Four years of tracking patient outcomes 01 midline, midclavicular and PICC line program 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 high chemical phlebitis risk) • TNA ITPN • Vesicant Chemotherapy · Non-Chemotherapy drip in the home setting · Nafcillin · Dopamine · Dilantin • Vancomycin Questions? Consult your pharmadst, midline or P1CC line resource person. 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 rtides on peripherally insel1ed central venous catheter (PICC lines) and midline catheters abound these days in the liter- ature. 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 prac- tice decisions [being) based on research - the remaining 88 percent [being] based on custom or habit - the need for accurate data becomes more apparent"l The following data are helping us make better decisions in our PICC and midline catheter program. OUR PROGRAM Period I May 1994 tlu'ough September 1995 Our hospital stalted a midline cathe- ter program in 1994. While we do not have a specifically designated IV team, the nurses were trained to place the catheters. Unfortunately, during the first time period only 25 percent of the mid- line catheters placed had outcome data. Since this was a more expensive cathe- ter to place, with several "up front" expenses, and since we could not show what became of them, the program was in jeopardy. A group of committed nurses pursued keeping the program and made outcome monitoring manda- tOlY. The genesis of our program came from this goal: the nurse who places the line tracks it to the end of therapy or its removal. This served several pur- poses. 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 peo- ple and was not a huge burden for any one person. Period 2 December 1995 through August 1996 Due to the FDA repol1s, one hyper- sensitivity reaction and a high pWebitis rate, we changed to a different midline catheter (L-Cath, Luther Medical, Tusin, 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 ther- apy or removal for other reasons. The pWebitis rate dropped from 21% to 7%. Period 3 eptember 1996 through ovember 1996 Since we were often using midlines for the delivery of inappropriate infusates, we generated a list of "What F a II I998 .JVAD 19 Jane Banton BSN, CRNI and Kristine Leahy-Gross RN, BS assessin catheter er ormance Four years 01 tracking patient outcomes 01 midline, midclavicular and PICC line program 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 high chemical phlebitiS risk) • TNAITPN • Vesicant Chemotherapy • Non-Chemotherapy drip in the home setting • Nafcillin • Dopamine · Dilantin • Vancomycin Questionsl Consult your pharmacist, midline or P1CC line resource person. 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 ltides on peripherally insened central venous catheter (PICC lines) and midline catheters abound these days in the liter- ature. 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 prac- tice decisions [being) based on research - the remaining 88 percent [being] based on custom or habit - the need for accurate data becomes more apparent'" The following data are helping us make bener decisions in our PICC and midline catheter program. OUR PROGRAM Period I May 1994 tlu'ough September 1995 Our hospital stalted a midline cathe- ter program in 1994. While we do not have a specifically designated IV team, the nurses were trained to place the catheters. UnfOlwnately, during the first time period only 25 percent of the mid- line catheters placed had outcome data. Since tl1is was a more expensive cathe- ter to place, with several "up front" expenses, and since we could not show what became of tl1em, the program was in jeopardy. A group of committed nurses pursued keeping the program and made outcome monitoring manda- tory. The genesis of our program came from this goal: the nurse who places the line tracks it to the end of therapy or its removal. This served several pur- poses. 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 peo- ple and was not a huge burden for any one person. Period 2 December 1995 tl1rough August 1996 Due to the FDA repons, one hyper- sensitivity reaction and a high pWebitis rate, we changed to a different midline catheter (L-Cath, Lutl1er Medical, Tusin, 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 ther- apy or removal for other reasons. The pWebitis rate dropped from 21% to 7%. Period 3 eptember 1996 tl1rough November 1996 Since we were often using midlines for the delivery of inappropriate infusates, we generated a list of "What F a II I998 .JVAD 19
Transcript
Four years of trackingpatient outcomes 01 midline,
midclavicular and PICC line program
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 tohigh chemical phlebitis risk)
• TNA ITPN
• Vesicant Chemotherapy
· Non-Chemotherapy drip in the home setting
· Nafcillin
· Dopamine
· Dilantin
• Vancomycin
Questions? Consult your pharmadst, midline or P1CC line resource person.
The following antibiotics will cause less phlebitis if they are administered in 2S0ccand 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 endof therapy. Giving these meds this way will also decrease phlebitis with a shortperipheral IV catheter:
Erythromycin
Ampho B
Ticarcillin Jun-97
rtides on peripherally insel1edcentral venous catheter (PICClines) and midline cathetersabound these days in the literature. We want to thank all ofyou who are writing them
because as we share our "line" stories,programs, and outcomes, we will learnfrom each other. We agree with Pooleand Vasilios who recently wrote thatwith "only 12 percent of medical practice decisions [being) based on research- the remaining 88 percent [being]based on custom or habit - the need foraccurate data becomes more apparent"lThe following data are helping us makebetter decisions in our PICC and midlinecatheter program.
