- Email: [email protected]
Assessing catheter performance: Four years of tracking patient outcomes of midline, midclavicular and PICC line program
Jane Banton BSN, CRNI and Kristine Leahy-Gross RN, BS
assessin catheter er ormance Four years of 01 tracking patient outcomes 01 midline, midclavicular and PICC line program rtides ltides on peripherally insel1ed insened central venous catheter (PICC lines) and midline catheters abound these days in the literature. We want to thank all of you who are writing them because as we share our "line" stories, programs, and outcomes, we will learn from each other. We agree with Poole and Vasilios who recently wrote that with "only 12 percent of medical practice decisions [being) based on research - the remaining 88 percent [being] based on custom or habit - the need for apparent"l accurate data becomes more apparent'" The following data are helping us make better decisions in our PICC and midline bener catheter program.
OUR PROGRAM
Period I May 1994 tlu'ough September 1995 Our hospital stalted a midline catheter program in 1994. While we do not have a specifically designated IV team, the nurses were trained to place the Unfortunately, during the first catheters. UnfOlwnately, time period only 25 percent of the midline catheters placed had outcome data. Since this tl1is was a more expensive catheter to place, with several "up front" expenses, and since we could not show what became of them, tl1em, the program was in jeopardy. A group of committed nurses pursued keeping the program and made outcome monitoring mandatOlY. The genesis of our program came tory. from this goal: the nurse who places the line tracks it to the end of therapy or its removal. This served several purposes. First of all it was a great learning
experience, especially for nurses new to the program. Secondly, the data were collected concurrently. Thirdly, the data were collected by several people and was not a huge burden for any one person.
Period 2 through August 1996 December 1995 tl1rough repol1s, one hyperDue to the FDA repons, sensitivity reaction and a high pWebitis rate, we changed to a different midline Luther Medical, Tusin, catheter (L-Cath, Lutl1er CA) in November 1995. A polyurethane midline catheter was chosen over a sili-
cone-based catheter for reasons of increased cannula strength, higher flow rates and available customer support. More nurses were trained and there was an increase in the number of midline catheters tracked to either end of therapy or removal for other reasons. The pWebitis rate dropped from 21% to 7%.
Period 3 ovember eptember 1996 through tl1rough November 1996 Since we were often using midlines for the delivery of inappropriate infusates, we generated a list of "What
What NOT to put in a midline catheter
·
• Hyperosmolar Concentrations of any Therapy (In general, therapy over 600 mOsmol/L requires central tip location due to phlebitis risk) high chemical phlebitiS
TNA ITPN • TNAITPN
• Vesicant Chemotherapy
·
• Non-Chemotherapy drip in the home setting
· · ·
• Nafcillin • Dopamine Dilantin
• Vancomycin
Questions? Consult your pharmacist, pharmadst, midline or P1CC line resource person. Questionsl The following antibiotics will cause less phlebitis if they are administered in 2S0cc and given over I to 2 hours. The midline catheters can be used for these meds; however, due to their irritating nature, the midline catheter may not last to the end of therapy. Giving these meds this way will also decrease phlebitis with a short peripheral IV catheter: Erythromycin Ampho B Ticarcillin
Jun-97
Fa I I
I 9 9 8
.JVAD
19
PICC I MIDCLAVICULAR I MIDLINE QI DATA FORM
11 'atient Name: 'atient Name:
_
iome iome Phone: Phone:
_
Figure I
Assessment Allergies __ __ Poor venous access WBC HCT Pits PT
Age
o0 00 11 00
2 00 3 00
Sex
Medical Record Number
4
o Male o Female
OCHF
Therapy Type OPVD
OCF
o Sepsis
ODVT
OSBO
o ESRD o Hematuria o Infection o Multiple Fx's o Pancreatitis
o Surgery o Thrombocytopenia o Transplant o Other
Gauge
l) L-cath
016 gauge
l) Arrow
018 gauge
)BD lBD
020 gauge
l) V-cath
Lot #
(medication namels) namals)
o Antiinfectiv
OCHI
Anticipated length of therapy
lrand
PTT PIT INR ALB Diabetic
7 00 8 00 9 00
,., '~
o ArDS AIDS o Burns o Cancer o Cardiac Arrest o Cardiomyopathy o Cellulitis o Colitis
00
5 00 6 00
Diagnosis
I
o Chemo o Pain
o Blood Products
OTNA
o Heparin Gtt
o IV Fluids
o Steroids
o Other
__
Lumen
Vein
o Single o Double
o Basilic o Left o Cephalic o Right o Median Cubital Basilic o Median Cubital Cephalic
~ 0 0 CD
CD
0CD
l
0
0 CD
0CD
I
• di1
easy
Location
Ease of placement: Removal of guidewire:
0 CD
) Other lOther
'ip Placement l) Innominate
Number of CXR's
# attempts
# caths used
Total time for cath placemen
01
10 1 0
10 1 0
2 0
2 0
3 0
3 0
o 0 to 30 minutes o031 31 to 60 minutes
)SVC lSVC
02
l) Subclavian
ONA
l) SVC/RA Junction
If mUltiple CXR's, please _ comment
o 61 to 90 minutes
o > 90 minutes
l) NA (Midline only)
:atheter Length Advanced nsertion comments
11
cm I inches _
Draft
~I
11
I
Figure I Inserted by ID Number
o 00
Insertion date
1 00 2 00
[D/[D/[D DJ/DJ/DJ
3 00 00 5 00 6 00 7 00 8 00 9 00
If discharged, Home Care Agency: Discharge date: Phone:
4
Unit/clinic where placed
[D/[D DJ/DJ Reason for removal
o Infiltraton
o Leak
o Migration o Phlebitis
o Patient pUlled
o Change to different VAD
o Sepsis-Fever? Drainage? +Bld cx? o Therapy completed
o Occlusion
0
If Urokinase used, was it successful?
