An Evidence-Based Systematic Review of Literature for the Reduction of PICC Line Occlusions

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ʈ˜iÊ"VVÕȜ˜Ã Linda Bartock, DNP, ACNP

Abstract Peripherally inserted central venous catheters (PICCs) are known to have difficulties with catheter occlusions. This paper evaluates the scope of PICC occlusions, their prevalence and severity, and potential interventions to decrease incidence. A systematic review of the literature is performed and demonstrates three potential interventions: utilization of a dedicated PICC insertion team, implementation of a valved PICC, and nursing education of PICC care. The evidence from the literature is evaluated, and implementation of the proposed interventions is discussed.

Introduction atheter occlusions are a prevalent issue facing patients requiring Peripherally Inserted Central Venous Catheters (PICCs). While some of the tertiary care facilities in the Baltimore-Washington metropolitan area have nurse practitioner and nursing run Vascular Access Services (VAS) that place most PICCs for inpatients within the facilities, some patients have required multiple procedures due to occlusions. This paper evaluates current research and evidence related to the prevention of PICC occlusions, and potential applications for translation of the evidence.



Prevalence and Severity of PICC Occlusions The use of peripherally inserted central venous catheters (PICCs) in the healthcare setting has become increasingly popular over the last decade as it provides venous access for patients requiring prolonged antibiotic therapy and infusion of caustic solutions. These catheters benefit patients due to their decreased cost, complication rates, and infection rates when compared to other central venous catheters (CVCs) (Hoffer, 2001). However, catheter occlusions are frequently cited as a drawback to PICCs with an incidence of 7-25% (Hoffer, 1999). As noted by Maria Eulalia Juve, “Although occlusions account for less than 25% of all VAD dysfunctions, it is among the most frequent complications of VADs in the hospital setting.” (Juve, 2003) Catheter occlusions are typically sorted into three main types: biological, mechanical and physical. Biological occlusions result from formation of thrombus(es) in and around the inserted catheter, mechanical occlusions are obstructions caused by kinked or malpositioned catheters, and physical occlusions are due to pre-

cipitation of incompatible solutions or drug residue (Juve, 2003). Biological occlusions are impacted by two main factors; nursing care of the catheter including flushing protocol, and catheter type including type of material used (Abdullah, 2005). Mechanical occlusions are impacted by nursing care, catheter type including type of material used, insertion techniques or operators (Fong, 2001), and migration of catheters post-procedure. Physical occlusions are usually attributed to nursing care, type of infusate, and catheter type including type of material used. The impact of PICC occlusions on patients and families is significant. Occluded catheters can lead to the inability to infuse medications or treatments (Hoffer, 1999). Occlusions also place the patient at risk for thrombotic events including deep venous thrombosis (DVT) and emboli from the original PICC line (Abdullah, 2005; Gonsalves, 2003). Occluded catheters place the patient at risk for mechanical complications, such as pneumothoraces and hematomas, and psychological trauma associated with multiple procedures. Also, patients are at risk for increased scar tissue and vascular damage with repeated procedures (Gonsalves, 2003). Finally, the patients and families bear the brunt of increased costs from PICC occlusions with repeat admissions, emergency department (ED) visits, costs of repeated procedures, and prolonged therapy due to missed doses. In addition to affecting patients and families, healthcare systems are also impacted by PICC occlusions. The nursing community is impacted because occluded catheters cause nursing staff to not be able to provide care for their patients, which yields negative attitudes toward PICCs (Hinson, 1996). Catheter occlusions result in repeat procedures, increased ED visits, increased readmission rates, and prolonged length of stay. Each of these factors is costly to the healthcare system through use of manpower and actual financial burden.

Correspondence concerning this article should be addressed to [email protected] DOI: 10.2309/java.15-2-3

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Purpose of Evidence Review Based on the prevalence and impacts to practice, this paper

