Although he's known as “the PICC guy” around the University of Michigan Health System, Vineet Chopra, MD, MSc, FACP, appreciates the difficulty many hospitalists face choosing vascular access devices for their patients. “It's not easy, because there's no good data. … We have general, very nonspecific recommendations,” he said during his Hospital Medicine 2017 session “Take Your PICC!”
Choosing an inappropriate device can have serious consequences for patients. For example, you'd never want to place a PICC with more lumens than necessary because the risk of bloodstream infection increases with the lumens, Dr. Chopra reported. “If you look at a single lumen, the rate's about 2%, a double lumen it goes to 3%, a triple it moves up to almost 4%,” he said.
To help clinicians choose the best device, Dr. Chopra and colleagues developed the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), a set of recommendations on vascular access device selection, published by Annals of Internal Medicine on Sept. 15, 2015. (See the October 2015 ACP Hospitalist for more on MAGIC.) Now he's working to get those recommendations from paper into practice.
How it works
In Michigan, a consortium of 51 hospitals collaborates on a quality improvement (QI) initiative funded by Blue Cross/Blue Shield and Blue Care Network. “About two years ago, we started with a pilot that's since morphed led to a full-fledged statewide project looking at PICC use, outcomes and complications,” said Dr. Chopra. The project began by gathering data on how vascular devices are used in the participating facilities and then moved on to developing strategies for bringing care in line with the MAGIC recommendations.
The strategies varied by hospital. At some hospitals, the solutions were as simple as a form that helped clinicians choose a PICC or midline. At the University of Michigan, an order set based on the guidelines was integrated into the electronic health record. “It basically takes the MAGIC criteria and puts it into Epic. It forces people to look at the indication for use,” said Dr. Chopra. “If you choose difficult access [as the indication], the next question is how long you're going to use it for. If you say less than five days, it will ask you for a clinical reason—why are you doing that?” The tool also asks about the number of lumens required and the patient's renal function, among other factors, to help ensure appropriate use.
Results and challenges
Since the project launched, participating hospitals' practices have come more in line with the recommendations, Dr. Chopra reported. “They're all different, but they're all able to do it,” he said.
Across Michigan, the percentage of PICCs that were single-lumen increased from 36.6% in the second quarter of 2015 to 40.9% in the first quarter of 2016. Meanwhile, triple-lumen use dropped from 13.5% to 10.0% in the same period. The percentage of PICCs in place for less than five days (another practice counter to the recommendations) dropped from 24.0% to 19.0% overall.
PICC complications are also decreasing. “We've seen a drop in our DVT rates for the first time. We've gone from 3% down to 2%,” said Dr. Chopra. A community hospital that participated in the initial pilot project showed a 48% drop in occlusion events and a 32% decrease in venous thromboembolism and central line-associated bloodstream infections in a year of order-set use.
“We estimate they saved about $600,000 conservatively,” said Dr. Chopra. “Pretty good for a vascular access nurse-led QI project, right?”
Challenges faced by the program include clinician buy-in, especially in the ICU. The evidence base isn't very robust, with few meta-analyses or systematic reviews, Dr. Chopra noted. Hospitals may also lack the resources to modify their electronic medical record systems.
To help such facilities and expand their work outside the state, Dr. Chopra and colleagues created a website of free resources and more recently, another tool. “There's an app for that,” he said. The recently released MAGIC app is free for Android and iOS devices and works similarly to the University of Michigan order set, asking questions about a patient's indications for vascular access and offering guidance on device selection.
For example, “If you choose IV antibiotics, the next question is, ‘Have you gained [infectious disease] approval?’ If you are bold enough to say no, it says, ‘Whoa, stop,’” Dr. Chopra described. He noted that it's entirely up to the clinician using the app to follow the advice; the researchers are not tracking the data.
They do plan to follow up with users to see how the app is working or could be improved and hope to eventually add features for patients. “Wouldn't it be great if you, as a patient, could ask the right questions before you get the PICC or know how best to care for your device with videos or instructional diagrams?” Dr. Chopra said.
Words of wisdom
Although vascular access nurses are natural leaders of projects to improve PICC use, hospitalists have proven to have a key role in past efforts. “Because physicians don't like being told no by my colleagues in nursing, they need a physician champion,” said Dr. Chopra.