OUR PROGRAM
Period IMay 1994 tlu'ough September 1995Our hospital stalted a midline cathe
ter program in 1994. While we do nothave a specifically designated IV team,the nurses were trained to place thecatheters. Unfortunately, during the firsttime period only 25 percent of the midline catheters placed had outcome data.Since this was a more expensive catheter to place, with several "up front"expenses, and since we could not showwhat became of them, the program wasin jeopardy. A group of committednurses pursued keeping the programand made outcome monitoring mandatOlY. The genesis of our program camefrom this goal: the nurse who placesthe line tracks it to the end of therapyor its removal. This served several purposes. First of all it was a great learning
experience, especially for nurses newto the program. Secondly, the datawere collected concurrently. Thirdly,the data were collected by several people and was not a huge burden for anyone person.
Period 2December 1995 through August 1996Due to the FDA repol1s, one hyper
sensitivity reaction and a high pWebitisrate, we changed to a different midlinecatheter (L-Cath, Luther Medical, Tusin,CA) in November 1995. A polyurethanemidline catheter was chosen over a sili-
cone-based catheter for reasons ofincreased cannula strength, higher flowrates and available customer support.More nurses were trained and there wasan increase in the number of midlinecatheters tracked to either end of therapy or removal for other reasons. ThepWebitis rate dropped from 21% to 7%.
Period 3eptember 1996 through ovember
1996Since we were often using midlines
for the delivery of inappropriateinfusates, we generated a list of "What
F a I I I 9 9 8 .JVAD 19
Jane Banton BSN, CRNI and Kristine Leahy-Gross RN, BS
assessin catheter er ormanceFour years 01 tracking
patient outcomes 01 midline,midclavicular and PICC line program
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 tohigh chemical phlebitiS risk)
• TNAITPN
• Vesicant Chemotherapy
• Non-Chemotherapy drip in the home setting
• Nafcillin
• Dopamine
· Dilantin
• Vancomycin
Questionsl Consult your pharmacist, midline or P1CC line resource person.
The following antibiotics will cause less phlebitis if they are administered in 2S0ccand 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 endof therapy. Giving these meds this way will also decrease phlebitis with a shortperipheral IV catheter:
Erythromycin
Ampho B
Ticarcillin Jun-97
ltides on peripherally insenedcentral venous catheter (PICClines) and midline cathetersabound these days in the literature. We want to thank all ofyou who are writing them
because as we share our "line" stories,programs, and outcomes, we will learnfrom each other. We agree with Pooleand Vasilios who recently wrote thatwith "only 12 percent of medical practice decisions [being) based on research- the remaining 88 percent [being]based on custom or habit - the need foraccurate data becomes more apparent'"The following data are helping us makebener decisions in our PICC and midlinecatheter program.
OUR PROGRAM
Period IMay 1994 tlu'ough September 1995Our hospital stalted a midline cathe
ter program in 1994. While we do nothave a specifically designated IV team,the nurses were trained to place thecatheters. UnfOlwnately, during the firsttime period only 25 percent of the midline catheters placed had outcome data.Since tl1is was a more expensive catheter to place, with several "up front"expenses, and since we could not showwhat became of tl1em, the program wasin jeopardy. A group of committednurses pursued keeping the programand made outcome monitoring mandatory. The genesis of our program camefrom this goal: the nurse who placesthe line tracks it to the end of therapyor its removal. This served several purposes. First of all it was a great learning
experience, especially for nurses newto the program. Secondly, the datawere collected concurrently. Thirdly,the data were collected by several people and was not a huge burden for anyone person.
Period 2December 1995 tl1rough August 1996Due to the FDA repons, one hyper
sensitivity reaction and a high pWebitisrate, we changed to a different midlinecatheter (L-Cath, Lutl1er Medical, Tusin,CA) in November 1995. A polyurethanemidline catheter was chosen over a sili-
cone-based catheter for reasons ofincreased cannula strength, higher flowrates and available customer support.More nurses were trained and there wasan increase in the number of midlinecatheters tracked to either end of therapy or removal for other reasons. ThepWebitis rate dropped from 21% to 7%.
Period 3eptember 1996 tl1rough November
1996Since we were often using midlines
for the delivery of inappropriateinfusates, we generated a list of "What
Not To Put In Midlines" (Table I). Wealso looked closely at our outcomes forvancomycin and nafcillin infused viamidline catheters and compared them toall infusions via these catheters. Wefound that nafcillin had a combinedpWebitis and infiltration rate of 70%, andthat the rate for infusion of vancomycinwas 26%. In contrast, the combinedphlebitis and infiltration rate of the 208midline catheters overall (for all medications delivered) was only 17%, so weclearly had a problem. To monitor thisfully, we developed a standardizedprogress note so nurses could documentoutcomes and complications efficientlyand con,sjstently.
Period 4ovember 1996 tl1fough February 1997
During this time period, we changedthe type of transparent dressing wewere using due to reports of difficulty inremoving that type of dressing. We alsowrote a PICC line proposal, did a PICCcatheter pilot evaluation program, andtrained some of the midline catheternurses to place PICC lines.
