- Email: [email protected]
The Direct and Indirect Costs of Ultrasound-Guided Peripherally Inserted Central Catheter Repositioning at a Large Academic Medical Center
O R I G I N A L
A R T I C L E
The Direct and Indirect Costs of Ultrasound-Guided Peripherally Inserted Central Catheter Repositioning at a Large Academic Medical Center Eric J. Keller, MA Edouard Semaan, MD Jung Lee, PA-C Emily Aragona, PA-C Heather Molina, PA-C Riad Salem, MD, MBA Scott A. Resnick, MD Howard Chrisman, MD, MBA Jeremy D. Collins, MD Division of Interventional Radiology, Northwestern University, Chicago, IL
Abstract Background: To assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters. Methods: This retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N ¼ 400, aged 58 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a c2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews. Results: Initial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (c2 ¼ 9.603, P ¼ .002; f ¼ 0.155, P ¼ .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours. Conclusions: PICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients’ perceptions of quality health care. Keywords: PICC placement, malpositioning, quality improvement
Correspondence concerning this article should be addressed to [email protected] http://dx.doi.org/10.1016/j.java.2016.05.002 Copyright © 2016 ASSOCIATION FOR VASCULAR ACCESS. Published by Elsevier Inc. All rights reserved.
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Introduction ince the Institute of Medicine’s landmark 2001 publication Crossing the Quality Chasm,1 there have been growing efforts to maximize health care quality while reducing costs. Nevertheless, there continues to be ample opportunity throughout American health care to address
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variations in practices and spending to provide care that is truly efficient, effective, safe, patient-centered, timely, and equitable.2,3 One potential area for quality improvement identified at our center was malpositioning of peripherally inserted central catheter (PICC) lines, requiring subsequent imaging and repositioning and delaying patient care. Central venous access is a key aspect of care for many patients, and PICCs are a popular choice for such access due to their patient tolerability, cost savings, capability with therapies, and lower insertion risks than central venous catheters.4-6 Despite their popularity, there is significant variation in the use of PICCs and controversy regarding data comparing complication rates associated with various means of central venous access.4,7,8 Common PICC-associated complications include extremity deep vein thrombosis, infection, phlebitis, catheter fracture, and catheter tip malpositioning.9-11 There is also controversy regarding optimal catheter tip positioning. In general, PICCs are placed via the basilic, brachial, or cephalic veins with a goal of threading the catheter tip to or near the cavoatrial junction (CAJ) where blood flow is turbulent and ideal for infusion delivery.12-14 Risks of malpositioning include cardiac tamponade, thrombosis, and arrhythmias13,15; so our standard protocol has been to confirm acceptable catheter tip positioning with a chest radiograph (CXR) and reposition as necessary. Routine use of angiography rooms for PICC insertion, although efficient, is not cost-effective. Newer electrocardiography (ECG)-guided catheter systems have been developed in an attempt to reduce the need for confirmatory CXRs and repositioning with multiple studies reporting superior placement accuracy with these systems.16-19 Although these results are promising, there are little data on the costs of PICC malpositioning to evaluate whether these newer systems are cost-effective. Thus, we retrospectively analyzed 400 consecutive PICC placements at our institution assessing primary technical success as well as the direct and indirect costs associated with catheter repositioning. Methods Before this analysis, a Northwestern University Institutional Review Board approved our methods. Informed consent was waived due to the retrospective nature of our analysis. Cohort Selection Electronic medical records were used to identify 250 consecutive inpatient PICC placements from May 2012 to August 2012 and 150 consecutive outpatient PICC placements from October 2010 to August 2012 (400 patients in total). All PICCs were placed using ultrasound (US)-guidance coupled with external measurement techniques and postinsertion CXRs to confirm catheter tip location. Inpatient placements were performed by 1 of 2 PICC nurse (PN) teams, whereas outpatient placement were performed by a physician assistant. Assessment of PICC Tip Location Postinsertion CXRs were obtained from our institution’s picture archiving and communication system and re-reviewed
Figure. Postinsertion chest radiograph for a 75year-old man, showing the peripherally inserted central catheter tip (red asterisk) position at the cavoatrial junction. SVC ¼ superior vena cava. by a radiologist. On the CXRs, patients’ superior vena cavas (SVCs) were divided into 3 approximately 2.2-cm sections: high SVC, mid SVC, and low SVC, using the carina as a landmark that is 1.3 cm below the midpoint of the SVC20 (see the Figure). Subsequent repositioning procedures were identified by reviewing patients’ electronic medical records. Assessment of Direct and Indirect Repositioning Costs Additional costs of repositioning were calculated based on 2012 Medicare reimbursement rates: CXR ¼ $46, fluoroscopy room use without catheter replacement ¼ $117, and fluoroscopy room use with catheter replacement ¼ $805. A survey was emailed to all 5 PNs at our institution with a response rate of 60% (3 out of 5) to assess inpatient labor costs and delays in patient care. See Table 1 for survey questions. Statistical Analysis All statistical analyses were performed in SPSS (IBM-SPSS Inc, Armonk, NY). Percentages were calculated for initial and final catheter tip locations as well as repositioning rates. The average direct cost of initial PICC placement was subtracted from the average total cost for patients requiring repositioning to estimate the direct reposition cost. A multivariate analysis was performed to determine whether patients’ demographic characteristics (eg, age and gender) or PICC placement characteristics (eg, date of placement) were associated with the need for repositioning. Repositioning rates between outpatients/ physician assistants and inpatients/PNs were compared using a c2 test and phi coefficient for correlation strength. A P value .05 was considered statistically significant.