_ _ _
Total catheter days
o 000 1 000 2 000 3 000
Other: Please explain ..___,____,.-~--r--,.---r-----.,..___,____,.-..,....-----r----. '---'---"-~--'--"--"----''---'---''--r----r----,
4 000 5 000 5·000 6 000 7 000 8 000 9 000
OYes ONo
Removal date
[D DJ / DJ /DJ
Removedby Removed by
_
_
Catheter repaired? OYes If yes. yes, explain?
_
ONo
Comments
Draft
1If--------------------1i 1 I f - - - - - - - - - - - - - - - - - - - 1 i ~I ....VAC .JVAD Fa I I 21 a
I 9 9 8
Not To Put In Midlines" (Table O. I). We also looked closely at our outcomes for vancomycin and nafcillin infused via midline catheters and compared them to all infusions via these catheters. We found found that that nafeillin nafcillin had a combined phlebitis pWebitis and and infiltration rate of 70%, and that the rate for infusion of vancomycin was 26%. In contrast, the combined phlebitis phlebitis and infiltration rate of the 208 midline catheters overall (for all medications delivered) was only 17%, so we clearly clearly had had a problem. To monitor this fully, we developed a standardized progress note so nurses could document outcomes and complications efficiently and and cofl,'ijstently. con,sjstently.
Period 4 ovember 1996 through tl1fough February 1997 During this time period, we changed the type of transparent dressing we were using due due to reports of difficulty in removing that type of dressing. We also wrote a PICC line proposal, did a PICC catheter pilot evaluation program, and trained some of the midline catheter nurses to place PICC lines.
Period 5 March 1997 through tl1fough June 1997 March We expanded the PICC line program throughout the hospital during this program and it was so well accepted that it practically grew itself. As soon as nurses and physicians found out that a central line could be placed easily in the clinic bedsjde, we were in demand. or at the bedsjde, he number of radiologyInterestingly, "the placed PICC lines has gone up in the year following the beginning of the PICC line program. We seem to nurse PICC using more PICC lines in general and be using fewer Hickman central venous catheters and short-term non-tunneled central lines. We also changed the extension set lines. clamp from from a slide clamp to a push clamp to allow allow for easier manipulation during positive pressure flushing.
Period 6
~VAD .JVAD
Period 7 October 1997 through t!1fough JanualY January 1998 Most importantly, by this point in our program, we developed and put into practice the use of a scannable tracking form so that data could be entered directly into the database rather than be entered manually. The same form is used whether the line is PICC, midline or midclavicular catheter (Figure 1). Researchers of medical outcomes are often inhibited by cumbersome formsbased data collection. Many times while assessing outcomes, data collection can be inaccurate (data entIy errors) and costly (data entIy entry personnel). However, with the use of a scannable form or optical image-based in1age-based data collection tool, we were able to improve data integrity and eliminate the expense of data entry personnel. The first step in our use of optical image-based data collection was the development of an inexpensive form using PC-based software that is compatible with our in-house scanner. The software itself is used to design and print a scannable form that can be duplicated by standard copying. By obviating the need for professional design and offset printing, we form deSign were able to recognize great cost savings. Moreover, the image-based data
Fall
1998
collection system is senSItive to to all kinds of marks, so forms need not be completed with a #2 pencil or ballpoint pen. Thereby, 111ereby, increasing the chances of getting good reads. Another advantage of image-based scanning is that an actual image of each scanned documemoIY. So, ment is saved in computer memory. if there is any question as to whether the scanner has read the bubble or form image correctly, a picture of the form can be retrieved for verification. One more compelling feature of imagebased software is that it allows OCR or Optical Character Recognition (machine print), ICR or Intelligent Character Recognition (handprint), OMR Optical Mark Read (mark sense) data processing and bar code recognition. OCRlICR allow the software to interpret not only bubbles or "marks", but also hand-written print. This allows much greater flexibility in the utility of scannable forms. Once the form was developed, we we were able to fine-tune the properties of our database to enable complex queries on various outcomes. We have found that optical imagebased data collection has been extremely useful in our collection of data and in evaluating PICC, midline and midclavicular catheter outcomes. By using image-based data collection we were able to improve the integrity, improve the timelines of data entry and eliminate the expense of data entry entIy personnel.
Distribution of IV therapies delivered via midline, midclavicular and PICC catheters inserted between October I, 1997 and January 31, 1998. Type of Infusate
Midline Catheter
Anti-infective agent
57%
Blood Products
6%
Chemotherapy
6%
Heparin Gtt
June 1997 through September 1997 As a result of our monitoring propro~ gram, we we noted noted a 10% occlusion rate, so we proposed switching from 10 to 100 u/mL u/mL heparinized saline to heparinized saline mixture and a twice a day flush if if the line was not in use use..
22
We also started putting a label on the extension set so any staff member could identify whether the line was a PICC, midline, or midclavicular catheter.
0
IV F
15%
Pain management
6%
Steroids
0
TNA
0
Other
9%
Percentage Delivered via: Midclavicular Catheter 51% 6% 2% 4% 14% 10% 5% 0 9%
P1CC PICC Catheter 44% 10% 7% 2% 3% 11% 3% 14% 8%
Outcomes for midclavicular and PICC lines placed between January 1997 and January 1998 Total No. of PICCand Midclavicular Catheters Placed
Mean Indwelling Time (days)
Therapy Completed
Phlebitis
Infection
Occlusion
Leak
Migration
Other
1/97 to 9/97
150
16
58%
6%
7%*
10%
3%
7%
10%
10/97 to 1/98
319
19
70%
3%
7%**
5%
3%
1%
11%
Time Period
* Data represent all catheters removed for signs & symptoms of infection. ** Data represent 2% confirmed catheter-related infections and 5% suspected catheter-related local infections. Midline Outcome Summary From the stalt of the monitoring program through the end of 1997, midline catheter outcomes over time showed a decrease in phlebitis, infiltration and occlusion with an increase in the number of lines that made it to the end of therapy without complications (Figure 2). The length of time midline catheters remained indwelling ranged from 1 to 94 days overall, giving a mean indwelling time of approximately 10 days. The length of time midline catheters remained in place was shorter in the early stages of our program Cl to 47 days) than in more recent stages Cl to 94 days). This was a reflection of both our increasing experience with which medications are appropriate for delively via midline catheters, and the modifications of our catheter maintenance reginles. For example, in the first monitoring time period we had not established which IV solutions and medications were inappropriate for delivery via midline catheters, and so 21 % of the devices were removed due to the presentation of phlebitis. In contrast, by the end of 1997, the phlebitis rate for midline catheters was only 6% (Figure 2). Midline catheters primarily were used to deliver anti-infective agents, with other IV medications and solutions delivered less frequently (Table II).