Period 5March 1997 tl1fough June 1997We expanded the PICC line program
throughout the hospital during this program and it was so well accepted that itpractically grew itself. As soon as nursesand physicians found out that a centralline could be placed easily in the clinicor at the bedsjde, we were in demand.Interestingly, "the number of radiologyplaced PICC lines has gone up in theyear following the beginning of thenurse PICC line program. We seem tobe using more PICC lines in general andfewer Hickman central venous cathetersand short-term non-tunneled centrallines. We also changed the extension setclamp from a slide clamp to a pushclamp to allow for easier manipulationduring positive pressure flushing.
Period 6June 1997 through September 1997As a result of our monitoring pro~
gram, we noted a 10% occlusion rate,so we proposed switching from 10u/mL heparinized saline to 100 u/mLheparinized saline mixture and a twicea day flush if the line was not in use.
We also started putting a label on theextension set so any staff member couldidentify whether the line was a PICC,midline, or midclavicular catheter.
Period 7October 1997 t!1fough January 1998Most importantly, by this point in our
program, we developed and put intopractice the use of a scannable trackingform so that data could be entereddirectly into the database rather than beentered manually. The same form isused whether the line is PICC, midlineor midclavicular catheter (Figure 1).
Researchers of medical outcomes areoften inhibited by cumbersome formsbased data collection. Many times whileassessing outcomes, data collection canbe inaccurate (data entIy errors) andcostly (data entry personnel). However,with the use of a scannable form oroptical in1age-based data collection tool,we were able to improve data integrityand eliminate the expense of data entrypersonnel.
The first step in our use of opticalimage-based data collection was thedevelopment of an inexpensive formusing PC-based software that is compatible with our in-house scanner. Thesoftware itself is used to design andprint a scannable form that can beduplicated by standard copying. Byobviating the need for professionalform design and offset printing, wewere able to recognize great cost savings. Moreover, the image-based data
collection system is senSItive to allkinds of marks, so forms need not becompleted with a #2 pencil or ballpointpen. Thereby, increasing the chances ofgetting good reads. Another advantageof image-based scanning is that anactual image of each scanned document is saved in computer memory. So,if there is any question as to whetherthe scanner has read the bubble orimage correctly, a picture of the formcan be retrieved for verification. Onemore compelling feature of imagebased software is that it allows OCR orOptical Character Recognition (machineprint), ICR or Intelligent CharacterRecognition (handprint), OMR OpticalMark Read (mark sense) data processing and bar code recognition. OCRlICRallow the software to interpret not onlybubbles or "marks", but also hand-written print. This allows much greater flexibility in the utility of scannable forms.Once the form was developed, wewere able to fine-tune the properties ofour database to enable complex querieson various outcomes.
We have found that optical imagebased data collection has beenextremely useful in our collection ofdata and in evaluating PICC, midlineand midclavicular catheter outcomes.By using image-based data collectionwe were able to improve the integrity,improve the timelines of data entry andeliminate the expense of data entrypersonnel.
22 ~VAD Fall 1998
Distribution of IV therapies delivered viamidline, midclavicular and PICC catheters inserted
Not To Put In Midlines" (Table O. Wealso looked closely at our outcomes forvancomycin and nafcillin infused viamidline catheters and compared them toall infusions via these catheters. Wefound that nafeillin had a combinedphlebitis and infiltration rate of 70%, andthat the rate for infusion of vancomycinwas 26%. In contrast, the combinedphlebitis and infiltration rate of the 208midline catheters overall (for all medications delivered) was only 17%, so weclearly had a problem. To monitor thisfully, we developed a standardizedprogress note so nurses could documentoutcomes and complications efficientlyand cofl,'ijstently.
Period 4ovember 1996 through February 1997
During this time period, we changedthe type of transparent dressing wewere using due to reports of difficulty inremoving that type of dressing. We alsowrote a PICC line proposal, did a PICCcatheter pilot evaluation program, andtrained some of the midline catheternurses to place PICC lines.
Period 5March 1997 through June 1997We expanded the PICC line program
throughout the hospital during this program and it was so well accepted that itpractically grew itself. As soon as nursesand physicians found out that a centralline could be placed easily in the clinicor at the bedsjde, we were in demand.Interestingly, he number of radiologyplaced PICC lines has gone up in theyear following the beginning of thenurse PICC line program. We seem tobe using more PICC lines in general andfewer Hickman central venous cathetersand short-term non-tunneled centrallines. We also changed the extension setclamp from a slide clamp to a pushclamp to allow for easier manipulationduring positive pressure flushing.
Period 6June 1997 through September 1997As a result of our monitoring pro
gram, we noted a 10% occlusion rate,so we proposed switching from 10u/mL heparinized saline to 100 u/mLheparinized saline mixture and a twicea day flush if the line was not in use.