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Table 1. Nurse Survey Questions Related to Peripherally Inserted Central Catheter (PICC) Use 1. Approximately how many ultrasound-guided PICC insertion procedures do you perform per day? 2. Approximately how much time (in minutes) do you spend on average to determine if a PICC placed by you or a colleague is in a suitable location for use and communicating this information to the care team? 3. Assume a PICC is malpositioned in the internal jugular vein. How much time (in minutes) do you spend arranging nonfluoroscopic approaches for repositioning, confirming the catheter’s final position as acceptable, and informing the referring service that the PICC is ready for use? 4. Assume a PICC is malpositioned in the axillary vein, and you suspect a venous stenosis or occlusion. How much time (in minutes) to you spend arranging fluoroscopy (ie, interventional radiology) for catheter repositioning or replacement? 5. Approximately how many PICCs are not usable by the clinical service until the day after placement? (Please express as a percentage) 6. If it was possible to determine PICC tip location easily and simply during the procedure, would the time saved following-up PICC locations enable you to potentially perform more procedures per day? (For argument’s sake assume that any such system does not add time to the procedure.) If not, please provide a brief explanation.
Results The 400 patients included in this investigation had an average age of 58 17 years with 225 men and 175 women. PICC placement was achievable in 397 out of 400 patients (99.2%). Upper extremity venous access could not be achieved in 3 patients (2 outpatients and 1 inpatient) due to repeated vasospasm. Optimal tip location at the CAJ or high right atrium without the need for repositioning was achieved on initial placement in 133 out of 397 (33.5%). Nonoptimal but acceptable tip location in the SVC was achieved in 200 out of 397 (50.4%) for a total initial placement success rate of 83.2% (333 out of 400). Repositioning was required in 64 out of 397 patients (16.1%), requiring a total of 77 repositioning procedures. There was no significant relationship between the need for repositioning and patient age, patient gender, or procedure date. However, malpositioned PICCs were more commonly observed in inpatients (51 out of 249; 20.5%) than outpatients (13 out of 148; 8.8%), yielding a statistically significant difference with a low to moderate association between inpatient PICC placement and the need for repositioning (c2 ¼ 9.603, P ¼ .002; f ¼ 0.155, P ¼ .002). Repositioned tip locations outside the SVC or right atrium were most often positioned in the ipsilateral internal jugular vein 11 out of 64 patients (17.2%), subclavian vein in 8 out of 64 patients (12.5%), or brachiocephalic vein in 7 out of 64 patients (10.9%). Repositioning rates based on initial catheter tip location included 100% of those in the axillary veins (3 patients), subclavian veins (9 patients), internal jugular veins (12 patients), brachiocephalic veins (13 patients), azygous arch (6 patients), and lower right atrium (7 patients) as well as 3 out of 29 (10.3%) in the high SVC and 11 out of 41 (26.8%) in the high right atrium. Final catheter tip location in the SVC, high right atrium, or at the CAJ was achieved in 59 out of 64 (92.2%) patients following repositioning. For the other 5 patients (4 out of 5 were inpatients), the catheter tip was left
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in the ipsilateral axillary vein (n ¼ 1), subclavian vein (n ¼ 1), brachiocephalic vein (n ¼ 2), or azygous arch (n ¼ 1) often due to more proximal vessel occlusion (Table 2). Repositioning in 16 out of 64 patients (25.0%) required performance by an interventional radiologist under fluoroscopy. All other repositioning attempts were performed by the original operator. The average additional direct cost of PICC repositioning was $186.03 per catheter ($223.82 per patient) for a total additional cost of $14,324.48 from 61 additional CXRs and 16 additional fluoroscopy-guided procedures. Staff spent an average of 15 minutes determining PICC positioning and 36 additional minutes arranging repositioning procedures, if needed, for a total average additional staff time of 50 minutes per catheter. Due to delays caused by waiting for CXRs and repositioning procedures to be performed, 23 out of 397 PICCs (5.8%) could not be used on the day of initial insertion. No complications other than malpositioning or inability to achieve upper extremity venous access occurred in any of the 400 patients reviewed. Discussion PICCs are widely used to achieve central venous access and have historically been placed using ultrasound guidance for venous access, with blind advancement of an externally measured catheter length necessary to reach the target tip location, assessing the final location with a CXR. This approach can require repositioning in a large number of patients with rates reported as high as 50.8% in a study of ICU patients,21 exposing patients to additional radiation, discomfort, and delays in care. We sought to understand this potential source of inefficiency at our center, finding that catheter tip repositioning was required in 16% of 400 consecutive patients who underwent US-guided PICC placement with external measurement techniques. Repositioning efforts cost an additional $14,324.48 in total with significant indirect costs in additional staff time and delays in care.
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Table 2. Catheter Tip Position and Repositioning, by Patient Cohort Initial tip location
Outpatients n %
Inpatients n
Total n
%
%
Axillary vein ipsilateral
2
1.33
1
0.40
3
0.75
Subclavian vein ipsilateral
2
1.33
6
2.40
8
2.00
Subclavian vein contralateral
1
0.67
0
0.00
1
0.25
BCV ipsilateral
2
1.33
5
2.00
7
1.75
BCV contralateral
0
0.00
6
2.40
6
1.50
Azygous arch
0
0.00
6
2.40
6
1.50
SVC: High
10
6.67
19
7.60
29
7.25
SVC: Mid
33
22.00
56
22.40
89
22.25
SVC: Low
38
25.33
47
18.80
85
21.25
CAJ
39
26.00
64
25.60
103
25.75
High RA
19
12.67
22
8.80
41
10.25
Low RA
1
0.67
6
2.40
7
1.75
Internal jugular ipsilateral
1
0.67
10
4.00
11
2.75
Internal jugular contralateral
0
0.00
1
0.40
1
0.25
No vein access
2
1.33
1
0.40
3
0.75
150
100.00
250
100.00
400
100.00
No
135
91.22
198
79.52
333
83.88
Yes
13
8.78
51
20.48
64
16.12
Axillary vein ipsilateral
0
0.00
1
1.96
1
1.56
Subclavian vein ipsilateral
1
7.69
0
0.00
1
1.56
BCV ipsilateral
0
0.00
2
3.92
2
3.13
Azygous arch
0
0.00
1
1.96
1
1.56
SVC: High
0
0.00
3
5.88
3
4.69
SVC: Mid
1
7.69
13
25.49
14
21.88
SVC: Low
1
7.69
12
23.53
13
20.31
CAJ
9
69.23
18
35.29
27
42.19
High RA
1
7.69
1
1.96%
2
3.13
13
100.00
51
100.00%
64
100.00
Total Repositioning
Final repositioned tip location
Total
BCV ¼ Brachiocephalic vein; CAJ ¼ Cavoatrial junction; RA ¼ Right atrium; SVC ¼ Superior vena cava.
