Figure - available via license: CC BY
Content may be subject to copyright.
Data on PICC Appropriateness and Complications by ID Physician Approval
Source publication
Importance
Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous antimicrobial therapy. However, inappropriate PICC use may lead to patient harm.
Objective
To evaluate whether infectious disease physician approval prior to PICC placement for intravenous antimicrobials is associated with more appropriate device...
Citations
... Although PICCs and totally implantable venous access devices (TIVADs) are both better than CVCs in terms of the occlusion rate [26,27], PICCs and TIVADs are more suitable for long-term infusion therapy patients, while CVCs are more suitable for short-term infusion therapy and surgery patients. A 25-38% occlusion rate was found for the CVC, and a new flushing and locking technique was designed to solve this problem. ...
Background
Maintaining venous access is of great clinical importance. Running a slow continuous infusion to keep the vein open (KVO) is often used in peripheral intravenous catheters (PIVCs). Previous studies have compared the effects of intermittent flushing and continuous infusion via peripherally inserted central catheters (PICCs). In this study, we applied KVO to central venous catheters (CVCs) and compared the occlusion rate of this technique with that of the intermittent flushing technique.
Method
This is a randomized controlled trial of 14 hospitals in China. A total of 250 patients will be recruited in this study, and they will be randomized at a 1:1 ratio. After study inclusion, patients who will undergo CVC insertion will receive intermittent flushing with prefilled saline syringes (control group) or KVO infusion with elastic pumps (test group). All the catheters will be checked for patency by scoping Catheter Injection and Aspiration (CINAS) Classification on Days 3 and 7. The primary outcome is the rate of catheter occlusion in 7 days. Patients will be followed up until 9 days after CVC insertion, catheter occlusion, or catheter removal. The secondary outcomes are the rate of catheter occlusion in 3 days, nurse satisfaction, cost-effectiveness, adverse event rate, catheter-related bloodstream infection rate, catheter-related thrombosis rate, extravasation rate, phlebitis rate, and catheter migration.
Discussion
We expect that the trial will generate findings that can provide an evidence-based basis for the improvement and optimization of clinical catheter flushing techniques.
Trial registration
Chinese Clinical Trial Registry, ChiCTR2200064007. Registered on 23 September 2022. https://www.chictr.org.cn/showproj.html?proj=177311.
... Peripherally inserted central catheters, or PICCs, are a form of central venous access used for intermediate to long-term use, with average time in situ ranging from one week to six months [6]. While PICCs can allow for the outpatient treatment of bacteremia, septic arthritis, or osteomyelitis, as well as the administration of chemotherapeutic drugs, they are associated with signifcant complications, including central line-associated bloodstream infections and deep venous thrombosis [7,8]. Te use of PICCs has increased in recent years, so has the incidence of these complications [9,10]. ...
Trueperella bernardiae is a Gram-positive bacterium known to cause a wide variety of opportunistic infections in humans. We report a novel case of T. bernardiae bacteremia in a paraplegic patient due to a peripherally inserted central catheter- (PICC-) associated infection that was treated successfully with piperacillin/tazobactam.
... They provide expert clinical care for complex ID, tailoring treatment plans to individual patients and improving outcomes while reducing costs [4,[22][23][24][25][26]. Infectious diseases consultation has demonstrated significant benefits, including a 19% reduction in in-hospital mortality and a 41% decrease in costs [16]. Infectious diseases physicians are champions of antimicrobial stewardship, preventing the development of resistant organisms and reducing healthcare-associated infections through appropriate antibiotic use [27][28][29][30]. They track and respond to ID outbreaks, preventing large-scale epidemics and saving costs by controlling economic and social impacts [1,3]. ...
