A peripherally inserted central catheter (PICC) is used for reliable delivery of medical therapies and blood sampling. In the PICU, PICCs are an important option for patients with a history of difficult IV access and those with prolonged requirements for central vascular access. Limited pediatric data suggest that PICCs have a reduced rate of central line-associated bloodstream infection (CLABSI) compared with temporary central venous catheters (CVCs) (1). In addition, smaller caliber catheters may reduce venous thromboembolism (VTE) rates while obviating the risk of infiltration associated with peripheral IV catheters. There are no published pediatric guidelines regarding patient selection criteria for PICC placement, and this task is often left to the discretion of front-line providers in the PICU.
There is also no single or multiinstitution literature describing bedside PICC placement practice in PICU populations. Within our institution, PICCs for PICU patients historically were almost exclusively placed in the interventional radiology (IR) suite using fluoroscopic guidance by trained IR specialists. Placement of a PICC in IR requires order placement, scheduling, and transport to and from the PICU setting. This workflow results in potential delays in timely PICC placement, removal of vital staffing resources from the PICU, and extraction of critically ill patients from the resource-rich PICU environment. Neonatal literature from our institution previously described successful translation of PICC placement performance and safety from the IR suite to the bedside (2).
We developed a two-phase iterative PICU bedside PICC service (BPS) quality improvement (QI) initiative. The primary aim for phase I was to develop criteria identifying PICU patients that would benefit from PICC placement and to distinguish subsets amenable to bedside PICC placement resulting in a PICU PICC evaluation tool (PICU PET). The secondary aim for phase I was successful implementation of BPS as measured by overall percentage of PICCs placed at the bedside of PICU patients and balanced by BPS performance and patient safety metrics. The aim for phase II was to increase BPS providers for bedside PICC placement in critically ill patients with continued evaluation of implementation outcome, process measures, and balancing metrics.
Training, Process Development, and Implementation
This QI intervention took place in a large quaternary care medical-surgical PICU with 55 beds averaging over 3,800 admissions per year. Two PICU physicians (T.W.C, A.S.H.) trained in PICC placement by performing a minimum 10 ultrasound-guided upper extremity PICC placements supervised by IR physicians. Simultaneously, IR and PICU specialists in vascular access developed expert consensus criteria identifying PICU patients for PICC placement and patient characteristics suggesting optimal location and provider for technical performance resulting in PICU PET (Fig. 1). Patients with characteristics rendering them high-risk for transportation were “suggested” for PICC placement in the PICU whereas characteristics benefitted by use of fluoroscopy during the procedure were “suggested” for placement in IR. Patients with characteristics associated with difficult access or increased risk of complication were “suggested” for PICC placement by an IR specialist. All other patients were considered “amenable” for BPS provider placement. PICU PET was disseminated among PICU and IR providers as part of ongoing education and program implementation, and final decision for catheter placement location was undertaken by the primary care service in coordination with BPS providers and IR.
BPS was integrated in clinical care on June 1, 2015 (phase I) comprised of the two trained PICU physicians. These physicians screened PICU patients with PICC orders using guidance from PICU PET to identify appropriate patients for bedside PICC placement. After achieving targeted performance goals during phase I, BPS expanded September 1, 2016 (phase II) to include vascular access service (VAS) providers with PICC placement privileges in IR (C.A.C., R.L.B., T.M.B., Me.D.W.) as well as a nurse practitioner with prior bedside PICC experience at a different institution (Ma.D.W.). All BPS PICCs were placed using ultrasound guidance. Workflow process mapping resulted in translation of PICU PET to an electronic assessment note built within the electronic health record (EHR; Epic, Verona, WI) to improve interdisciplinary communication.