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Our initial technical success rate (34%) and malposition rate (16%) were similar to other studies. Reported bedside PICC team malposition rates tend to range from 0%-30% with an average optimal tip position rate of 45.87% on first attempt.22,23 However, success rates can vary considerably. A well-cited study by Trerotola et al24 found 70% of 2,367 PICC placements to be initially successful with a 10% malposition rate. Part of this variance likely comes from differences in study cohorts. Our inpatients were significantly more likely to require PICC repositioning than outpatients (20% vs 9%). This is reasonable given that inpatients are more likely to have conditions that complicate the navigation of the catheter tip from a superficial peripheral vein to the SVC before final positioning. Sicker patients may have electrolyte or hemodynamic abnormalities making them more prone to peripheral vasospasm or thrombosis, impeding catheter progression. Furthermore, inpatients often have fewer peripheral veins that are suitable for US-guided access. Challenges of positioning the catheter tip at/near the CAJ are less relevant to external measurement techniques where the operator is relatively blind to final tip placement than an array of techniques and devices that have been developed to reduce PICC malpositioning. Fluoroscopically guided PICC insertion is efficient and accurate but not cost-effective. Using ultrasound at the time of insertion helps the operator identify malpositioning near the venous access and adjust the PICC during the initial placement,25 but this approach does not allow the operator to identify the catheter positioning within the chest without a confirmatory CXR. A popular solution to this challenge has been newer intravascular ECG-guided catheter systems. The CAJ lies close to the sinoatrial node, causing ECG recordings from the catheter tip to achieve a maximum P-wave amplitude when the tip is positioned at the CAJ and become biphasic if advanced into the right atrium. Two large studies26,27 and a smaller investigation16 found ECG-guided catheters to be > 90% sensitive and specific for indicating catheter tip location with almost no need for repositioning. Three other studies comparing ECG-guided systems to conventional external measurement with anatomic landmarks found ECG-guided placement to be significantly more accurate.18,19 Certain arrhythmias (eg, atrial fibrillation) can limit the ability of ECG-guided catheters to identify the final tip position, as can variations in the proximity of patients’ CAJs and sinoatrial nodes.28 Nevertheless, implementing PICC insertion devices combining US and intravascular ECG guidance has been shown to significantly reduce malposition rates, the need for confirmatory CXRs (by 84%), and costs ($17,317.30 over a 1-year study period).29,30 See Table 3 for a list of such devices currently on the market. Unfortunately, minimal methodologic information is available for the study reporting such dramatic cost savings, and a recent extensive report by the UK National Institute for Health and Care Excellence found a US- or ECG-guided system to be cost-neutral due to no or low quality evidence for many important outcomes.31 However, the UK National Institute for Health and Care Excellence report also noted that ECG-guided systems would yield cost savings if factors such as reduced nursing time,
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Table 3. Ultrasound and ElectrocardiogramGuided (ECG) Peripherally Inserted Central Catheter Placement Devices on the Market Name
Description
Sherlock 3CG Tip Confirmation Systema
Ultrasound guidance, magnetic tip tracking, plus intravascular ECG
Celerity Tip Confirmation Systemb
External and intravascular ECG alone
Arrow VPS G4c
Intravascular ECG plus intravascular Doppler
a
Bard Access Systems, Inc. Salt Lake City, UT. Angiodynamics, Latham, NY. c Teleflex Inc, Research Triangle Park, NC. b
CXR use, and repositioning efforts were sufficiently illustrated. Our results suggest that there is significant potential to reduce these indirect costs as well as the direct costs of repositioning at our center. Furthermore, it is important to address patients’ perceptions of the quality of their care. Delays in treatment and failed positioning attempts undermine patients’ trust in their providers and decrease the likelihood that they will highly value their care experience. Thus, future work is needed to compare various approaches to PICC placement in terms of the costs we assessed as well as patients’ perceptions of their care. Another strategy for maximizing the cost-effectiveness of advanced PICC guidance systems would be to prospectively identify high-risk patients for malpositioning and use more expensive PICC placement systems judiciously. We have since begun testing the implementation of an US- and ECG-guided catheter placement system in our division of interventional radiology, but such a system may be unnecessary for less complicated PICC placements. For example, we found an outpatient reposition rate of 8.8% compared with 20.5% for inpatients. Even with near-perfect performance of the new system, it may be most cost-effective to use electronic medical records to document which patients may be at risk for more complicated PICC insertions, such as those with vascular anomalies, hypercoagulable states, history of previous catheter use, or history of previous PICC malpositioning. When a PICC placement is ordered in such a patient, the electronic medical record could suggest the use of the more expensive PICC placement system to reduce the risk of catheter malposition and subsequent delays in care. We intend to implement such an approach at our institution pending the performance of the new placement system. We believe this method will help ensure high-risk patients receive therapies safely and efficiently, supporting their perceptions of quality health care. Our study had important limitations. This analysis was performed at a single center, limiting the external validity of our results. Although this was performed as a retrospective
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study, we assessed consecutive procedures to reduce the risk of selection bias. Our use of surveys also exposes this study to recall bias but the surveys were anonymous, the PICC nurses regularly perform these procedures, and respondents would have little reason to intentionally misrepresent their experiences. Finally, we did not assess the influence of repositioning on patients’ perceptions of their care, which would have strengthened the significance of our results. In an effort to assess inefficiencies associated with PICC placement at our institution, we analyzed 400 consecutive patients, finding optimal catheter placement was achieved in 34% of patients and optimal or acceptable placement in a total of 84%. Repositioning for the 77 unacceptably positioned PICCs cost an additional $186.03 and 50 minutes of staff time per catheter. Assuming an average hourly wage of $38 per hour for these staff members at our institution, repositioning cost $217.70 per catheter in addition to exposing patients to 61 additional CXRs and 16 additional fluoroscopically guided procedures, and delaying catheter use 24 hours for 23 patients. Institutions should analyze their vascular access service PICC placement procedures to ascertain the efficiency of care delivery and downstream costs associated with delays in catheter use.