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evaluates potential ways to lower PICC occlusion rates through a systematic review of the evidence in selected and reported literature. More specifically, what are the best clinical practices to reduce the incidence of occluded PICC lines? Search Strategy In order to appropriately evaluate the current research in the field of PICC occlusions, a systematic review of the literature was performed with two databases (PubMed and CINAHL) and additional handsearch articles that were not in the systematic review, but addressed the clinical question. Inclusion criteria were: • Catheter must be a PICC line • Articles must focus primarily on adults because practice initiatives derived from the review will be applied to an adult population • Prevention of catheter occlusions must be an outcome variable • Articles must be available electronically and in English • Only articles within the last 15 years will be accepted, but preference will be shown to those within the last 10 years due to the small number of articles fitting inclusion criteria. Based on the above criteria, the PubMed search terms were as follows: (Catheterization [Mesh] OR Catheterization, Peripheral [Mesh] OR Catheterization, Central Venous [Mesh]) AND Occlu* AND Periph* AND Venous* The three Mesh terms, which included all types of catheterizations within the database, combined with Occlu*, Periph*, and Venous* helped limit the data specifically to catheters that had occlusions, were inserted peripherally, and were inserted in the venous system. Search limits were: Date of publication 1/1/1993 to 2009; Humans; and English. This search yielded a total of 193 articles, of which, 29 titles initially appeared to meet the inclusion criteria. In addition to the PubMed search, a secondary search within the CINAHL database was performed to give a more inclusive review of the current available literature. The CINAHL search terms were as follows: [“PICC” OR (MM “Catheterization, Peripheral Central Venous”) OR (MM “Catheterization, Central Venous+”) OR (MM “Catheterization, Peripheral+”)] AND [(MM “Catheter Occlusion”) OR (MM “Catheter-Related Thrombosis”) OR Obstruct* OR Thromb* OR Block*] The first four search terms were combined with OR to yield a comprehensive list of catheterizations. The last five search terms were combined with OR and added to the original search with AND to limit to catheter occlusions, catheter thromboses, obstructions, thromboses, and/or blockages. This was limited by articles within the last 10 years, published in English, and with adult subjects. The final result was 67 articles, of which 18 titles appeared to meet the inclusion criteria. In addition to the PubMed and CINAHL searches, there were 23 articles that appeared to meet criteria, based on title search, which were obtained from outside sources including the Co-

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chrane database and listed as handsearch articles. Collectively, all three reviews yielded a total of 280 articles (3 titles appeared in more than one database). A title review narrowed the results to 67 articles, which were pulled and reviewed individually. Of these, 58 articles were excluded because they did not meet the inclusion criteria. This left a remaining 9 articles to be included in the literature review, of which 7 were deemed research articles, and 2 were non-research (see table 1). All articles were evaluated using the Johns Hopkins Nursing Evidence-Based Practice Rating Scale (Newhouse, 2007). Research Evidence The results and recommendations of the seven research articles included are listed in table 1. However, compilation of the results and recommendations showed three potential interventions that may lead to lower occlusion rates, the use of valved PICCs, education of the nursing staff, and use of a dedicated PICC team for procedures. A total of three articles evaluated the first intervention, the use of valved PICCs. Hinson (1996) showed lower occlusion rates and decreased need for thrombolytic agents for valved PICCs over clamped PICCs (p=.001). Hoffer (1999) demonstrated half as many occlusions in valved PICCs versus clamped PICCs, but was not statistically significant (p=.10). However, the overall complication rate (occlusions and infections) was significantly lower in the valved PICCs when compared to the clamped PICCs (p=.02). The third article, a more recent study by Hoffer (2001), compared proximal versus distal valves, and while there was no significant difference in occlusion rates, the proximal valved PICCs had fewer catheter fractures and were significantly more durable (p<.01). It should be noted that one article mentioned that using valved PICCs resulted in decreased use of heparin, increased flow rates, increased patient satisfaction, and increased cost savings. (Hoffer, 1999) The second and third interventions noted to decrease PICC occlusion rates were the education of nursing staff caring for the PICC lines and the implementation of a dedicated PICC team to place PICC lines. Ngo (2005) evaluated the efficacy of a video-taped educational seminar for nursing staff. This addressed PICC management and assessment techniques including: blood return assessment, mechanical obstruction assessment, and positioning techniques, in addition to communication strategies with physicians. This study demonstrated that increased nursing knowledge of PICC care and feelings of selfefficacy yielded a significant reduction in catheter occlusions over a 6-month period from 29% down to 8.5% (p<.000). In 2001, Funk combined the two interventions by implementing a dedicated PICC team. It was theorized that intensified training of the nursing staff (the methods of which were not detailed in the paper) and developed proficiency of the PICC team would lead to lower occlusion rates. The results demonstrated that implementation of a dedicated PICC team and education of bedside nurses was associated with a total of 15 occlusions as compared to 32 occlusions prior to these interventions (p=.02). Non-research Evidence In addition to the research evidence available for reduction of PICC occlusions, there is a small body of non-research evi-