PICC Line & Midclavicular Catheter Outcome Summary Initially the data for the longer line catheters-Plee and midclavicular catheters-were pooled together in our monitoring program. From Januaty through September 1997, 150 Plee and midclav-
icular catheters were inselted, while in just four montlls (October 1997 tllrough January 1998) more than double that number were placed (Table Ill). During this period, as a reflection of various changes in our policies and procedures, tlle mean indwelling time increased, while the rates of most catheter-related complications decreased (Table Ill). Most importantly, the proportion of these longer lines that remained indwelling until IV therapy had been completed increased from 58% to 70%. We are now placing more Plee lines and fewer midline catlleters. For example, from October 1997 through January 1998, of the 363 lines entered in the database, 178 were Plee lines, 141 were
midclavicular catlleters, and only 44 were midline catheters.
Data Summary from the most recent monitoring period analyzed October 1, 1997 thru January 31, 1998 The types of IV medications and solutions delivered via Plee, midclavicular and midline catheters during this time period were delineated based upon our past experiences. While anti-infective agents and IV fluids comprised the majority of the medications delivered, midline catheters were not used to infuse steroids or TNA (Table II). A similar medication distribution was used with midclavicular catheters, while the
Distribution of removal reasons for midline, midclavicular and PICC catheters inserted between Ocotber I, 1997 and January 31, 1998 Device Placed: Midline catheter
Midclavicular catheter
PICC
73%
69%
Removed by patient
60% 12%
6%
5%
Line change to a different VAD
8%
Occlusion
5% 2%
6% 6%
3% 3%
1%
2%
Removal reason
Therapy completed
Migration
line
2% 2%
2%
3%
NR
NR
Phlebitis
NR*
4%
Suspected catheter-related local infection
NR
1%
1% 10%
Catheter-related sepsis
NR
NR
Other
4%
1%
Leak Infiltration
3% 1%
* NR= Not reported
Fall
1998
.JVAC
23
blood cultures from one site, or the patient has no blood cultures done at all, we designated those as local or potential catheter-related infections. In addition, one of the infection control nurses in our hospital reviews all cases and helps us to determine the catheter-related sepsis rate various vascular access devices. with our valious For the time period 1 October 1997 through 31 January 1998, the 319 PICC and midclavicular lines indwelled a total of 6,170 catheter days. With a sepsis rate of only 2%, the sepsis rate can also be designated as 1 confirmed catheterrelated infection per 1,000 days indwelling. Overall, PICC lines are repolted to have a low infection rate; we plan to keep our sepsis rate below 3%. 30/0. In addition to looking at removal data, we also wanted to see if midline catheters that were in place less than 6 days and PICC lines in place for more than 9 days were more likely to be removed for end of therapy or because of complications. Cost effectiveness of these lines has been compared. 2.•3 We wanted to make celtain certain a midline or PICC catheter indwelling for a short time period was removed for end of therapy peIiod at least 50% of the time and not for reasons like complications or because the
more hyperosmotic and irritating medications were delivered primarily via PICC lines (Table 11). IT). By selecting the most appropriate device for the IV medication needed for the patient's therapy, we found that most lines remained indwelling until the end of therapy, and fewer lines were removed for catheter-related complications (Table IV). One of the more compromising catheter-related complications for patients requiring IV therapy is infection. infectiof4 The definition of PICC line infection varies in the literature, as does how a PICC line infection is r ported.3.4.3 ported. 3•4'; Initially we identified a PICC line-related infection based upon the symptomology present, but soon realized that such an assessment can be misleading. This led us to assess our methodology and terminology related to septic conditions. ow we are defining defming a PICC-related infection based on positive blood cultures from the line and a peripheral site and a patient with signs/symptoms of sepsis. If a patient has a positive tip culture and negative blood cultures, or a patient has a fever with negative blood cultures, or a patient has exit site drainage and negative blood cultures, or a patient has only one set of
patient had been discharged on oral medications. We wanted to ensure that these lines were placed for the appropriate patients and that we maintained a cost-effective program. During the time period 1 October JanualY 1998, PICC 1997 through 31 January lines were removed for end of therapy without complications at approximately the same rates, 69% and 67%, whether they were in place for over 9 days or not. The same was true for midclavicular catheters, 74% and 71% for over 9 days or not, respectively. These percentages reflect the total PICC and midclavicular lines that made it to the end of therapy, which was 70%. As reflected in other studies, 61% of the PICC lines remained indwelling for greater than 9 days, while and only 47% of midclavicular catheters stayed indwelling 9 days or more. An example of a "short dwell PICe" that made it to the end of therapy PIce was placed in a patient for sarcoma. The treatment was a continuous infusion of adriamycin for 96 hours for one cycle only. She had surgery one month later, and the line was pulled at the end of the vesicant infusion. The number of midline catheters removed for end of therapy without
Performance Outcomes
Figure 2 80 70 60 ~
c 50 0
:;::I QI
a:: Cl:
40
ii ~ 30
E QI a:: Cl:
20 10 0 6/94 thru 9/95
12/95 thru 8/96
9/96 thru 11/96
12/96 thru 2/97
3/97 thru 6/97
7/97 thru 9/97
10/97 thru 12/97
Monitoring Periods •
24
End ofTherapy
..JVAC '"'VAC
Fa I I
•
I 9 9 8
Phlebitis
•
Infiltration
D Occlusion
complications after indwelling for less than than 66 days was only 21%. The overall number of midlines that made it to the end end of therapy was 51%. If a midline catheter was in 66 days or longer then the number of catheters that made to that point was 88% (Figure 2). However, if aa midline midline catheter was indwelling for less than 66 days, typically the removal reasons were removal by the patient, line line change to a different VAD, phlebitis, occlusion, occlusion, migration, or leaking.