8.
9.
10.
11.
12.
13. 14.
Disclosures The authors have no conflicts of interest to disclose. References 1. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 2. Blumenthal D, Stremikis K, Cutler D. Health care spendingda giant slain or sleeping? N Engl J Med. 2013;369:2551-2557. 3. Wennberg JE, Fisher ES. Dartmouth Institute for Health Policy and Clinical Practice. Tracking the Care of Patients with Severe Chronic Illness. Lebanon, NH: Dartmouth Institute for Health Policy and Cllincal Practice, Center for Health Policy Research; 2008. 4. Woller SC, Stevens SM, Evans RS. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) initiative: a summary and review of peripherally inserted central catheter and venous catheter appropriate use. J Hosp Med. 2016;11:306-310. 5. Burns T, Lamberth B. Facility wide benefits of radiology vascular access teams. Radiol Mgmt. 2010;32:28-32. quiz 33-24. 6. Johansson E, Hammarskjold F, Lundberg D, Arnlind MH. Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: a systematic review of the literature. Acta Oncol. 2013;52:886-892. 7. Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a multispecialty panel using the
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RAND/UCLA appropriateness method. Ann Intern Med. 2015;163:S1-S40. Chopra V, Flanders SA, Saint S. The problem with peripherally inserted central catheters. JAMA. 2012;308: 1527-1528. Loughran SC, Borzatta M. Peripherally inserted central catheters: a report of 2506 catheter days. JPEN J Parenter Enteral Nutr. 1995;19:133-136. Morano SG, Latagliata R, Girmenia C, et al. Catheterassociated bloodstream infections and thrombotic risk in hematologic patients with peripherally inserted central catheters (PICC). Support Care Cancer. 2015;23: 3289-3295. Sriskandarajah P, Webb K, Chisholm D, et al. Retrospective cohort analysis comparing the incidence of deep vein thromboses between peripherally-inserted and long-term skin tunneled venous catheters in hemato-oncology patients. Thromb J. 2015;13:21. Cheung E, Baerlocher MO, Asch M, Myers A. Venous access: a practical review for 2009. Can Fam Physician. 2009;55:494-496. Ganeshan A, Warakaulle DR, Uberoi R. Central venous access. Cardiovasc Intervent Radiol. 2007;30:26-33. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. Espen. ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009;28:365-377. Tan PL, Gibson M. Central venous catheters: the role of radiology. Clin Radiol. 2006;61:13-22. Brimacombe SD, McMonagle L, Wechalekar A, McNamara CJ. Does electrocardiogram offer an alternative to radiological imaging in the confirmation of tip positioning for the insertion of peripherally inserted central catheters; a comparison of 120 patients. Blood. 2014;124: 1314. Pittiruti M, La Greca A, Scoppettuolo G. The electrocardiographic method for positioning the tip of central venous catheters. J Vasc Access. 2011;12:280-291. Liu YJ, Dong L, Lou XP, et al. Evaluating ECG-aided tip localization of peripherally inserted central catheter in patients with cancer. Int J Clin Exper Med. 2015;8: 14127-14129. Baldinelli F, Capozzoli G, Pedrazzoli R, Marzano N. Evaluation of the correct position of peripherally inserted central catheters: anatomical landmark vs. electrocardiographic technique. J Vasc Access. 2015;16:394-398. Caruso LJ, Gravenstein N, Layon AJ, Peters K, Gabrielli A. A better landmark for positioning a central venous catheter. J Clin Monitor Comput. 2002;17:331-334. Johnston AJ, Bishop SM, Martin L, See TC, Streater CT. Defining peripherally inserted central catheter tip position and an evaluation of insertions in one unit. Anaesthesia. 2013;68:484-491. Hostetter R, Nakasawa N, Tompkins K, Hill B. Precision in central venous catheter tip placement: a review of the literature. J Assoc Vasc Access. 2010;15:112-125.
