter-related upper extremity venous thrombosis. Up To Date 2018
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
- 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 |
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Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership |
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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
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.
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 |
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Providers, IR, Vascular Team, Hospital Leadership/Nursing Leadership |
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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
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.
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 |
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Providers, IR, Vascular Access Team, Hospital Leadership/Nursing Leadership, QI Department |
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Providers, IR, Vascular Access Team, Hospital Leadership/Nursing Leadership, QI Department |
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Providers, IR, Vascular Access Team, Hospital Leadership/Nursing Leadership, QI Department |
Articles/References
McDonald EG, & Lee, TC. Venous catheter use in medical inpatients through regular physician audits using an online tool. JAMA Internal Medicine 2015
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Validation Survey
DVT Step 5 Validation - Line Necessity/Removal.
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 |
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Providers |
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Providers |
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Providers |
Resources/Tools
Decision Tools
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Articles/References
Chopra, V et al. Risk of Venous Thromboembolism Associated with Peripherally Inserted Central Catheters: A Systematic Review and Meta-Analysis. LANCET 2013
Evans, RS et al. Reduction of Peripherally Inserted Central Catheter-Associated DVT. CHEST 2013
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
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Validation Survey
DVT Step 6 Validation - Final Validation.
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.