We also started putting a label on theextension set so any staff member couldidentify whether the line was a PICC,midline, or midclavicular catheter.
Period 7October 1997 through JanualY 1998Most importantly, by this point in our
program, we developed and put intopractice the use of a scannable trackingform so that data could be entereddirectly into the database rather than beentered manually. The same form isused whether the line is PICC, midlineor midclavicular catheter (Figure 1).
Researchers of medical outcomes areoften inhibited by cumbersome formsbased data collection. Many times whileassessing outcomes, data collection canbe inaccurate (data entIy errors) andcostly (data entIy personnel). However,with the use of a scannable form oroptical image-based data collection tool,we were able to improve data integrityand eliminate the expense of data entrypersonnel.
The first step in our use of opticalimage-based data collection was thedevelopment of an inexpensive formusing PC-based software that is compatible with our in-house scanner. Thesoftware itself is used to design andprint a scannable form that can beduplicated by standard copying. Byobviating the need for professionalform deSign and offset printing, wewere able to recognize great cost savings. Moreover, the image-based data
collection system is senSItive to allkinds of marks, so forms need not becompleted with a #2 pencil or ballpointpen. 111ereby, increasing the chances ofgetting good reads. Another advantageof image-based scanning is that anactual image of each scanned document is saved in computer memoIY. So,if there is any question as to whetherthe scanner has read the bubble orimage correctly, a picture of the formcan be retrieved for verification. Onemore compelling feature of imagebased software is that it allows OCR orOptical Character Recognition (machineprint), ICR or Intelligent CharacterRecognition (handprint), OMR OpticalMark Read (mark sense) data processing and bar code recognition. OCRlICRallow the software to interpret not onlybubbles or "marks", but also hand-written print. This allows much greater flexibility in the utility of scannable forms.Once the form was developed, wewere able to fine-tune the properties ofour database to enable complex querieson various outcomes.
We have found that optical imagebased data collection has beenextremely useful in our collection ofdata and in evaluating PICC, midlineand midclavicular catheter outcomes.By using image-based data collectionwe were able to improve the integrity,improve the timelines of data entry andeliminate the expense of data entIypersonnel.
22 .JVAD Fall 1998
Outcomes for midclavicular and PICC lines placedbetween January 1997 and January 1998
Total No. ofPICCand Mean
Time Midclavicular IndwellingPeriod Catheters Time Therapy
Placed (days) 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%
* Data represent all catheters removed for signs & symptoms of infection.
** Data represent 2% confirmed catheter-related infections and 5% suspected catheter-related local infections.
Distribution of removal reasons for midline,midclavicular
band PICC catheters inserted between
Ocot er I, 1997 and January 31, 1998
Device Placed:
Removal reason Midline Midclavicular PICCcatheter catheter line
Therapy completed 60% 73% 69%
Removed by patient 12% 6% 5%
Line change to a different VAD 8% 6% 3%
Occlusion 5% 6% 3%
Migration 2% 1% 2%
Leak 2% 2% 3%
Infiltration 2% NR NR
Phlebitis NR* 4% 1%
Suspected catheter-related local infection NR 1% 10%
Catheter-related sepsis NR NR 3%
Other 4% 1% 1%
* NR= Not reported
Midline Outcome SummaryFrom the stalt of the monitoring pro
gram through the end of 1997, midlinecatheter outcomes over time showed adecrease in phlebitis, infiltration andocclusion with an increase in the numberof lines that made it to the end of therapy without complications (Figure 2).
The length of time midline cathetersremained indwelling ranged from 1 to94 days overall, giving a mean indwelling time of approximately 10 days. Thelength of time midline cathetersremained in place was shorter in theearly stages of our program Cl to 47days) than in more recent stages Cl to94 days). This was a reflection of bothour increasing experience with whichmedications are appropriate for delivelyvia midline catheters, and the modifications of our catheter maintenancereginles. For example, in the first monitoring time period we had not established which IV solutions andmedications were inappropriate fordelivery via midline catheters, and so21% of the devices were removed dueto the presentation of phlebitis. In contrast, by the end of 1997, the phlebitisrate for midline catheters was only 6%(Figure 2).
Midline catheters primarily were usedto deliver anti-infective agents, withother IV medications and solutionsdelivered less frequently (Table II).
PICC Line & MidclavicularCatheter Outcome Summary
Initially the data for the longer linecatheters-Plee and midclavicular catheters-were pooled together in our monitoring program. From Januaty throughSeptember 1997, 150 Plee and midclav-
icular catheters were inselted, while injust four montlls (October 1997 tllroughJanuary 1998) more than double thatnumber were placed (Table Ill). Duringthis period, as a reflection of variouschanges in our policies and procedures,tlle mean indwelling time increased,while the rates of most catheter-relatedcomplications decreased (Table Ill).Most importantly, the proportion ofthese longer lines that remainedindwelling until IV therapy had beencompleted increased from 58% to 70%.