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dence that must be evaluated and considered. General nursing knowledge demonstrates that inspecting solutions and medications for precipitates prior to infusion, using proper technique when obtaining blood samples, flushing after samples are obtained, monitoring fluids that are likely to precipitate, and patient education of PICC protocols will likely reduce the number of PICC occlusions (Rumsey, 1995). There is currently debate surrounding the proper protocol for flushing of PICCs and whether saline or heparin is more appropriate, however, standardized flushing protocols are noted to decrease occlusion rates. (Rumsey, 1995) and (Gorsky, 2005) There have also been economic savings reported with the use of valved PICCs due to decreased number of repeat procedures secondary to occlusions and infections. There are also cost savings related to the ability to use saline as a flushing solution in the valved PICCs, which is significantly cheaper than heparinized flushes. One particular cost analysis that compared two catheter types (valved vs. non-valved catheters) found that the valved catheters had fewer occlusions and decreased line maintenance costs. When this was evaluated at the health system level, it was estimated that the weekly cost savings for maintenance alone was $14.56/PICC. For an average of 60 PICCs per month, the cost savings to the healthcare system would exceed one-half million dollars per year (Hinson, 1996).

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Evaluation of the Evidence The strengths of the current research are abundant. First, six of the seven research articles had scientific evidence rating of II: B, and the last article had a I: C rating. Due to the nature of healthcare and the ethical considerations associated with performing research on human subjects, this is a fairly strong rating. Second, each of these studies had a sample size of 100 or greater, which is sufficient to draw statistical conclusions. Third, most of the samples were equally matched in age, gender, and race to prevent sampling bias. Fourth, of the studies that showed significance, there was a high level of statistical conclusion validity and construct validity. Fifth, the studies showed high reliability with regard to attrition, magnitude of the effect, strength of the associations made, and measures of clinical significance. Lastly, the studies were well controlled because there were very few confounders, and those that did have potential for confounding, listed or addressed this. Although these articles are of a moderately strong quality, there were also several weaknesses noted. First, due to lack of funding and time constraints, this systematic review includes articles strictly from PubMed and CINAHL, with additional handsearch articles from Cochrane and outside sources. While this provides a good preliminary review of literature, a larger systematic review utilizing MEDLINE, EMBASE, or Google scholar could yield a more robust literature review. Second, due to the quasi-experimental designs of the studies, many of the articles were unable to randomly select subjects and/or provide an adequate control group. Third, several of the articles had design flaws or results obtained that may have led to underreporting of occlusions yielding decreased data significance on report. Last, most of the articles did not provide information on precision of the effects including confidence intervals, power, sensitivity and specificity, which lowered the reliability substantially. Due to the small number of articles fitting inclusion criteria, there are several gaps in knowledge with regard to prevention of PICC occlusions within the adult population. First, there are no randomized controlled trials of a large scale that adequately describe the impact of valved catheters, nursing education of PICC care, and/or the implementation of dedicated PICC teams on occlusion rates. Second, the non-research literature evaluates the efficacy of prophylactic anticoagulants, standardized flushing protocols, and actual flushing solutions in reduction of occlusions; however current research in these areas is limited to infants and children. Due to this, there is little or no data on the impact of these interventions on PICC occlusions in the adult population. There are no standardized tools to predict PICC occlusions or protocols recommended to prevent occlusions. There is no research available that evaluates comorbidities, such as hematologic disorders, limitations of mobility, or presenting diagnoses and their impact on PICC occlusions. There are no known standards regarding the best insertion techniques or catheters to use in patients predisposed to PICC occlusions. Aside from the literature regarding valved versus non-valved catheters, there was no research located that compared catheter materials, catheter brands and types with regard to occlusion rates.