Trends and Benchmarking Besides using outcomes to look at your own performance over time, you can also compare your outcomes to national national standards or other PICC programs. For example, we recently were able to compare our data with an article published in Infusion magazine, I which presented presented PICC line and midclavicular catheter data collected from 1989 to 1995. The Oncological urses Society has published standards that include ranges for occlusion and phlebitis. 66 Dennis Maki, MD has published a comparison of sepsis rates for each of sevparison Iines. 7 Each eral types of central lines. program has to decide what outcomes will monitor and what acceptable they will outcomes are. All PICC programs do not function the same. Some of the many variables are type of PICC line, insertion techniques, care and maintenance protechniques,
cedures and use of infusion nurses or not. ew catheters and related support equipment (dressings, caps, flushes, securing mechanisms, etc) are available. How do we know if something new works if we don't know what the outcomes are? In this era of cost containment, how do we justify a more costly piece of equipment up front with the hope of saving money in the long run?
Staff-related variables urses have an initial PICC line training class and preceptorship at our hospital and then an annual review. They have to meet specific criteria in order to maintain the privilege of placing lines. Staff can then compare their outcomes with the total numbers. For example, one nurse placed 114 of the 363 lines during the time period analyzed (October 1997 through January 1998). Her mean dwell for PICC lines was 20 days. The number that made it to the end of therapy without complications was 680/0. 68%. Another nurse placed 21 of 363 longer lines and her mean dwell of PICC lines was 73 days. The number to end of therapy without complications was 7oo!&. 700A>.
Summary Using patient outcomes to drive our practice allows us to evaluate our PICC and midline program on a continuous basis. Some of our program goals are:
• Ongoing monitoring and reporting on the outcomes of all lines placed, with data summaries; • Change to latex-free insertion; • Increase continuity of care between and home; hospital and • Implement 100 u/mL heparinized saline flush protocol; • Evaluate new technology; tray; • Adopt a standardized site care tray; • Standardize diagnosis, definition, treatment of suspected PICC line infection; and • Continue to decrease complication rates and increase the number of lines that make it to the end of therapy without complications. Using a scannable form makes this less timeprocess more efficient and less person consuming. Requiring that the person who places the line track its outcome, ensures that accurate outcomes get collected on a timely basis. • lane Banton is the Clinical Coordinator for IV therapy at University Hospital and Clinics in Madison, WT. lane is a former IV nurse and is the PICC Program Program Coordinator for the hospital. Kristine Leahy-Gross is a Quality Improvement Analystfor Anaiystfor the same hospital. Kristine has has worked in quality improvement improvement for the past five years, with recent performance improvementprojects geared towards outcomes research.
REFERENCES 1. Poole, Poole, S.M., Vasilios, A.N. 1998. Out1.
2. 3.
4. 5.
6.
comes Measurements: Making sense of the data. Infusion 4(8): 25-28. Thomson, S. 1993. N therapy: A A feasibility study. Nursing Management 24(6): 68 A-G. Cardella, ].F., et al. at. 1996. Cumulative experience with 1,273 peripherally inserted central catheters at a single insti]VIR 7(1): 5-13. tution. jVIR Macklin, D. 1997. How to manage Macklin, Am] Nurs 97(9): 27-33. PICCs. Am] Merrell, S.W., et al. 1994. Peripherally inserted central venous catheters: Lowrisk alternatives for ongoing venous West] Med 160(1): 25-30. access. West] Camp-Sorrell, D. 1996. Access device guidelines: Recommendations for nursing practice and education. Oncology Nursing Press, pp. 60-63.
7. Maki, D.G. 1994. Infections caused by intravascular devices used for infusion therapy: Pathogenesis, prevention, and management. Infections Associated With Indwelling Medical Devices, 2nd Ed., pp. 155-212. 8. Kearns, P., et al. at. 1995. Complications of long arm catheters: A randomized trial of central vs. peripheral tip location. ]PEN 20(1): 20-24. 9. Miller, K., Kietrick, C. 1997. Experience with PICC at a university medical center. ] Intrav Nurs 20(3): 141-147. 10. Maki, D. 1994. Yes, Virginia, aseptic technique is very important: Maximal barrier precautions during insertion reduce the risk of central venous catheter-related bacteremia. 11. Goodwin, M.L., Carlson, I. 1993. The ll. peripherally inserted central catheter. A
12.
13.
retrospective look at three years of insertions.] Intrav Nurs Nurs 16(2): 92-103. Lam, S., et at. 1994. Peripherally inserted al. inserted central catheters in an acute care hospital. Arch Inter Med 154: 1833-1837. INS Position Papers. 1997. PICC, Midclavicular and Midlines. INS Standards of Practice.
14. Brown,]. 1995. An overview of vascular access for the alternate care setting. Infusion: 2: 17-26 15. Brown, ]. 1994. Peripherally inserted central catheters: An alternate route of vascular access. Infusion 1: 21-26. 16. Ryder, M. 1995. Peripheral access options. Surg Oncol Clinics Clinics ofNorth Am 4(3): 392-422. 17. Adams, A. A. 1995. Venous access devices: Case Studies for appropriate selection. InfUSiOn. 2: 11-14.