Implementation Outcome, Process Measures, and Balancing Metrics
All patients with bedside PICCs placed by BPS had demographic information extracted including age, weight, and sex from the EHR. Other patient characteristics within PICU PET were extracted from the EHR including active vasoactive infusion, “advanced” ventilatory support (including high-frequency oscillatory ventilation, high-frequency percussive ventilation, or airway pressure release ventilation), institutionally defined “critical airway,” history of prior VTE, history of prior difficult PICC placement, active anticoagulation infusion, history of cardiac anesthesia requirement, presence of nontemporary central catheter, and concern for future dialysis requirement. Data collected were initially transferred to an electronic Research Electronic Data Capture (RED-Cap) database. An automated data visualization application, QlikView (Qlik Technologies, Inc., Lund, Sweden), extracted patient characteristic data from the EHR and categorized patients by suggested provider and location for placement. After verifying no discrepancies between the REDCap database and QlikView application during phase I, phase II data was directly exported from the QlikView application.
Our primary outcome was the proportion of PICCs placed at the bedside of PICU patients compared with other locations.
Process measures included concordance of provider and placement location with PICU PET, percentage completion of the electronic assessment note, time to PICC placement for BPS placed PICCs versus those placed in IR, and estimated hospital charges for BPS placed PICCs versus those placed in IR. Concordance was measured with the term “suggested” as targeted goal for location and provider for placement as per PICU PET criteria. PICCs placed in PICU patients in an operating room or cardiac catheterization laboratory were excluded for assessment of concordance. Time to PICC placement was defined as the time from the EHR order to documentation of catheter insertion.
Balancing metrics were categorized as performance or safety. Performance metrics for BPS PICC placement included successful venous access and central tip position (within the superior vena cava to the right atrium for upper extremity PICCs and inferior vena cava to the right atrium for lower extremity PICCs). We targeted greater than 90% success in vascular access and central tip position as defining feasibility of concept to move to phase II. Safety outcomes were CLABSI (including mucosal barrier injury laboratory-confirmed bloodstream infections [MBI-LCBI] and non-MBI-LCBIs ) and central line-associated VTE. Data were extracted from an institutional safety and harm prevention QlikView application and cross-referenced with our developed PICU PICC QlikView application. BPS rates were compared with rates in IR as well as to rates of temporary CVCs in PICU patients. Temporary CVCs were defined as nontunneled central venous access devices placed in PICU patients within our institution excluding PICCs, ports, Broviacs, and apheresis/dialysis catheters. All rates are expressed using in-hospital catheter days.
Data were reviewed from June 1, 2015, to May 31, 2017, with a 12-month run-in for primary outcome displayed in statistical process control charts. Descriptive statistics were used to characterize patient population, process measures, and safety metrics. Fisher exact test was used to compare categorical data, Mann-Whitney U test for continuous data, and Fisher exact with mid-P correction for CLABSI and VTE incidence density rates with significance level 0.05. The study was deemed exempt from Institutional Review Board review at The Children’s Hospital of Philadelphia.
During phase I, 282 PICCs were placed in PICU patients with BPS placing 68 bedside PICCs (24%). During phase II, 211 PICCs were placed in PICU patients with BPS placing 62 bedside PICCs (29%). Patient characteristics for PICCs placed by BPS and catheters placed in IR are described in Table 1. Overall, 71 of 282 of PICCs (25%) were placed at the bedside of PICU patients during phase I and 73 of 211 (35%) during phase II (Fig. 2). Between phase I and phase II there was an increase in the number of bedside PICCs placed in the ICU by IR physicians (2/71 vs 11/73; p = 0.02) as well as an increase in the number of bedside PICCs placed by VAS providers (1/71 vs 23/73; p < 0.001).
Overall concordance between assessment tool and location/provider are demonstrated in Table 2. The PICC assessment note was completed by BPS providers in 42% of evaluable patients (88/211) during phase II. The time from order to successful PICC placement was significantly reduced in patients with BPS catheter placement (n = 121; median 6 hr [interquartile range (IQR), 2–23 hr]) compared with IR catheter placement (n = 326; median 34 hr [IQR, 19–61 hr]; p < 0.001).
Balancing Metrics: Performance
During phase I, venous access was achieved by BPS in 94% of attempted patients (68/73) with central tip position in 94% of patients (64/68) successfully accessed. During phase II, venous access was achieved by BPS in 98% of attempted patients (62/63) with central tip position in 100% of patients successfully accessed.