2010

Translation for Practice and Further Research Because of the small number of articles fitting inclusion criteria, a need for further investigation into best practices for the prevention of PICC occlusions within the adult population is necessary. It is obvious from the literature that use of valved PICCs, nursing education of PICC care, and the implementation of dedicated PICC teams are correlated with decreased incidence of catheter occlusions. However, due to the significant gaps in available literature and research, future efforts should focus further substantiating the efficacy of these three interventions in a large sample study. Research to evaluate prophylactic anticoagulants, standardized flushing protocols, and actual flushing solutions to reduce occlusion rates should be expanded to the adult population. Further evaluation into the impact of comorbidities on occlusion rates and interventions to reduce occlusions in high-risk populations is needed. Plus, evaluation of the impact of catheter materials, catheter brands and types with regard to occlusion rates should be evaluated to further expand the body of knowledge. When this literature review is applied to practice, the current evidence would support the implementation of any of the three major strategies to reduce PICC occlusion rates. It must be noted, though, that there are significant gaps in the knowledge at this point in time and future research is warranted for reduction of PICC occlusion rates in the adult population. It is recommended that this systematic review of literature be evaluated and reviewed at an institutional level and applied only in settings where deemed safe and prudent by the healthcare professionals and providers within that setting. Conclusion In conclusion, PICC occlusions are a highly prevalent clinical concern that has many patient, family, community and health care system implications. The clinical and economical costs are great, and reduction of occlusion rates can significantly improve the quality of healthcare for many patients. Evaluation of better practices, current research and evidence lead to the identification of three viable practice changes to assist in prevention of PICC occlusions. The translation of these practice changes would incorporate the implementation of valved catheters, utilization of dedicated PICC insertion teams, and education of nursing staff, which could lead to better outcomes and improved patient care. Acknowledgments To Dr Sharon Dudley-Brown for her expert instruction and attention to detail. To Dr Julie Stanik-Hutt for her wisdom and guidance during the pursuit of my doctoral degree. And finally, to my husband for his patience, love and continued support. References Abdullah, B. J., Mohammad, N., Sangkar, J. V., Abd Aziz, Y. F., Gan, G. G., Goh, K. Y., et al. (2005). Incidence of upper limb venous thrombosis associated with peripherally inserted central catheters (PICC). The British Journal of Radiology, 78(931), 596-600.

2010

Bowers, L., Speroni, K. G., Jones, L., & Atherton, M. (2008). Comparison of occlusion rates by flushing solutions for peripherally inserted central catheters with positive pressure lueractivated devices. Journal of Infusion Nursing, 31(1), 22-27. Fong, N. I., Holtzman, S. R., Bettmann, M. A., & Bettis, S. J. (2001). Peripherally inserted central catheters: Outcome as a function of the operator. Journal of Vascular and Interventional Radiology, 12(6), 723-729. Frederick, D. G. (1993). Tongue blade stabilizes PICC to prevent flow occlusion. Oncology Nursing Forum, 20(4), 699. Funk, D., Gray, J., & Plourde, J. (2001). Concise communications. Two-year trends of peripherally inserted central catheter-line complications at a tertiary-care hospital: Role of nursing expertise. Infection Control & Hospital Epidemiology, 22(6), 377-379. Gonsalves, C. F., Eschelman, D. J., Sullivan, K. L., DuBois, N., & Bonn, J. (2003). Incidence of central vein stenosis and occlusion following upper extremity PICC and port placement. Cardiovascular and Interventional Radiology, 26(2), 123-127. Gorski, L. A., & Czaplewski, L. M. (2005). I.V. rounds. managing complications of midlines and PICCs. Nursing, 35(6), 68-69. Hinson, E. K., & Blows, L. (1996). Skilled IV therapy clinicianʼs product evaluation of open-ended versus closed-ended valve PICC lines: A cost savings clinical report. Journal of Intravenous Nursing, 19(4), 198-210. Hoffer, E. K., Bloch, R. D., Borsa, J. J., Santulli, P., Fontaine, A. B., & Francoeur, N. (2001). Peripherally inserted central catheters with distal versus proximal valves: Prospective randomized trial. Journal of Vascular and Interventional Radiology, 12(10), 1173-1177. Hoffer, E. K., Borsa, J., Santulli, P., Bloch, R., & Fontaine, A. B. (1999). Prospective randomized comparison of valved versus nonvalved peripherally inserted central vein catheters. American Journal of Roentgenology, 173(5), 1393-1398. Juve, M. E. (2003). Intravenous catheter declotting: Same outcomes with lower dose urokinase? Journal of Infusion Nursing, 26(4), 245-251. Newhouse, R., Dearholt, S., Poe, S., Pugh, L.C., & White, K. (2007). The Johns Hopkins Nursing Evidence-Based Practice Rating Scale. Baltimore, MD: The Johns Hopkins Hospital, Johns Hopkins University School of Nursing. Ngo, A., & Murphy, S. (2005). A theory-based intervention to improve nursesʼ knowledge, self-efficacy, and skills to reduce PICC occlusion. Journal of Infusion Nursing, 28(3), 173-181. Rumsey, K. A., & Richardson, D. K. (1995). Management of infection and occlusion associated with vascular access devices. Seminars in Oncology Nursing, 11(3), 174-183. Yamamoto, A. J., Solomon, J. A., Soulen, M. C., Tang, J., Parkinson, K., Lin, R., et al. (2002). Sutureless securement device reduces complications of peripherally inserted central venous catheters. Journal of Vascular and Interventional Radiology, 13(1), 77-81.

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