We are now placing more Plee linesand fewer midline catlleters. For example, from October 1997 through January1998, of the 363 lines entered in thedatabase, 178 were Plee lines, 141 were
midclavicular catlleters, and only 44were midline catheters.
Data Summary from themost recent monitoringperiod analyzed
October 1, 1997 thru January 31, 1998The types of IV medications and solu
tions delivered via Plee, midclavicularand midline catheters during this timeperiod were delineated based upon ourpast experiences. While anti-infectiveagents and IV fluids comprised themajority of the medications delivered,midline catheters were not used toinfuse steroids or TNA (Table II). A similar medication distribution was usedwith midclavicular catheters, while the
Fall 1998 .JVAC 23
Outcomes for midclavicular and PICC lines placedbetween January 1997 and January 1998
Total No. ofPICCand Mean
Time Midclavicular IndwellingPeriod Catheters Time Therapy
Placed (days) 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%
* Data represent all catheters removed for signs & symptoms of infection.
** Data represent 2% confirmed catheter-related infections and 5% suspected catheter-related local infections.
Distribution of removal reasons for midline,midclavicular
band PICC catheters inserted between
Ocot er I, 1997 and January 31, 1998
Device Placed:
Removal reason Midline Midclavicular PICCcatheter catheter line
Therapy completed 60% 73% 69%
Removed by patient 12% 6% 5%
Line change to a different VAD 8% 6% 3%
Occlusion 5% 6% 3%
Migration 2% 1% 2%
Leak 2% 2% 3%
Infiltration 2% NR NR
Phlebitis NR* 4% 1%
Suspected catheter-related local infection NR 1% 10%
Catheter-related sepsis NR NR 3%
Other 4% 1% 1%
* NR= Not reported
Midline Outcome SummaryFrom the stalt of the monitoring pro
gram through the end of 1997, midlinecatheter outcomes over time showed adecrease in phlebitis, infiltration andocclusion with an increase in the numberof lines that made it to the end of therapy without complications (Figure 2).
The length of time midline cathetersremained indwelling ranged from 1 to94 days overall, giving a mean indwelling time of approximately 10 days. Thelength of time midline cathetersremained in place was shorter in theearly stages of our program Cl to 47days) than in more recent stages Cl to94 days). This was a reflection of bothour increasing experience with whichmedications are appropriate for delivelyvia midline catheters, and the modifications of our catheter maintenancereginles. For example, in the first monitoring time period we had not established which IV solutions andmedications were inappropriate fordelivery via midline catheters, and so21% of the devices were removed dueto the presentation of phlebitis. In contrast, by the end of 1997, the phlebitisrate for midline catheters was only 6%(Figure 2).
Midline catheters primarily were usedto deliver anti-infective agents, withother IV medications and solutionsdelivered less frequently (Table II).
PICC Line & MidclavicularCatheter Outcome Summary
Initially the data for the longer linecatheters-Plee and midclavicular catheters-were pooled together in our monitoring program. From Januaty throughSeptember 1997, 150 Plee and midclav-
icular catheters were inselted, while injust four montlls (October 1997 tllroughJanuary 1998) more than double thatnumber were placed (Table Ill). Duringthis period, as a reflection of variouschanges in our policies and procedures,tlle mean indwelling time increased,while the rates of most catheter-relatedcomplications decreased (Table Ill).Most importantly, the proportion ofthese longer lines that remainedindwelling until IV therapy had beencompleted increased from 58% to 70%.
We are now placing more Plee linesand fewer midline catlleters. For example, from October 1997 through January1998, of the 363 lines entered in thedatabase, 178 were Plee lines, 141 were
midclavicular catlleters, and only 44were midline catheters.
Data Summary from themost recent monitoringperiod analyzed
October 1, 1997 thru January 31, 1998The types of IV medications and solu
tions delivered via Plee, midclavicularand midline catheters during this timeperiod were delineated based upon ourpast experiences. While anti-infectiveagents and IV fluids comprised themajority of the medications delivered,midline catheters were not used toinfuse steroids or TNA (Table II). A similar medication distribution was usedwith midclavicular catheters, while the
Fall 1998 .JVAC 23
more hyperosmotic and irritating medications were delivered primarily viaPICC lines (Table 11).
By selecting the most appropriatedevice for the IV medication needed forthe patient's therapy, we found thatmost lines remained indwelling until theend of therapy, and fewer lines wereremoved for catheter-related complications (Table IV).
One of the more compromising catheter-related complications for patientsrequiring IV therapy is infectiof4 The definition of PICC line infection varies in theliterature, as does how a PICC line infection is r ported.3.4.3 Initially we identifieda PICC line-related infection based uponthe symptomology present, but soonrealized that such an assessment can bemisleading. This led us to assess ourmethodology and terminology related toseptic conditions. ow we are defining aPICC-related infection based on positiveblood cultures from the line and aperipheral site and a patient withsigns/symptoms of sepsis. If a patient hasa positive tip culture and negative bloodcultures, or a patient has a fever withnegative blood cultures, or a patient hasexit site drainage and negative blood cultures, or a patient has only one set of
blood cultures from one site, or thepatient has no blood cultures done at all,we designated those as local or potentialcatheter-related infections. In addition,one of the infection control nurses in ourhospital reviews all cases and helps us todetermine the catheter-related sepsis ratewith our various vascular access devices.
