One of the most important patient care decisions that infusion nurses make relates to choosing the most appropriate vascular access device (VAD). The Infusion Nurses Society's Infusion Nursing Standards of Practice have long recommended that the least invasive device be placed for the prescribed therapy. The use of peripherally inserted central catheters (PICCs) has become a prevalent practice because of the ease of placement in the arm by trained clinicians and, often, perceptions of low complication rates. However, a PICC is a central vascular access device (CVAD) and is associated with significant complications, including venous thrombosis and bloodstream infections. Indications for PICC use are a topic of discussion among many of us, with few directives defining the appropriateness of PICC use versus other VADs.
Dr. Vineet Chopra and colleagues1 performed a notable study recently published in the Annals of Internal Medicine: the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). As infusion nurses, we must be familiar with research published beyond our journal. Because of the relevance of the results of this study to infusion nursing practice and the INS mission to advance best practice through evidence-based practice and research, a brief summary is presented. Also, of note, this study was cited and used to support a number of practice criteria in the upcoming 2016 Infusion Therapy Standards of Practice.
The aims of the study were to develop appropriateness criteria for PICC/VAD selection, care, and management in hospitalized adult patients. This study used a methodology called the RAND/University of California Los Angeles (UCLA) Appropriateness Method. This methodology was developed for the purpose of allowing measurement of overuse of medical and surgical procedures. Briefly, it includes a systematic review and synthesis of scientific evidence, selection of panelists, creation of clinical scenarios, a rating process, and analysis of the results. Panelists selected for this study included leading national and international experts representing vascular access nursing, a variety of relevant medical specialties, and pharmacy. Experts were asked to rate appropriateness of insertion, maintenance, and care issues related to PICCs in a variety of clinical patient scenarios as well as scenarios addressing appropriate practices for PICC care and management, and treatment of PICC complications. Panelists were asked to rate these scenarios individually and during a follow-up on-site meeting. Ratings for PICC use were based in the context of patient needs and included comparisons with other VADs when relevant.
Based on the results, recommendations are presented in easy-to-read tables providing guidance in VAD choice and appropriate PICC insertion, care, and maintenance practices. VAD choice is rated as appropriate, neutral, or inappropriate based on the proposed duration of infusion and compatibility of the infusate with peripheral administration. For example, the panelists felt that it is appropriate to place a PICC when the infusate is compatible with peripheral administration only when the duration of infusion therapy exceeded 6 days; for infusions anticipated for a duration of less than or equal to 5 days, appropriate VAD options included short peripheral catheters, ultrasound-guided short peripheral catheters, and midline catheters.
One of the limitations noted by the researchers was that direct care nurses, who often request PICCs, were not included in the panel. Although hospitals with vascular access teams may use study results to guide practice, many hospitals do not have such teams. How do patients in these hospitals receive best practices in VAD selection? There is a great need to reach nurses who prefer PICCs for convenience and don't necessarily consider or even recognize the risks associated with CVADs such as PICCs. This is an ongoing challenge for the infusion and vascular access community. Although beyond the scope of this study, another challenge is the growing practice of infusion therapy beyond the acute care setting. Limited vascular access skills and lack of knowledge often lead to preference for a PICC when a less invasive VAD, such as a short peripheral catheter or midline, may be the safer and more appropriate choice.
I urge all nurses and infusion teams to carefully read, review, and discuss this study. This work represents an important achievement-the first time so many specialties in medicine, nursing, surgery, and pharmacy were brought together to focus on vascular access. Within our organizations, interprofessional collaboration should be a standard of practice. Are there opportunities for better collaboration and better VAD decision making within your organization?
As stated in the paper, "clinicians often do not reflect carefully enough on the nature of venous access or weigh inherent risks and benefits" in decision making and that a decision to place a PICC is made without consideration of other devices. Clearly, selecting the most appropriate VAD is not a black-and-white answer that can be placed into a simple algorithm. However, this study provides the clinician with guidance from expert clinicians based on clinical relevance and scientific evidence.
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