Infectious diseases (ID) physicians play a pivotal role in patient care and public health, yet concerns are mounting about their under-compensation compared to other medical specialties. This trend sees ID physicians, including new graduates, receiving lower remuneration than their general and hospital medicine peers, despite their significant contributions. The persistent disparity in compensation has been identified as a key factor behind the declining interest in the ID specialty among medical students and residents, potentially threatening patient care quality, research advancement, and diversity within the ID workforce. This viewpoint underscores the urgent need for the ID community to rally behind the Infectious Diseases Society of America (IDSA) in advocating for fair compensation for ID physicians and researchers. While focusing on wellness and work-life balance is vital, it is critical to address compensation, a significant source of distress for physicians. Failure to confront the issue of under-compensation promptly may jeopardize the future growth and sustainability of the ID specialty.
... Work to reduce short-term and multi-lumen PICC use and PICC placement in patients with chronic kidney disease evolved, with hospitals innovating using evidence, clinical context, and benchmarked data to spur performance. Ongoing measurement has demonstrated sustained patient safety benefits, which we have published previously [18,19,27], showing that, with the appropriate strategy, evidence can translate into clinical practice. ...
Peripherally inserted central catheters (PICCs) are prevalent devices for medium-to-long-term intravenous therapy but are often associated with morbid and potentially lethal complications. This multi-center study sought to identify barriers and facilitators of implementing evidence-based appropriateness criteria to improve PICC safety and patient outcomes in a pay-for-performance model. Participating hospitals received an online toolkit with five recommendations: establishing a vascular access committee; implementing a clinical decision tool for PICC appropriateness; avoiding short-term PICC use (≤5 days); increasing use of single-lumen PICCs; and avoiding PICC placement in patients with chronic kidney disease. Longitudinal online surveys conducted biannually October 2014–November 2018 tracked implementation efforts. A total of 306 unique surveys from 34 hospitals were completed. The proportion of hospitals with a dedicated committee overseeing PICC appropriateness increased from 53% to 97%. Overall, 94% of hospitals implemented an initiative to reduce short-term and multi-lumen PICC use, and 91% integrated kidney function into PICC placement decisions. Barriers to implementation included: achieving agreement from diverse disciplines, competing hospital priorities, and delays in modifying electronic systems to enable appropriate PICC ordering. Provision of quarterly benchmarking reports, a decision algorithm, access to an online toolkit, and presence of local champion support were cited as crucial in improving practice. Structured quality improvement efforts including a multidisciplinary vascular access committee, clear targets, local champions, and support from an online education toolkit have led to sustained PICC appropriateness and improved patient safety.
... 25 Thus, interventions that promote and facilitate subspecialist consultation prior to PICC insertion could be important, especially at sites without VATs, to reduce potential hazards. 26 VAT sites also used explicit decision-making criteria, namely MAGIC, 1 which emerging evidence suggests is associated with improved safety and lower overall PICC use. 5 27 28 Nonetheless, many ordering clinicians were not aware that appropriateness criteria existed, and no formal criteria were used at the non-VAT sites. This finding suggests a universal need for better education and strategies to seamlessly facilitate decisionmaking, such as embedding appropriateness criteria as part of a PICC order set, as was done at one VAT site. ...
Background
Peripherally inserted central catheters (PICCs) provide reliable intravenous access for delivery of parenteral therapy. Yet, little is known about PICC care practices or how they vary across hospitals. We compared PICC-related processes across hospitals with different insertion delivery models.
Methods
We used a descriptive qualitative methodology and a naturalist philosophy, with site visits to conduct semistructured interviews completed between August 2018 and January 2019. Study sites included five Veterans Affairs Medical Centres, two with vascular access teams (VATs), two with PICC insertion primarily by interventional radiology (IR) and one without on-site PICC insertion capability. Interview participants were healthcare personnel (n=56), including physicians, bedside and vascular access nurses, and IR clinicians. Data collection focused on four PICC domains: use and decision-making process, insertion, in-hospital management and patient discharge education. We used rapid analysis and a summary matrix to compare practices across sites within each domain.
Results
Our findings highlight the benefits of dedicated VATs across all PICC-related process domains, including implementation of criteria to guide PICC placement decisions, timely PICC insertion, more robust management practices and well-defined patient discharge education. We also found areas with potential for improvement, such as clinician awareness of PICC appropriateness criteria and alternative devices, deployment of VATs and patient discharge education.