For the time period 1 October 1997through 31 January 1998, the 319 PICCand midclavicular lines indwelled a totalof 6,170 catheter days. With a sepsis rateof only 2%, the sepsis rate can also bedesignated as 1 confirmed catheterrelated infection per 1,000 days indwelling. Overall, PICC lines are repolted tohave a low infection rate; we plan tokeep our sepsis rate below 3%.
In addition to looking at removaldata, we also wanted to see if midlinecatheters that were in place less than 6days and PICC lines in place for morethan 9 days were more likely to beremoved for end of therapy or becauseof complications. Cost effectiveness ofthese lines has been compared.2
.3 Wewanted to make celtain a midline orPICC catheter indwelling for a short timeperiod was removed for end of therapyat least 50% of the time and not for reasons like complications or because the
patient had been discharged on oralmedications. We wanted to ensure thatthese lines were placed for the appropriate patients and that we maintained acost-effective program.
During the time period 1 October1997 through 31 January 1998, PICClines were removed for end of therapywithout complications at approximatelythe same rates, 69% and 67%, whetherthey were in place for over 9 days ornot. The same was true for midclavicular catheters, 74% and 71% for over 9days or not, respectively. These percentages reflect the total PICC and midclavicular lines that made it to the end oftherapy, which was 70%. As reflected inother studies, 61% of the PICC linesremained indwelling for greater than 9days, while and only 47% of midclavicular catheters stayed indwelling 9 daysor more. An example of a "short dwellPICe" that made it to the end of therapywas placed in a patient for sarcoma.The treatment was a continuous infusion of adriamycin for 96 hours for onecycle only. She had surgery one monthlater, and the line was pulled at the endof the vesicant infusion.
The number of midline cathetersremoved for end of therapy without
more hyperosmotic and irritating medications were delivered primarily viaPICC lines (Table IT).
By selecting the most appropriatedevice for the IV medication needed forthe patient's therapy, we found thatmost lines remained indwelling until theend of therapy, and fewer lines wereremoved for catheter-related complications (Table IV).
One of the more compromising catheter-related complications for patientsrequiring IV therapy is infection. The definition of PICC line infection varies in theliterature, as does how a PICC line infection is r ported.3•4'; Initially we identifieda PICC line-related infection based uponthe symptomology present, but soonrealized that such an assessment can bemisleading. This led us to assess ourmethodology and terminology related toseptic conditions. ow we are defming aPICC-related infection based on positiveblood cultures from the line and aperipheral site and a patient withsigns/symptoms of sepsis. If a patient hasa positive tip culture and negative bloodcultures, or a patient has a fever withnegative blood cultures, or a patient hasexit site drainage and negative blood cultures, or a patient has only one set of
blood cultures from one site, or thepatient has no blood cultures done at all,we designated those as local or potentialcatheter-related infections. In addition,one of the infection control nurses in ourhospital reviews all cases and helps us todetermine the catheter-related sepsis ratewith our valious vascular access devices.
For the time period 1 October 1997through 31 January 1998, the 319 PICCand midclavicular lines indwelled a totalof 6,170 catheter days. With a sepsis rateof only 2%, the sepsis rate can also bedesignated as 1 confirmed catheterrelated infection per 1,000 days indwelling. Overall, PICC lines are repolted tohave a low infection rate; we plan tokeep our sepsis rate below 30/0.
In addition to looking at removaldata, we also wanted to see if midlinecatheters that were in place less than 6days and PICC lines in place for morethan 9 days were more likely to beremoved for end of therapy or becauseof complications. Cost effectiveness ofthese lines has been compared. 2
•3 Wewanted to make certain a midline orPICC catheter indwelling for a short timepeIiod was removed for end of therapyat least 50% of the time and not for reasons like complications or because the
patient had been discharged on oralmedications. We wanted to ensure thatthese lines were placed for the appropriate patients and that we maintained acost-effective program.
During the time period 1 October1997 through 31 JanualY 1998, PICClines were removed for end of therapywithout complications at approximatelythe same rates, 69% and 67%, whetherthey were in place for over 9 days ornot. The same was true for midclavicular catheters, 74% and 71% for over 9days or not, respectively. These percentages reflect the total PICC and midclavicular lines that made it to the end oftherapy, which was 70%. As reflected inother studies, 61% of the PICC linesremained indwelling for greater than 9days, while and only 47% of midclavicular catheters stayed indwelling 9 daysor more. An example of a "short dwellPIce that made it to the end of therapywas placed in a patient for sarcoma.The treatment was a continuous infusion of adriamycin for 96 hours for onecycle only. She had surgery one monthlater, and the line was pulled at the endof the vesicant infusion.
