Use a decision tool to guide the appropriateness of PICC use prior to insertion

Action Items:

• Identify, adapt and deploy a decision-tool to guide clinicians in determining the appropriateness of CVC or PICC placement prior to insertion
• Ensure that the decision to use a PICC is made in consultation with operators familiar with recommendations from the decision tool;
• Designate a physician champion to support use of the decision tool and assist with resolving disagreements between inserter and ordering physician or managing uncertainty regarding best practice 
• Share the proposed decision tool with front-line clinicians and members of the vascular access committee to ensure buy-in and feedback of the tool 
• Communicate use of decision-tool to clinicians and front line staff through educational sessions (morning report, grand rounds, nursing huddles/blitzes, etc.)
• Implement the decision-tool via approaches such as a nursing checklist for PICC use vs. use of other non-central venous access devices, computerized decision support within the electronic health system, etc.

Resources & Tools: 

• Decision Tools:
  • The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
    • Video – How to use the MAGIC App
    • Video - The Michigan MAGIC, PICC Appropriateness & Mindful Medicine
    • App - ImprovePICC MAGIC App
    • MAGIC Guidelines PowerPoint Presentation
  • An Introduction to the 2021 Infusion Therapy Standards of Practice
  • Infusion Therapy Standards of Practice 2016 – Overview Presentation
  • Infusion Therapy Standards of Practice 2021 (Paid)
  • Intermountain Medical Center Algorithm for IV Access
  • ​​Vascular Access Dashboard (PICC Excellence)
• Example Inpatient PICC Order set Criteria
  
• Example PICC Insertion Note
• Example Midline Insertion Note​
• Centers for Disease Control & Prevention Guidelines for Prevention of IV catheter-related infections, 2011
• SHEA Compendium for preventing catheter-related infections 2014
• Michigan Medicine: Guidelines for administration of Antibiotics via Midline Catheter
• 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
• Video: Why catheter-to-vein ratio matters​

​References: 

• 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.

• Chopra V, et al. Improving Peripherally Inserted Catheter Appropriateness and reducing device -related complications: a quasiexperimental study in 52 Michigan hospitals

• DeVries M, et al. Infection free midline catheter implementation at a community hospital (2 years). Am J Infect Control. 2019
  • Adoption of a vascular access nurse led catheter program, coupled with device selection algorithms, contributes to the ability to select the right device for the patient, while decreasing excess central line usage without additional increased risks to the patient.
• Govindan S, et al. To PICC or not to PICC? A cross-sectional survey of vascular access practices in the ICU. J Crit Care. 2021
  • Variation in guideline-based vascular access practice exists in the ICU. Defined local protocols may improve guideline adherence.
• Lindquester WS, et al. Effects of the MAGIC Guidelines on PICC Placement Volume: Advanced Practice Provider and Physician Trends Among Medicare Beneficiaries From 2010 to 2018. AJR Am J Roentgenol. 2021
  • The volume of PICC placements has steadily decreased since 2010, with a sharper decline between 2015 and 2016 corresponding with the publication of the MAGIC evidence-based guidelines.
• 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 through which to assess 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 the burden of thrombosis.
• Sharp R, et al. Catheter to vein ratio and risk of peripherally inserted central catheter (PICC)-associated thrombosis according to diagnostic group: a retrospective cohort study. BMJ Open 2021;11(7)
  • This study confirmed that the risk of thrombosis is much higher in patients receiving intravenous chemotherapy via a PICC, and checking catheter-to-vein ratio is particularly important.
• Vaughn VM, et al. Association of Infectious Disease Physician Approval of Peripherally Inserted Central Catheter with Appropriateness and Complications. JAMA Netw Open. 2020
  • This study suggests that, when PICCs were placed for intravenous antimicrobial therapy, infectious disease physician approval of PICC insertion was associated with more appropriate device use and fewer complications. Policies aimed at ensuring infectious disease physician approval prior to PICC placement for antimicrobials may improve patient safety.

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