Fa I I
I 998
~VAD
2S
assessin catheter er ormance Four years of 01 tracking patient outcomes 01 midline, midclavicular and PICC line program rtides ltides on peripherally insel1ed insened central venous catheter (PICC lines) and midline catheters abound these days in the literature. We want to thank all of you who are writing them because as we share our "line" stories, programs, and outcomes, we will learn from each other. We agree with Poole and Vasilios who recently wrote that with "only 12 percent of medical practice decisions [being) based on research - the remaining 88 percent [being] based on custom or habit - the need for apparent"l accurate data becomes more apparent'" The following data are helping us make better decisions in our PICC and midline bener catheter program.
OUR PROGRAM
Period I May 1994 tlu'ough September 1995 Our hospital stalted a midline catheter program in 1994. While we do not have a specifically designated IV team, the nurses were trained to place the Unfortunately, during the first catheters. UnfOlwnately, time period only 25 percent of the midline catheters placed had outcome data. Since this tl1is was a more expensive catheter to place, with several "up front" expenses, and since we could not show what became of them, tl1em, the program was in jeopardy. A group of committed nurses pursued keeping the program and made outcome monitoring mandatOlY. The genesis of our program came tory. from this goal: the nurse who places the line tracks it to the end of therapy or its removal. This served several purposes. First of all it was a great learning
experience, especially for nurses new to the program. Secondly, the data were collected concurrently. Thirdly, the data were collected by several people and was not a huge burden for any one person.
Period 2 through August 1996 December 1995 tl1rough repol1s, one hyperDue to the FDA repons, sensitivity reaction and a high pWebitis rate, we changed to a different midline Luther Medical, Tusin, catheter (L-Cath, Lutl1er CA) in November 1995. A polyurethane midline catheter was chosen over a sili-
cone-based catheter for reasons of increased cannula strength, higher flow rates and available customer support. More nurses were trained and there was an increase in the number of midline catheters tracked to either end of therapy or removal for other reasons. The pWebitis rate dropped from 21% to 7%.
Period 3 ovember eptember 1996 through tl1rough November 1996 Since we were often using midlines for the delivery of inappropriate infusates, we generated a list of "What
What NOT to put in a midline catheter
·
• Hyperosmolar Concentrations of any Therapy (In general, therapy over 600 mOsmol/L requires central tip location due to phlebitis risk) high chemical phlebitiS
TNA ITPN • TNAITPN
• Vesicant Chemotherapy
·
• Non-Chemotherapy drip in the home setting
· · ·
• Nafcillin • Dopamine Dilantin
• Vancomycin
Questions? Consult your pharmacist, pharmadst, midline or P1CC line resource person. Questionsl The following antibiotics will cause less phlebitis if they are administered in 2S0cc and given over I to 2 hours. The midline catheters can be used for these meds; however, due to their irritating nature, the midline catheter may not last to the end of therapy. Giving these meds this way will also decrease phlebitis with a short peripheral IV catheter: Erythromycin Ampho B Ticarcillin
Jun-97
Fa I I
I 9 9 8
.JVAD
19
PICC I MIDCLAVICULAR I MIDLINE QI DATA FORM
11 'atient Name: 'atient Name:
_
iome iome Phone: Phone:
_
Figure I
Assessment Allergies __ __ Poor venous access WBC HCT Pits PT
Age
o0 00 11 00
2 00 3 00
Sex
Medical Record Number
4
o Male o Female
OCHF
Therapy Type OPVD
OCF
o Sepsis
ODVT
OSBO
o ESRD o Hematuria o Infection o Multiple Fx's o Pancreatitis
o Surgery o Thrombocytopenia o Transplant o Other
Gauge
l) L-cath
016 gauge
l) Arrow
018 gauge
)BD lBD
020 gauge
l) V-cath
Lot #
(medication namels) namals)
o Antiinfectiv
OCHI
Anticipated length of therapy
lrand
PTT PIT INR ALB Diabetic
7 00 8 00 9 00
,., '~
o ArDS AIDS o Burns o Cancer o Cardiac Arrest o Cardiomyopathy o Cellulitis o Colitis
00
5 00 6 00
Diagnosis
I
o Chemo o Pain
o Blood Products
OTNA
o Heparin Gtt
o IV Fluids
o Steroids
o Other
__
Lumen
Vein
o Single o Double
o Basilic o Left o Cephalic o Right o Median Cubital Basilic o Median Cubital Cephalic
~ 0 0 CD
CD
0CD
l
0
0 CD
0CD
I
• di1
easy
Location
Ease of placement: Removal of guidewire:
0 CD
) Other lOther
'ip Placement l) Innominate
Number of CXR's
# attempts
# caths used
Total time for cath placemen
01
10 1 0
10 1 0
2 0
2 0
3 0
3 0
o 0 to 30 minutes o031 31 to 60 minutes
)SVC lSVC
02
l) Subclavian
ONA
l) SVC/RA Junction
If mUltiple CXR's, please _ comment
o 61 to 90 minutes
o > 90 minutes
l) NA (Midline only)
:atheter Length Advanced nsertion comments
11
cm I inches _
Draft
~I
11
I
Figure I Inserted by ID Number
o 00
Insertion date
1 00 2 00
[D/[D/[D DJ/DJ/DJ
3 00 00 5 00 6 00 7 00 8 00 9 00
If discharged, Home Care Agency: Discharge date: Phone:
4
Unit/clinic where placed
[D/[D DJ/DJ Reason for removal
o Infiltraton
o Leak
o Migration o Phlebitis
o Patient pUlled
o Change to different VAD
o Sepsis-Fever? Drainage? +Bld cx? o Therapy completed
o Occlusion
0
If Urokinase used, was it successful?