Balancing Metrics: Safety
CLABSI rates for PICCs placed by BPS were similar to rates for PICCs placed in IR (Table 3). Only one BPS CLABSI occurred within 48 hours of catheter placement and, after review, was identified as an MBI-LCBI. Femoral PICCs accounted for six of 22 of all PICU PICC CLABSI (27%) which was not significantly different from rates in upper extremity PICCs (p = 0.25). PICCs with CLABSI had significantly longer duration of catheter use compared with PICCs without CLABSI (median 24 d [IQR, 15–38 d] vs median 13 d [IQR, 7–26 d]; p < 0.001).
Catheter-associated VTE rates for PICCs placed by the BPS were similar to rates placed in IR (Table 3). Overall, femoral PICCs accounted for five of 18 of VTE (28%) and their VTE incidence (5/88; 6%) was not significantly different from incidence in upper extremity PICCs (13/405, 3%; p = 0.34). Temporary femoral catheters accounted for 22 of 33 temporary CVC VTEs (67%), and their proportion of contribution to overall temporary CVC VTE rate is significantly higher than the proportion of contribution by femoral PICCs to overall PICC VTE rate (p = 0.01).
Through a multidisciplinary collaboration and a QI approach, we developed a standardized PICU PET to identify patients and suggest location and personnel for patient-centered PICC placement. We demonstrated that the creation and spread of a team comprised of trained physicians, nurse practitioners, and vascular access nurses specialized in bedside PICC techniques can result in a sustained increase in PICCs placed at the bedside in critically ill children. Process measures and balancing metrics highlight programmatic timeliness with shorter time to PICC insertion and safety with no significant difference in CLABSI and VTE rates compared with PICCs placed in IR.
Neonatology departments have published literature describing the implementation of successful nursing-led PICC services although no literature describes the development of such services within the PICU setting (4). Further, there is a paucity of literature suggesting “when” a patient requires a PICC. An international consensus panel recently published suggested indications for adult PICC placement (5). Since pediatric consensus guidelines do not exist regarding indications for PICCs, we developed PICU PET to help standardize our institutional practice. By phase II of the program, 35% of PICU patients requiring PICCs had one placed at the bedside, whether by BPS or IR providers. Thus, vital resources such as nursing staff, respiratory therapists, and physician providers could remain on the unit involved in the care of other critically ill children. Bedside PICC placement also obviates risks of physiologic instability and medically necessary device dislodgements related to intrahospital transport (6–10).
We found that the largest proportion of BPS placed PICCs were in patients amenable to BPS as identified by PICU PET (92/130; 71%). This suggests that BPS providers were adherent to the evaluation tool for the majority of their catheters placed. We also found strong concordance (87%) when our tool suggested PICC placement by IR specialists in the IR suite. This is not surprising since, prior to BPS, this was our unit-based standard practice. There was low concordance in patients suggested for PICU location and amenable to BPS. BPS placed a similar number of catheters (24/48; 50%) in this population as in patients amenable to both PICU location and BPS (68/147; 46%), a category in which there was high concordance. We believe that these data reflect limitations to the number of BPS providers available rather than problems with the selection tool, but this will be tested further with spread of BPS trained providers. Further, the overall number of BPS PICCs placed from phase I to phase II actually decreased (68 vs 62). This is likely due to a shift in workflow to prioritize VAS utilization within the context of their ongoing training and program development over ICU physician PICC placement, which is supported by the increased number of VAS BPS catheters placed in phase II.
We did not find strong concordance in PICU bedside placement by IR physicians, although we identified an overall increase in the number of catheters placed at the bedside by IR physicians from phase I to phase II. Multidepartmental collaboration and improved communication may have led to buy-in regarding bedside placement by our IR colleagues. As there is a potential cost to transporting critically ill patients from the ICU to the IR suite, there is also a cost to removing IR providers from their own practice environment, an important metric likely taken into consideration during procedural planning although unable to be quantified within the scope of our program implementation. Developing improved methods of assessing the characteristics of tool performance and strengthening workflow processes is a next step in our program build.