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23. Song L, Li X, Guo Y, et al. Malposition of peripherally inserted central catheter: experience from 3012 cancer patients. Int J Nurs Pract. 2014;20:446-449. 24. Trerotola SO, Thompson S, Chittams J, Vierregger KS. Analysis of tip malposition and correction in peripherally inserted central catheters placed at bedside by a dedicated nursing team. J Vasc Intervent Radiol. 2007;18:513-518. 25. Schweickert WD, Herlitz J, Pohlman AS, Gehlbach BK, Hall JB, Kress JP. A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures. Crit Care Med. 2009;37: 1217-1221. 26. Wang G, Guo L, Jiang B, Huang M, Zhang J, Qin Y. Factors influencing intracavitary electrocardiographic P-wave changes during central venous catheter placement. PloS ONE. 2015;10:e0124846. 27. Pittiruti M, Bertollo D, Briglia E, et al. The intracavitary ECG method for positioning the tip of central venous
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catheters: results of an Italian multicenter study. J Vasc Access. 2012;13:357-365. Schummer W, Schummer C, Schelenz C, et al. Central venous cathetersdthe inability of intra-atrial ECG’ to prove adequate positioning. Br J Anaesth. 2004;93: 193-198. Butts R. CNS led implementation of ECG guided PICC placement technology decreases patient radiation exposure, nursing time and cost. J Assoc Vasc Access. 2015;20:255. Johnston AJ, Holder A, Bishop SM, See TC, Streater CT. Evaluation of the Sherlock 3CG Tip Confirmation System on peripherally inserted central catheter malposition rates. Anaesthesia. 2014;69:1322-1330. Dale M, Higgins A, Carolan-Rees G. Sherlock 3CG Tip Confirmation System for placement of peripherally inserted central catheters: a NICE medical technology guidance. Appl Health Econ Health Policy. 2016;14: 41-49.
A R T I C L E
The Direct and Indirect Costs of Ultrasound-Guided Peripherally Inserted Central Catheter Repositioning at a Large Academic Medical Center Eric J. Keller, MA Edouard Semaan, MD Jung Lee, PA-C Emily Aragona, PA-C Heather Molina, PA-C Riad Salem, MD, MBA Scott A. Resnick, MD Howard Chrisman, MD, MBA Jeremy D. Collins, MD Division of Interventional Radiology, Northwestern University, Chicago, IL
Abstract Background: To assess the technical success of ultrasound (US)-guided peripherally inserted central catheter (PICC) placement at a large academic medical center and evaluate the direct and indirect costs associated with malpositioned catheters. Methods: This retrospective chart review consisted of 250 consecutive inpatients and 150 consecutive outpatients (N ¼ 400, aged 58 17 years, 225 men and 175women) who underwent US-guided PICC placement at a single center. Repositioning rates were compared between high-complexity (inpatient) and low-complexity (outpatient) groups using a c2 test and phi coefficient. Initial and final catheter tip position was assessed by radiography. Direct costs of repositioning were estimated using Medicare reimbursement rates. Indirect costs, including additional staff time, imaging, and delays in treatment, were assessed via a survey of PICC nurses and chart reviews. Results: Initial PICC placement resulted in an optimal tip position in 34% of patients and an optimal or acceptable position in 84% of patients. Repositioning rates were significantly higher for inpatients with a low to moderate association between inpatient PICC placement and the need for repositioning (c2 ¼ 9.603, P ¼ .002; f ¼ 0.155, P ¼ .002). In total, 77 catheters required repositioning, costing on average an additional $186.03 and 50 minutes of staff time per catheter as well as delaying catheter use in 23 patients for at least 24 hours. Conclusions: PICC malpositioning is a significant source of inefficiency, especially for inpatient services, that should be addressed to reduce expenditures and maximize patients’ perceptions of quality health care. Keywords: PICC placement, malpositioning, quality improvement
Correspondence concerning this article should be addressed to [email protected] http://dx.doi.org/10.1016/j.java.2016.05.002 Copyright © 2016 ASSOCIATION FOR VASCULAR ACCESS. Published by Elsevier Inc. All rights reserved.
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Introduction ince the Institute of Medicine’s landmark 2001 publication Crossing the Quality Chasm,1 there have been growing efforts to maximize health care quality while reducing costs. Nevertheless, there continues to be ample opportunity throughout American health care to address
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variations in practices and spending to provide care that is truly efficient, effective, safe, patient-centered, timely, and equitable.2,3 One potential area for quality improvement identified at our center was malpositioning of peripherally inserted central catheter (PICC) lines, requiring subsequent imaging and repositioning and delaying patient care. Central venous access is a key aspect of care for many patients, and PICCs are a popular choice for such access due to their patient tolerability, cost savings, capability with therapies, and lower insertion risks than central venous catheters.4-6 Despite their popularity, there is significant variation in the use of PICCs and controversy regarding data comparing complication rates associated with various means of central venous access.4,7,8 Common PICC-associated complications include extremity deep vein thrombosis, infection, phlebitis, catheter fracture, and catheter tip malpositioning.9-11 There is also controversy regarding optimal catheter tip positioning. In general, PICCs are placed via the basilic, brachial, or cephalic veins with a goal of threading the catheter tip to or near the cavoatrial junction (CAJ) where blood flow is turbulent and ideal for infusion delivery.12-14 Risks of malpositioning include cardiac tamponade, thrombosis, and arrhythmias13,15; so our standard protocol has been to confirm acceptable catheter tip positioning with a chest radiograph (CXR) and reposition as necessary. Routine use of angiography rooms for PICC insertion, although efficient, is not cost-effective. Newer electrocardiography (ECG)-guided catheter systems have been developed in an attempt to reduce the need for confirmatory CXRs and repositioning with multiple studies reporting superior placement accuracy with these systems.16-19 Although these results are promising, there are little data on the costs of PICC malpositioning to evaluate whether these newer systems are cost-effective. Thus, we retrospectively analyzed 400 consecutive PICC placements at our institution assessing primary technical success as well as the direct and indirect costs associated with catheter repositioning. Methods Before this analysis, a Northwestern University Institutional Review Board approved our methods. Informed consent was waived due to the retrospective nature of our analysis. Cohort Selection Electronic medical records were used to identify 250 consecutive inpatient PICC placements from May 2012 to August 2012 and 150 consecutive outpatient PICC placements from October 2010 to August 2012 (400 patients in total). All PICCs were placed using ultrasound (US)-guidance coupled with external measurement techniques and postinsertion CXRs to confirm catheter tip location. Inpatient placements were performed by 1 of 2 PICC nurse (PN) teams, whereas outpatient placement were performed by a physician assistant. Assessment of PICC Tip Location Postinsertion CXRs were obtained from our institution’s picture archiving and communication system and re-reviewed