_ _ _
Total catheter days
o 000 1 000 2 000 3 000
Other: Please explain ..___,____,.-~--r--,.---r-----.,..___,____,.-..,....-----r----. '---'---"-~--'--"--"----''---'---''--r----r----,
4 000 5 000 5·000 6 000 7 000 8 000 9 000
OYes ONo
Removal date
[D DJ / DJ /DJ
Removedby Removed by
_
_
Catheter repaired? OYes If yes. yes, explain?
_
ONo
Comments
Draft
1If--------------------1i 1 I f - - - - - - - - - - - - - - - - - - - 1 i ~I ....VAC .JVAD Fa I I 21 a
I 9 9 8
Not To Put In Midlines" (Table O. I). We also looked closely at our outcomes for vancomycin and nafcillin infused via midline catheters and compared them to all infusions via these catheters. We found found that that nafeillin nafcillin had a combined phlebitis pWebitis and and infiltration rate of 70%, and that the rate for infusion of vancomycin was 26%. In contrast, the combined phlebitis phlebitis and infiltration rate of the 208 midline catheters overall (for all medications delivered) was only 17%, so we clearly clearly had had a problem. To monitor this fully, we developed a standardized progress note so nurses could document outcomes and complications efficiently and and cofl,'ijstently. con,sjstently.
Period 4 ovember 1996 through tl1fough February 1997 During this time period, we changed the type of transparent dressing we were using due due to reports of difficulty in removing that type of dressing. We also wrote a PICC line proposal, did a PICC catheter pilot evaluation program, and trained some of the midline catheter nurses to place PICC lines.
Period 5 March 1997 through tl1fough June 1997 March We expanded the PICC line program throughout the hospital during this program and it was so well accepted that it practically grew itself. As soon as nurses and physicians found out that a central line could be placed easily in the clinic bedsjde, we were in demand. or at the bedsjde, he number of radiologyInterestingly, "the placed PICC lines has gone up in the year following the beginning of the PICC line program. We seem to nurse PICC using more PICC lines in general and be using fewer Hickman central venous catheters and short-term non-tunneled central lines. We also changed the extension set lines. clamp from from a slide clamp to a push clamp to allow allow for easier manipulation during positive pressure flushing.
Period 6
~VAD .JVAD
Period 7 October 1997 through t!1fough JanualY January 1998 Most importantly, by this point in our program, we developed and put into practice the use of a scannable tracking form so that data could be entered directly into the database rather than be entered manually. The same form is used whether the line is PICC, midline or midclavicular catheter (Figure 1). Researchers of medical outcomes are often inhibited by cumbersome formsbased data collection. Many times while assessing outcomes, data collection can be inaccurate (data entIy errors) and costly (data entIy entry personnel). However, with the use of a scannable form or optical image-based in1age-based data collection tool, we were able to improve data integrity and eliminate the expense of data entry personnel. The first step in our use of optical image-based data collection was the development of an inexpensive form using PC-based software that is compatible with our in-house scanner. The software itself is used to design and print a scannable form that can be duplicated by standard copying. By obviating the need for professional design and offset printing, we form deSign were able to recognize great cost savings. Moreover, the image-based data
Fall
1998
collection system is senSItive to to all kinds of marks, so forms need not be completed with a #2 pencil or ballpoint pen. Thereby, 111ereby, increasing the chances of getting good reads. Another advantage of image-based scanning is that an actual image of each scanned documemoIY. So, ment is saved in computer memory. if there is any question as to whether the scanner has read the bubble or form image correctly, a picture of the form can be retrieved for verification. One more compelling feature of imagebased software is that it allows OCR or Optical Character Recognition (machine print), ICR or Intelligent Character Recognition (handprint), OMR Optical Mark Read (mark sense) data processing and bar code recognition. OCRlICR allow the software to interpret not only bubbles or "marks", but also hand-written print. This allows much greater flexibility in the utility of scannable forms. Once the form was developed, we we were able to fine-tune the properties of our database to enable complex queries on various outcomes. We have found that optical imagebased data collection has been extremely useful in our collection of data and in evaluating PICC, midline and midclavicular catheter outcomes. By using image-based data collection we were able to improve the integrity, improve the timelines of data entry and eliminate the expense of data entry entIy personnel.
Distribution of IV therapies delivered via midline, midclavicular and PICC catheters inserted between October I, 1997 and January 31, 1998. Type of Infusate
Midline Catheter
Anti-infective agent
57%
Blood Products
6%
Chemotherapy
6%
Heparin Gtt
June 1997 through September 1997 As a result of our monitoring propro~ gram, we we noted noted a 10% occlusion rate, so we proposed switching from 10 to 100 u/mL u/mL heparinized saline to heparinized saline mixture and a twice a day flush if if the line was not in use use..
22
We also started putting a label on the extension set so any staff member could identify whether the line was a PICC, midline, or midclavicular catheter.
0
IV F
15%
Pain management
6%
Steroids
0
TNA
0
Other
9%
Percentage Delivered via: Midclavicular Catheter 51% 6% 2% 4% 14% 10% 5% 0 9%
P1CC PICC Catheter 44% 10% 7% 2% 3% 11% 3% 14% 8%
Outcomes for midclavicular and PICC lines placed between January 1997 and January 1998 Total No. of PICCand Midclavicular Catheters Placed
Mean Indwelling Time (days)
Therapy Completed
Phlebitis
Infection
Occlusion
Leak
Migration
Other
1/97 to 9/97
150
16
58%
6%
7%*
10%
3%
7%
10%
10/97 to 1/98
319
19
70%
3%
7%**
5%
3%
1%
11%
Time Period
* Data represent all catheters removed for signs & symptoms of infection. ** Data represent 2% confirmed catheter-related infections and 5% suspected catheter-related local infections. Midline Outcome Summary From the stalt of the monitoring program through the end of 1997, midline catheter outcomes over time showed a decrease in phlebitis, infiltration and occlusion with an increase in the number of lines that made it to the end of therapy without complications (Figure 2). The length of time midline catheters remained indwelling ranged from 1 to 94 days overall, giving a mean indwelling time of approximately 10 days. The length of time midline catheters remained in place was shorter in the early stages of our program Cl to 47 days) than in more recent stages Cl to 94 days). This was a reflection of both our increasing experience with which medications are appropriate for delively via midline catheters, and the modifications of our catheter maintenance reginles. For example, in the first monitoring time period we had not established which IV solutions and medications were inappropriate for delivery via midline catheters, and so 21 % of the devices were removed due to the presentation of phlebitis. In contrast, by the end of 1997, the phlebitis rate for midline catheters was only 6% (Figure 2). Midline catheters primarily were used to deliver anti-infective agents, with other IV medications and solutions delivered less frequently (Table II).