Balancing metrics resulted in important data to guide program development as well as identify future research and QI targets. Successful procedural performance by BPS PICU physicians in phase I demonstrated concept feasibility and supported inclusion of VAS and nurse practitioner experienced providers within the BPS framework. Notably, our BPS PICC CLABSI rate was lower than the rate of PICCs placed in IR, although not reaching statistical significance. There are a number of factors likely contributing to this trend. Selection bias was purposeful within PICU PET. Some patient factors selected for IR (younger age, history of underlying cardiac disease, presence of indwelling nontemporary CVCs) are also factors associated with CLABSI (11–13). PICCs placed in IR were also present for, on average, a greater number of in-hospital days compared with BPS placed catheters. Our PICC data are limited to total in-hospital catheter days, and bloodstream infection does not necessarily indicate catheter removal within our institution. Thus our association of CLABSI with catheter duration, as described in prior pediatric studies, should be interpreted within this context (14 , 15). Further studies in pediatric populations using larger datasets and structured methodology should focus on the complex interactions between patient characteristics, device selection, as well as performance and catheter maintenance practices on PICC CLABSI rates.
We chose to review our PICU temporary CVC data during the 2 years of BPS integration. Our temporary CVC CLABSI rates trended lower, although not reaching statistical significance, than our PICC CLABSI rates. Although we have reason to suspect PICCs reduce CLABSI risk (1), other data suggest that PICCs may not be the panacea we envision. A recent Canadian group reviewed central catheter placement data from 1995 to 2013 and found that all other types of catheters assessed had a statistically significant decrease in CLABSI rates compared with PICCs on univariate analysis (16). In assessing the clinical associations with PICC infections, Advani et al (14) found that PICU exposure alone increased the rate of infection (incidence rate ratio, 1.80; 95% CI, 1.18–2.75; p = 0.01), a finding observed in adult populations as well (17).
There was no statistically significant difference in VTE rates between BPS placed PICCs and PICCs placed in IR. Although there is increasing interest in the pediatric community to investigate vascular access risk factors associated with VTE, providers currently have minimal published data to guide decisions (18). We did find higher rates of VTE associated with temporary CVCs, particularly when placed in a lower extremity. Adult literature demonstrates higher risks of VTE with PICCs versus temporary CVCs as well increased risk of VTE for temporary femoral CVCs versus subclavian or jugular CVCs (18–20). There are no data on VTE risks comparing catheter type in pediatric populations, although literature supports the femoral vessel as portending higher VTE risk for all catheter types (21 , 22).
There are many limitations to our study. Some of the findings may not be applicable to all PICU practice environments particularly as units may already employ bedside PICC placement services and/or have access to portable fluoroscopy equipment for procedural guidance. Regarding safety metrics, there were changes in the CLABSI-prevention strategies during the 2-year study period, but these changes were implemented on all PICCs throughout our PICU so any effects should be seen in both bedside and IR-placed PICCs. We also do not have catheter day data or safety data on temporary CVCs outside of our PICU. We suspect that use of temporary CVCs following transition from the PICU environment to non-ICU floors is limited given patient stability required for transfer and institutional initiative to transition temporary CVCs to PICCs for prolonged access. We also do not track transport-associated patient complications, so our program implementation is unable to determine the effect of bedside PICC placement on this measure.
A unit-specific PICU PET was developed through multidisciplinary collaboration within the context of a departmental QI initiative to develop a bedside PICC program (BPS). Vascular access specialists were able to integrate PICU PET in a PICU practice environment resulting in increased bedside PICC placement. BPS PICC placement improved value and quality of care through reduced time to procedural performance while maintaining CLABSI and VTE rates statistically similar to those of PICCs placed in IR.
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Keywords:©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
central line-associated bloodstream infection; implementation; peripherally inserted central catheter; quality improvement; vascular access; venous thromboembolism