Figure. Postinsertion chest radiograph for a 75year-old man, showing the peripherally inserted central catheter tip (red asterisk) position at the cavoatrial junction. SVC ¼ superior vena cava. by a radiologist. On the CXRs, patients’ superior vena cavas (SVCs) were divided into 3 approximately 2.2-cm sections: high SVC, mid SVC, and low SVC, using the carina as a landmark that is 1.3 cm below the midpoint of the SVC20 (see the Figure). Subsequent repositioning procedures were identified by reviewing patients’ electronic medical records. Assessment of Direct and Indirect Repositioning Costs Additional costs of repositioning were calculated based on 2012 Medicare reimbursement rates: CXR ¼ $46, fluoroscopy room use without catheter replacement ¼ $117, and fluoroscopy room use with catheter replacement ¼ $805. A survey was emailed to all 5 PNs at our institution with a response rate of 60% (3 out of 5) to assess inpatient labor costs and delays in patient care. See Table 1 for survey questions. Statistical Analysis All statistical analyses were performed in SPSS (IBM-SPSS Inc, Armonk, NY). Percentages were calculated for initial and final catheter tip locations as well as repositioning rates. The average direct cost of initial PICC placement was subtracted from the average total cost for patients requiring repositioning to estimate the direct reposition cost. A multivariate analysis was performed to determine whether patients’ demographic characteristics (eg, age and gender) or PICC placement characteristics (eg, date of placement) were associated with the need for repositioning. Repositioning rates between outpatients/ physician assistants and inpatients/PNs were compared using a c2 test and phi coefficient for correlation strength. A P value .05 was considered statistically significant.
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Table 1. Nurse Survey Questions Related to Peripherally Inserted Central Catheter (PICC) Use 1. Approximately how many ultrasound-guided PICC insertion procedures do you perform per day? 2. Approximately how much time (in minutes) do you spend on average to determine if a PICC placed by you or a colleague is in a suitable location for use and communicating this information to the care team? 3. Assume a PICC is malpositioned in the internal jugular vein. How much time (in minutes) do you spend arranging nonfluoroscopic approaches for repositioning, confirming the catheter’s final position as acceptable, and informing the referring service that the PICC is ready for use? 4. Assume a PICC is malpositioned in the axillary vein, and you suspect a venous stenosis or occlusion. How much time (in minutes) to you spend arranging fluoroscopy (ie, interventional radiology) for catheter repositioning or replacement? 5. Approximately how many PICCs are not usable by the clinical service until the day after placement? (Please express as a percentage) 6. If it was possible to determine PICC tip location easily and simply during the procedure, would the time saved following-up PICC locations enable you to potentially perform more procedures per day? (For argument’s sake assume that any such system does not add time to the procedure.) If not, please provide a brief explanation.
Results The 400 patients included in this investigation had an average age of 58 17 years with 225 men and 175 women. PICC placement was achievable in 397 out of 400 patients (99.2%). Upper extremity venous access could not be achieved in 3 patients (2 outpatients and 1 inpatient) due to repeated vasospasm. Optimal tip location at the CAJ or high right atrium without the need for repositioning was achieved on initial placement in 133 out of 397 (33.5%). Nonoptimal but acceptable tip location in the SVC was achieved in 200 out of 397 (50.4%) for a total initial placement success rate of 83.2% (333 out of 400). Repositioning was required in 64 out of 397 patients (16.1%), requiring a total of 77 repositioning procedures. There was no significant relationship between the need for repositioning and patient age, patient gender, or procedure date. However, malpositioned PICCs were more commonly observed in inpatients (51 out of 249; 20.5%) than outpatients (13 out of 148; 8.8%), yielding a statistically significant difference with a low to moderate association between inpatient PICC placement and the need for repositioning (c2 ¼ 9.603, P ¼ .002; f ¼ 0.155, P ¼ .002). Repositioned tip locations outside the SVC or right atrium were most often positioned in the ipsilateral internal jugular vein 11 out of 64 patients (17.2%), subclavian vein in 8 out of 64 patients (12.5%), or brachiocephalic vein in 7 out of 64 patients (10.9%). Repositioning rates based on initial catheter tip location included 100% of those in the axillary veins (3 patients), subclavian veins (9 patients), internal jugular veins (12 patients), brachiocephalic veins (13 patients), azygous arch (6 patients), and lower right atrium (7 patients) as well as 3 out of 29 (10.3%) in the high SVC and 11 out of 41 (26.8%) in the high right atrium. Final catheter tip location in the SVC, high right atrium, or at the CAJ was achieved in 59 out of 64 (92.2%) patients following repositioning. For the other 5 patients (4 out of 5 were inpatients), the catheter tip was left
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in the ipsilateral axillary vein (n ¼ 1), subclavian vein (n ¼ 1), brachiocephalic vein (n ¼ 2), or azygous arch (n ¼ 1) often due to more proximal vessel occlusion (Table 2). Repositioning in 16 out of 64 patients (25.0%) required performance by an interventional radiologist under fluoroscopy. All other repositioning attempts were performed by the original operator. The average additional direct cost of PICC repositioning was $186.03 per catheter ($223.82 per patient) for a total additional cost of $14,324.48 from 61 additional CXRs and 16 additional fluoroscopy-guided procedures. Staff spent an average of 15 minutes determining PICC positioning and 36 additional minutes arranging repositioning procedures, if needed, for a total average additional staff time of 50 minutes per catheter. Due to delays caused by waiting for CXRs and repositioning procedures to be performed, 23 out of 397 PICCs (5.8%) could not be used on the day of initial insertion. No complications other than malpositioning or inability to achieve upper extremity venous access occurred in any of the 400 patients reviewed. Discussion PICCs are widely used to achieve central venous access and have historically been placed using ultrasound guidance for venous access, with blind advancement of an externally measured catheter length necessary to reach the target tip location, assessing the final location with a CXR. This approach can require repositioning in a large number of patients with rates reported as high as 50.8% in a study of ICU patients,21 exposing patients to additional radiation, discomfort, and delays in care. We sought to understand this potential source of inefficiency at our center, finding that catheter tip repositioning was required in 16% of 400 consecutive patients who underwent US-guided PICC placement with external measurement techniques. Repositioning efforts cost an additional $14,324.48 in total with significant indirect costs in additional staff time and delays in care.