The number of midline cathetersremoved for end of therapy without
complications after indwelling for lessthan 6 days was only 21%. The overallnumber of midlines that made it to theend of therapy was 51%. If a midlinecatheter was in 6 days or longer thenthe number of catheters that made tothat point was 88% (Figure 2). However,if a midline catheter was indwelling forless than 6 days, typically the removalreasons were removal by the patient,line change to a different VAD, phlebitis,occlusion, migration, or leaking.
Trends and BenchmarkingBesides using outcomes to look at
your own performance over time, youcan also compare your outcomes tonational standards or other PICC programs. For example, we recently wereable to compare our data with an articlepublished in Infusion magazine, I whichpresented PICC line and midclavicularcatheter data collected from 1989 to1995. The Oncological urses Societyhas published standards that includeranges for occlusion and phlebitis.6
Dennis Maki, MD has published a comparison of sepsis rates for each of several types of central Iines.7 Eachprogram has to decide what outcomesthey will monitor and what acceptableoutcomes are. All PICC programs do notfunction the same. Some of the manyvariables are type of PICC line, insertiontechniques, care and maintenance pro-
1. Poole, S.M., Vasilios, A.N. 1998. Outcomes Measurements: Making sense ofthe data. Infusion 4(8): 25-28.
2. Thomson, S. 1993. N therapy: A feasibilitystudy. Nursing Management 24(6): 68 A-G.
3. Cardella, ].F., et at. 1996. Cumulativeexperience with 1,273 peripherallyinserted central catheters at a single institution. ]VIR 7(1): 5-13.
4. Macklin, D. 1997. How to managePICCs. Am] Nurs 97(9): 27-33.
5. Merrell, S.W., et al. 1994. Peripherallyinserted central venous catheters: Lowrisk alternatives for ongoing venousaccess. West] Med 160(1): 25-30.
6. Camp-Sorrell, D. 1996. Access deviceguidelines: Recommendations for nursingpractice and education. Oncology Nursing Press, pp. 60-63.
cedures and use of infusion nurses ornot. ew catheters and related supportequipment (dressings, caps, flushes,securing mechanisms, etc) are available.How do we know if something newworks if we don't know what the outcomes are? In this era of cost containment, how do we justify a more costlypiece of equipment up front with thehope of saving money in the long run?
Staff-related variablesurses have an initial PICC line train
ing class and preceptorship at our hospital and then an annual review. Theyhave to meet specific criteria in order tomaintain the privilege of placing lines.Staff can then compare their outcomeswith the total numbers. For example,one nurse placed 114 of the 363 linesduring the time period analyzed (October 1997 through January 1998). Hermean dwell for PICC lines was 20 days.The number that made it to the end oftherapy without complications was 680/0.Another nurse placed 21 of 363 longerlines and her mean dwell of PICC lineswas 73 days. The number to end oftherapy without complications was 7oo!&.
SummaryUsing patient outcomes to drive our
practice allows us to evaluate our PICCand midline program on a continuousbasis. Some of our program goals are:
REFERENCES7. Maki, D.G. 1994. Infections caused by
intravascular devices used for infusiontherapy: Pathogenesis, prevention, andmanagement. Infections Associated WithIndwelling Medical Devices, 2nd Ed., pp.155-212.
8. Kearns, P., et at. 1995. Complications oflong arm catheters: A randomized trial ofcentral 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 barrierprecautions during insertion reduce therisk of central venous catheter-relatedbacteremia.
11. Goodwin, M.L., Carlson, I. 1993. Theperipherally inserted central catheter. A
• Ongoing monitoring and reportingon the outcomes of all lines placed,with data summaries;
• Change to latex-free insertion;• Increase continuity of care between
hospital and home;• Implement 100 u/mL heparinized
saline flush protocol;• Evaluate new technology;• Adopt a standardized site care tray;• Standardize diagnosis, definition,
treatment of suspected PICC lineinfection; and
• Continue to decrease complicationrates and increase the number oflines that make it to the end of therapy without complications.Using a scannable form makes this
process more efficient and less timeconsuming. Requiring that the personwho 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 Hospitaland Clinics in Madison, WT. lane is a former IV nurse and is the PICC ProgramCoordinator for the hospital. KristineLeahy-Gross is a Quality ImprovementAnalystfor the same hospital. Kristine hasworked in quality improvement for thepast five years, with recent performanceimprovementprojects geared towards outcomes research.
retrospective look at three years ofinsertions.] Intrav Nurs 16(2): 92-103.
12. Lam, S., et at. 1994. Peripherally insertedcentral catheters in an acute care hospital. Arch Inter Med 154: 1833-1837.
13. 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
16. Ryder, M. 1995. Peripheral accessoptions. Surg Oncol Clinics ofNorth Am
4(3): 392-422.17. Adams, A. 1995. Venous access devices:
Case Studies for appropriate selection.InfUSiOn. 2: 11-14.