PICC Line & Midclavicular Catheter Outcome Summary Initially the data for the longer line catheters-Plee and midclavicular catheters-were pooled together in our monitoring program. From Januaty through September 1997, 150 Plee and midclav-
icular catheters were inselted, while in just four montlls (October 1997 tllrough January 1998) more than double that number were placed (Table Ill). During this period, as a reflection of various changes in our policies and procedures, tlle mean indwelling time increased, while the rates of most catheter-related complications decreased (Table Ill). Most importantly, the proportion of these longer lines that remained indwelling until IV therapy had been completed increased from 58% to 70%. We are now placing more Plee lines and fewer midline catlleters. For example, from October 1997 through January 1998, of the 363 lines entered in the database, 178 were Plee lines, 141 were
midclavicular catlleters, and only 44 were midline catheters.
Data Summary from the most recent monitoring period analyzed October 1, 1997 thru January 31, 1998 The types of IV medications and solutions delivered via Plee, midclavicular and midline catheters during this time period were delineated based upon our past experiences. While anti-infective agents and IV fluids comprised the majority of the medications delivered, midline catheters were not used to infuse steroids or TNA (Table II). A similar medication distribution was used with midclavicular catheters, while the
Distribution of removal reasons for midline, midclavicular and PICC catheters inserted between Ocotber I, 1997 and January 31, 1998 Device Placed: Midline catheter
Midclavicular catheter
PICC
73%
69%
Removed by patient
60% 12%
6%
5%
Line change to a different VAD
8%
Occlusion
5% 2%
6% 6%
3% 3%
1%
2%
Removal reason
Therapy completed
Migration
line
2% 2%
2%
3%
NR
NR
Phlebitis
NR*
4%
Suspected catheter-related local infection
NR
1%
1% 10%
Catheter-related sepsis
NR
NR
Other
4%
1%
Leak Infiltration
3% 1%
* NR= Not reported
Fall
1998
.JVAC
23
blood cultures from one site, or the patient has no blood cultures done at all, we designated those as local or potential catheter-related infections. In addition, one of the infection control nurses in our hospital reviews all cases and helps us to determine the catheter-related sepsis rate various vascular access devices. with our valious For the time period 1 October 1997 through 31 January 1998, the 319 PICC and midclavicular lines indwelled a total of 6,170 catheter days. With a sepsis rate of only 2%, the sepsis rate can also be designated as 1 confirmed catheterrelated infection per 1,000 days indwelling. Overall, PICC lines are repolted to have a low infection rate; we plan to keep our sepsis rate below 3%. 30/0. In addition to looking at removal data, we also wanted to see if midline catheters that were in place less than 6 days and PICC lines in place for more than 9 days were more likely to be removed for end of therapy or because of complications. Cost effectiveness of these lines has been compared. 2.•3 We wanted to make celtain certain a midline or PICC catheter indwelling for a short time period was removed for end of therapy peIiod at least 50% of the time and not for reasons like complications or because the
more hyperosmotic and irritating medications were delivered primarily via PICC lines (Table 11). IT). By selecting the most appropriate device for the IV medication needed for the patient's therapy, we found that most lines remained indwelling until the end of therapy, and fewer lines were removed for catheter-related complications (Table IV). One of the more compromising catheter-related complications for patients requiring IV therapy is infection. infectiof4 The definition of PICC line infection varies in the literature, as does how a PICC line infection is r ported.3.4.3 ported. 3•4'; Initially we identified a PICC line-related infection based upon the symptomology present, but soon realized that such an assessment can be misleading. This led us to assess our methodology and terminology related to septic conditions. ow we are defining defming a PICC-related infection based on positive blood cultures from the line and a peripheral site and a patient with signs/symptoms of sepsis. If a patient has a positive tip culture and negative blood cultures, or a patient has a fever with negative blood cultures, or a patient has exit site drainage and negative blood cultures, or a patient has only one set of
patient had been discharged on oral medications. We wanted to ensure that these lines were placed for the appropriate patients and that we maintained a cost-effective program. During the time period 1 October JanualY 1998, PICC 1997 through 31 January lines were removed for end of therapy without complications at approximately the same rates, 69% and 67%, whether they were in place for over 9 days or not. The same was true for midclavicular catheters, 74% and 71% for over 9 days or not, respectively. These percentages reflect the total PICC and midclavicular lines that made it to the end of therapy, which was 70%. As reflected in other studies, 61% of the PICC lines remained indwelling for greater than 9 days, while and only 47% of midclavicular catheters stayed indwelling 9 days or more. An example of a "short dwell PICe" that made it to the end of therapy PIce was placed in a patient for sarcoma. The treatment was a continuous infusion of adriamycin for 96 hours for one cycle only. She had surgery one month later, and the line was pulled at the end of the vesicant infusion. The number of midline catheters removed for end of therapy without
Performance Outcomes
Figure 2 80 70 60 ~
c 50 0
:;::I QI
a:: Cl:
40
ii ~ 30
E QI a:: Cl:
20 10 0 6/94 thru 9/95
12/95 thru 8/96
9/96 thru 11/96
12/96 thru 2/97
3/97 thru 6/97
7/97 thru 9/97
10/97 thru 12/97
Monitoring Periods •
24
End ofTherapy
..JVAC '"'VAC
Fa I I
•
I 9 9 8
Phlebitis
•
Infiltration
D Occlusion
complications after indwelling for less than than 66 days was only 21%. The overall number of midlines that made it to the end end of therapy was 51%. If a midline catheter was in 66 days or longer then the number of catheters that made to that point was 88% (Figure 2). However, if aa midline midline catheter was indwelling for less than 66 days, typically the removal reasons were removal by the patient, line line change to a different VAD, phlebitis, occlusion, occlusion, migration, or leaking.