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Table 2. Catheter Tip Position and Repositioning, by Patient Cohort Initial tip location
Outpatients n %
Inpatients n
Total n
%
%
Axillary vein ipsilateral
2
1.33
1
0.40
3
0.75
Subclavian vein ipsilateral
2
1.33
6
2.40
8
2.00
Subclavian vein contralateral
1
0.67
0
0.00
1
0.25
BCV ipsilateral
2
1.33
5
2.00
7
1.75
BCV contralateral
0
0.00
6
2.40
6
1.50
Azygous arch
0
0.00
6
2.40
6
1.50
SVC: High
10
6.67
19
7.60
29
7.25
SVC: Mid
33
22.00
56
22.40
89
22.25
SVC: Low
38
25.33
47
18.80
85
21.25
CAJ
39
26.00
64
25.60
103
25.75
High RA
19
12.67
22
8.80
41
10.25
Low RA
1
0.67
6
2.40
7
1.75
Internal jugular ipsilateral
1
0.67
10
4.00
11
2.75
Internal jugular contralateral
0
0.00
1
0.40
1
0.25
No vein access
2
1.33
1
0.40
3
0.75
150
100.00
250
100.00
400
100.00
No
135
91.22
198
79.52
333
83.88
Yes
13
8.78
51
20.48
64
16.12
Axillary vein ipsilateral
0
0.00
1
1.96
1
1.56
Subclavian vein ipsilateral
1
7.69
0
0.00
1
1.56
BCV ipsilateral
0
0.00
2
3.92
2
3.13
Azygous arch
0
0.00
1
1.96
1
1.56
SVC: High
0
0.00
3
5.88
3
4.69
SVC: Mid
1
7.69
13
25.49
14
21.88
SVC: Low
1
7.69
12
23.53
13
20.31
CAJ
9
69.23
18
35.29
27
42.19
High RA
1
7.69
1
1.96%
2
3.13
13
100.00
51
100.00%
64
100.00
Total Repositioning
Final repositioned tip location
Total
BCV ¼ Brachiocephalic vein; CAJ ¼ Cavoatrial junction; RA ¼ Right atrium; SVC ¼ Superior vena cava.
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Our initial technical success rate (34%) and malposition rate (16%) were similar to other studies. Reported bedside PICC team malposition rates tend to range from 0%-30% with an average optimal tip position rate of 45.87% on first attempt.22,23 However, success rates can vary considerably. A well-cited study by Trerotola et al24 found 70% of 2,367 PICC placements to be initially successful with a 10% malposition rate. Part of this variance likely comes from differences in study cohorts. Our inpatients were significantly more likely to require PICC repositioning than outpatients (20% vs 9%). This is reasonable given that inpatients are more likely to have conditions that complicate the navigation of the catheter tip from a superficial peripheral vein to the SVC before final positioning. Sicker patients may have electrolyte or hemodynamic abnormalities making them more prone to peripheral vasospasm or thrombosis, impeding catheter progression. Furthermore, inpatients often have fewer peripheral veins that are suitable for US-guided access. Challenges of positioning the catheter tip at/near the CAJ are less relevant to external measurement techniques where the operator is relatively blind to final tip placement than an array of techniques and devices that have been developed to reduce PICC malpositioning. Fluoroscopically guided PICC insertion is efficient and accurate but not cost-effective. Using ultrasound at the time of insertion helps the operator identify malpositioning near the venous access and adjust the PICC during the initial placement,25 but this approach does not allow the operator to identify the catheter positioning within the chest without a confirmatory CXR. A popular solution to this challenge has been newer intravascular ECG-guided catheter systems. The CAJ lies close to the sinoatrial node, causing ECG recordings from the catheter tip to achieve a maximum P-wave amplitude when the tip is positioned at the CAJ and become biphasic if advanced into the right atrium. Two large studies26,27 and a smaller investigation16 found ECG-guided catheters to be > 90% sensitive and specific for indicating catheter tip location with almost no need for repositioning. Three other studies comparing ECG-guided systems to conventional external measurement with anatomic landmarks found ECG-guided placement to be significantly more accurate.18,19 Certain arrhythmias (eg, atrial fibrillation) can limit the ability of ECG-guided catheters to identify the final tip position, as can variations in the proximity of patients’ CAJs and sinoatrial nodes.28 Nevertheless, implementing PICC insertion devices combining US and intravascular ECG guidance has been shown to significantly reduce malposition rates, the need for confirmatory CXRs (by 84%), and costs ($17,317.30 over a 1-year study period).29,30 See Table 3 for a list of such devices currently on the market. Unfortunately, minimal methodologic information is available for the study reporting such dramatic cost savings, and a recent extensive report by the UK National Institute for Health and Care Excellence found a US- or ECG-guided system to be cost-neutral due to no or low quality evidence for many important outcomes.31 However, the UK National Institute for Health and Care Excellence report also noted that ECG-guided systems would yield cost savings if factors such as reduced nursing time,
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Table 3. Ultrasound and ElectrocardiogramGuided (ECG) Peripherally Inserted Central Catheter Placement Devices on the Market Name
Description
Sherlock 3CG Tip Confirmation Systema
Ultrasound guidance, magnetic tip tracking, plus intravascular ECG
Celerity Tip Confirmation Systemb
External and intravascular ECG alone
Arrow VPS G4c
Intravascular ECG plus intravascular Doppler
a
Bard Access Systems, Inc. Salt Lake City, UT. Angiodynamics, Latham, NY. c Teleflex Inc, Research Triangle Park, NC. b