F a I I I 998 ~VAD 2S
complications after indwelling for lessthan 6 days was only 21%. The overallnumber of midlines that made it to theend of therapy was 51%. If a midlinecatheter was in 6 days or longer thenthe number of catheters that made tothat point was 88% (Figure 2). However,if a midline catheter was indwelling forless than 6 days, typically the removalreasons were removal by the patient,line change to a different VAD, phlebitis,occlusion, migration, or leaking.
Trends and BenchmarkingBesides using outcomes to look at
your own performance over time, youcan also compare your outcomes tonational standards or other PICC programs. For example, we recently wereable to compare our data with an articlepublished in Infusion magazine, I whichpresented PICC line and midclavicularcatheter data collected from 1989 to1995. The Oncological urses Societyhas published standards that includeranges for occlusion and phlebitis.6
Dennis Maki, MD has published a comparison of sepsis rates for each of several types of central lines.7 Eachprogram has to decide what outcomesthey will monitor and what acceptableoutcomes are. All PICC programs do notfunction the same. Some of the manyvariables are type of PICC line, insertiontechniques, care and maintenance pro-
1. Poole, S.M., Vasilios, A.N. 1998. Outcomes Measurements: Making sense ofthe data. Infusion 4(8): 25-28.
2. Thomson, S. 1993. N therapy: A feasibilitystudy. Nursing Management 24(6): 68 A-G.
3. Cardella, ].F., et al. 1996. Cumulativeexperience with 1,273 peripherallyinserted central catheters at a single institution. jVIR 7(1): 5-13.
4. Macklin, D. 1997. How to managePICCs. Am] Nurs 97(9): 27-33.
5. Merrell, S.W., et al. 1994. Peripherallyinserted central venous catheters: Lowrisk alternatives for ongoing venousaccess. West] Med 160(1): 25-30.
6. Camp-Sorrell, D. 1996. Access deviceguidelines: Recommendations for nursingpractice and education. Oncology Nursing Press, pp. 60-63.
cedures and use of infusion nurses ornot. ew catheters and related supportequipment (dressings, caps, flushes,securing mechanisms, etc) are available.How do we know if something newworks if we don't know what the outcomes are? In this era of cost containment, how do we justify a more costlypiece of equipment up front with thehope of saving money in the long run?
Staff-related variablesurses have an initial PICC line train
ing class and preceptorship at our hospital and then an annual review. Theyhave to meet specific criteria in order tomaintain the privilege of placing lines.Staff can then compare their outcomeswith the total numbers. For example,one nurse placed 114 of the 363 linesduring the time period analyzed (October 1997 through January 1998). Hermean dwell for PICC lines was 20 days.The number that made it to the end oftherapy without complications was 68%.Another nurse placed 21 of 363 longerlines and her mean dwell of PICC lineswas 73 days. The number to end oftherapy without complications was 700A>.
SummaryUsing patient outcomes to drive our
practice allows us to evaluate our PICCand midline program on a continuousbasis. Some of our program goals are:
REFERENCES7. Maki, D.G. 1994. Infections caused by
intravascular devices used for infusiontherapy: Pathogenesis, prevention, andmanagement. Infections Associated With
Indwelling Medical Devices, 2nd Ed., pp.155-212.
8. Kearns, P., et al. 1995. Complications oflong arm catheters: A randomized trial ofcentral vs. peripheral tip location. ]PEN
20(1): 20-24.
9. Miller, K., Kietrick, C. 1997. Experiencewith PICC at a university medical center.] Intrav Nurs 20(3): 141-147.
10. Maki, D. 1994. Yes, Virginia, aseptic technique is very important: Maximal barrierprecautions during insertion reduce therisk of central venous catheter-relatedbacteremia.
ll. Goodwin, M.L., Carlson, I. 1993. Theperipherally inserted central catheter. A
• Ongoing monitoring and reportingon the outcomes of all lines placed,with data summaries;
• Change to latex-free insertion;• Increase continuity of care between
hospital and home;• Implement 100 u/mL heparinized
saline flush protocol;• Evaluate new technology;• Adopt a standardized site care tray;• Standardize diagnosis, definition,
treatment of suspected PICC lineinfection; and
• Continue to decrease complicationrates and increase the number oflines that make it to the end of therapy without complications.Using a scannable form makes this
process more efficient and less timeconsuming. Requiring that the personwho 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 Hospitaland Clinics in Madison, WT. lane is a former IV nurse and is the PICC ProgramCoordinator for the hospital. KristineLeahy-Gross is a Quality ImprovementAnaiystfor the same hospital. Kristine hasworked in quality improvement for thepast five years, with recent performanceimprovementprojects geared towards outcomes research.
retrospective look at three years ofinsertions.] Intrav Nurs 16(2): 92-103.
12. Lam, S., et al. 1994. Peripherally insertedcentral catheters in an acute care hospital. Arch Inter Med 154: 1833-1837.
13. 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