Trends and Benchmarking Besides using outcomes to look at your own performance over time, you can also compare your outcomes to national national standards or other PICC programs. For example, we recently were able to compare our data with an article published in Infusion magazine, I which presented presented PICC line and midclavicular catheter data collected from 1989 to 1995. The Oncological urses Society has published standards that include ranges for occlusion and phlebitis. 66 Dennis Maki, MD has published a comparison of sepsis rates for each of sevparison Iines. 7 Each eral types of central lines. program has to decide what outcomes will monitor and what acceptable they will outcomes are. All PICC programs do not function the same. Some of the many variables are type of PICC line, insertion techniques, care and maintenance protechniques,
cedures and use of infusion nurses or not. ew catheters and related support equipment (dressings, caps, flushes, securing mechanisms, etc) are available. How do we know if something new works if we don't know what the outcomes are? In this era of cost containment, how do we justify a more costly piece of equipment up front with the hope of saving money in the long run?
Staff-related variables urses have an initial PICC line training class and preceptorship at our hospital and then an annual review. They have to meet specific criteria in order to maintain the privilege of placing lines. Staff can then compare their outcomes with the total numbers. For example, one nurse placed 114 of the 363 lines during the time period analyzed (October 1997 through January 1998). Her mean dwell for PICC lines was 20 days. The number that made it to the end of therapy without complications was 680/0. 68%. Another nurse placed 21 of 363 longer lines and her mean dwell of PICC lines was 73 days. The number to end of therapy without complications was 7oo!&. 700A>.
Summary Using patient outcomes to drive our practice allows us to evaluate our PICC and midline program on a continuous basis. Some of our program goals are:
• Ongoing monitoring and reporting on the outcomes of all lines placed, with data summaries; • Change to latex-free insertion; • Increase continuity of care between and home; hospital and • Implement 100 u/mL heparinized saline flush protocol; • Evaluate new technology; tray; • Adopt a standardized site care tray; • Standardize diagnosis, definition, treatment of suspected PICC line infection; and • Continue to decrease complication rates and increase the number of lines that make it to the end of therapy without complications. Using a scannable form makes this less timeprocess more efficient and less person consuming. Requiring that the person who places the line track its outcome, ensures that accurate outcomes get collected on a timely basis. • lane Banton is the Clinical Coordinator for IV therapy at University Hospital and Clinics in Madison, WT. lane is a former IV nurse and is the PICC Program Program Coordinator for the hospital. Kristine Leahy-Gross is a Quality Improvement Analystfor Anaiystfor the same hospital. Kristine has has worked in quality improvement improvement for the past five years, with recent performance improvementprojects geared towards outcomes research.
REFERENCES 1. Poole, Poole, S.M., Vasilios, A.N. 1998. Out1.
2. 3.
4. 5.
6.
comes Measurements: Making sense of the data. Infusion 4(8): 25-28. Thomson, S. 1993. N therapy: A A feasibility study. Nursing Management 24(6): 68 A-G. Cardella, ].F., et al. at. 1996. Cumulative experience with 1,273 peripherally inserted central catheters at a single insti]VIR 7(1): 5-13. tution. jVIR Macklin, D. 1997. How to manage Macklin, Am] Nurs 97(9): 27-33. PICCs. Am] Merrell, S.W., et al. 1994. Peripherally inserted central venous catheters: Lowrisk alternatives for ongoing venous West] Med 160(1): 25-30. access. West] Camp-Sorrell, D. 1996. Access device guidelines: Recommendations for nursing practice and education. Oncology Nursing Press, pp. 60-63.
7. Maki, D.G. 1994. Infections caused by intravascular devices used for infusion therapy: Pathogenesis, prevention, and management. Infections Associated With Indwelling Medical Devices, 2nd Ed., pp. 155-212. 8. Kearns, P., et al. at. 1995. Complications of long arm catheters: A randomized trial of central vs. peripheral tip location. ]PEN 20(1): 20-24. 9. Miller, K., Kietrick, C. 1997. Experience with PICC at a university medical center. ] Intrav Nurs 20(3): 141-147. 10. Maki, D. 1994. Yes, Virginia, aseptic technique is very important: Maximal barrier precautions during insertion reduce the risk of central venous catheter-related bacteremia. 11. Goodwin, M.L., Carlson, I. 1993. The ll. peripherally inserted central catheter. A
12.
13.
retrospective look at three years of insertions.] Intrav Nurs Nurs 16(2): 92-103. Lam, S., et at. 1994. Peripherally inserted al. inserted central catheters in an acute care hospital. Arch Inter Med 154: 1833-1837. INS Position Papers. 1997. PICC, Midclavicular and Midlines. INS Standards of Practice.
14. Brown,]. 1995. An overview of vascular access for the alternate care setting. Infusion: 2: 17-26 15. Brown, ]. 1994. Peripherally inserted central catheters: An alternate route of vascular access. Infusion 1: 21-26. 16. Ryder, M. 1995. Peripheral access options. Surg Oncol Clinics Clinics ofNorth Am 4(3): 392-422. 17. Adams, A. A. 1995. Venous access devices: Case Studies for appropriate selection. InfUSiOn. 2: 11-14.
Fa I I
I 998
~VAD
2S