CXR use, and repositioning efforts were sufficiently illustrated. Our results suggest that there is significant potential to reduce these indirect costs as well as the direct costs of repositioning at our center. Furthermore, it is important to address patients’ perceptions of the quality of their care. Delays in treatment and failed positioning attempts undermine patients’ trust in their providers and decrease the likelihood that they will highly value their care experience. Thus, future work is needed to compare various approaches to PICC placement in terms of the costs we assessed as well as patients’ perceptions of their care. Another strategy for maximizing the cost-effectiveness of advanced PICC guidance systems would be to prospectively identify high-risk patients for malpositioning and use more expensive PICC placement systems judiciously. We have since begun testing the implementation of an US- and ECG-guided catheter placement system in our division of interventional radiology, but such a system may be unnecessary for less complicated PICC placements. For example, we found an outpatient reposition rate of 8.8% compared with 20.5% for inpatients. Even with near-perfect performance of the new system, it may be most cost-effective to use electronic medical records to document which patients may be at risk for more complicated PICC insertions, such as those with vascular anomalies, hypercoagulable states, history of previous catheter use, or history of previous PICC malpositioning. When a PICC placement is ordered in such a patient, the electronic medical record could suggest the use of the more expensive PICC placement system to reduce the risk of catheter malposition and subsequent delays in care. We intend to implement such an approach at our institution pending the performance of the new placement system. We believe this method will help ensure high-risk patients receive therapies safely and efficiently, supporting their perceptions of quality health care. Our study had important limitations. This analysis was performed at a single center, limiting the external validity of our results. Although this was performed as a retrospective
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study, we assessed consecutive procedures to reduce the risk of selection bias. Our use of surveys also exposes this study to recall bias but the surveys were anonymous, the PICC nurses regularly perform these procedures, and respondents would have little reason to intentionally misrepresent their experiences. Finally, we did not assess the influence of repositioning on patients’ perceptions of their care, which would have strengthened the significance of our results. In an effort to assess inefficiencies associated with PICC placement at our institution, we analyzed 400 consecutive patients, finding optimal catheter placement was achieved in 34% of patients and optimal or acceptable placement in a total of 84%. Repositioning for the 77 unacceptably positioned PICCs cost an additional $186.03 and 50 minutes of staff time per catheter. Assuming an average hourly wage of $38 per hour for these staff members at our institution, repositioning cost $217.70 per catheter in addition to exposing patients to 61 additional CXRs and 16 additional fluoroscopically guided procedures, and delaying catheter use 24 hours for 23 patients. Institutions should analyze their vascular access service PICC placement procedures to ascertain the efficiency of care delivery and downstream costs associated with delays in catheter use.
8.
9.
10.
11.
12.
13. 14.
Disclosures The authors have no conflicts of interest to disclose. References 1. Institute of Medicine Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001. 2. Blumenthal D, Stremikis K, Cutler D. Health care spendingda giant slain or sleeping? N Engl J Med. 2013;369:2551-2557. 3. Wennberg JE, Fisher ES. Dartmouth Institute for Health Policy and Clinical Practice. Tracking the Care of Patients with Severe Chronic Illness. Lebanon, NH: Dartmouth Institute for Health Policy and Cllincal Practice, Center for Health Policy Research; 2008. 4. Woller SC, Stevens SM, Evans RS. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) initiative: a summary and review of peripherally inserted central catheter and venous catheter appropriate use. J Hosp Med. 2016;11:306-310. 5. Burns T, Lamberth B. Facility wide benefits of radiology vascular access teams. Radiol Mgmt. 2010;32:28-32. quiz 33-24. 6. Johansson E, Hammarskjold F, Lundberg D, Arnlind MH. Advantages and disadvantages of peripherally inserted central venous catheters (PICC) compared to other central venous lines: a systematic review of the literature. Acta Oncol. 2013;52:886-892. 7. Chopra V, Flanders SA, Saint S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results from a multispecialty panel using the
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23. Song L, Li X, Guo Y, et al. Malposition of peripherally inserted central catheter: experience from 3012 cancer patients. Int J Nurs Pract. 2014;20:446-449. 24. Trerotola SO, Thompson S, Chittams J, Vierregger KS. Analysis of tip malposition and correction in peripherally inserted central catheters placed at bedside by a dedicated nursing team. J Vasc Intervent Radiol. 2007;18:513-518. 25. Schweickert WD, Herlitz J, Pohlman AS, Gehlbach BK, Hall JB, Kress JP. A randomized, controlled trial evaluating postinsertion neck ultrasound in peripherally inserted central catheter procedures. Crit Care Med. 2009;37: 1217-1221. 26. Wang G, Guo L, Jiang B, Huang M, Zhang J, Qin Y. Factors influencing intracavitary electrocardiographic P-wave changes during central venous catheter placement. PloS ONE. 2015;10:e0124846. 27. Pittiruti M, Bertollo D, Briglia E, et al. The intracavitary ECG method for positioning the tip of central venous
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