Conclusion
Vascular access nurses play critical roles in all aspects of PICC-related care. There is variation in PICC decision-making, care and maintenance, and patient education across hospitals. Quality and safety improvement opportunities to reduce this variation are highlighted.
A literature review was conducted to evaluate the potential economic and clinical impact of hydrogel catheter materials on the incidence of catheter-related complications. Of 10,635 abstracts initially screened, 75 studies were included with 36 in outcomes, 28 for catheter materials, and 13 for economic analysis. The economic evaluation of peripherally inserted central catheters revealed a cost of $24,558 dollars for catheter-related thrombosis, $12,982 for infection, and $624 for occlusion which equate to a total national complication cost of $4.5 billion dollars annually. There was a 50% reduction in projected savings for all complications with the application of a hydrogel catheters which equated to nearly $1.8 million dollars annually for a typical 1000-bed acute care or $560,000 for a 300-bed facility. Limited clinical research on the hydrophilic catheter material suggests a remarkable and cost-effective reduction for incidence of common catheter complications. More research is needed to confirm data from existing studies.
Background:
The natural history of cystic fibrosis (CF) lung disease is a chronic deterioration of lung function with intermittent episodes of pulmonary infectious exacerbations (PExs). Reliable venous access is a milestone of effective management of such exacerbations, managed both in hospital and outpatient chronic therapy. The aim of our study was to analyse the feasibility of ultrasound-guided positioning of Long Peripheral Catheters (LPC) as reliable mid-term venous access in children affected by CF.
Methods:
In this single-centre prospective study, over a 60-month period, we included paediatric CF subjects admitted with pulmonary infectious exacerbations and undergoing intravenous antibiotic treatment. LPCs were inserted in all participants by paediatric anaesthesiologists with ultrasound guide technique. Prospective data were collected assessing catheter positioning procedure and complications.
Results:
A total of 122 LPC insertions were performed in 55 CF children. Participants had a median age of 6,75 years (IQR 3,7-13,5) at the time of catheter insertion. Implantation was successful on the first attempt in 86% of cases; 2 (1%) major insertion-related complications were reported. 88% of catheters were electively removed at the end of antibiotic therapy without any complication. 7% of the catheters were removed electively for occlusion and 2% for local dislodgment.
Conclusions:
The results of the present study suggest that ultrasound-guided positioning of LPCs are safe alternative means of peripheral venous access in children with chronic diseases such as CF. This article is protected by copyright. All rights reserved.
Introduction: Native osteomyelitis caused by Extended-Spectrum Beta-Lactamase producing Enterobacterales (ESBL-PE) is a matter of expert in antibiotics. Very limited epidemiologic and outcome data are available, warranting a study of these cases.
Methods: We included osteomyelitis patients infected with ESBL-PE treated in a reference center for bone and joint infections (BJIs) between 2011 and 2019 in a retrospective cohort study.
Results: Twenty-nine patients with native BJI (mean age 44.4 ± 15.7 years) were analyzed. Fifteen cases were paraplegic patients with ischial pressure sores breaching the hip capsule. Other cases included eight other hip infections, four tibial infections and two foot infections. Infections were mostly polymicrobial (n=23; 79.3%), including S. aureus (n=13) of which 8 were methicillin-resistant. Klebsiella pneumoniae (n=13) was the most frequent ESBL-producing species identified, followed by Escherichia coli (n=10), including 3 E. coli/K. pneumoniae co-infections and Enterobacter sp. (n=9). ESBL-PE were rarely susceptible to fluoroquinolones (n=4; 13.8%). Most therapies were based on carbapenems (n=22) and combination therapies (n=19). Median duration of treatment was 41 (5-60) days. Primary control of the infection was achieved in (n=18/29, 62.1%) of cases and up to 86.2% after second look surgeries, after a median follow-up of 6 (1-36) months. Infection with ESBL-producing K. pneumoniae was associated with failure (p=0.001), whereas age, localization of infection, prior colonization and antimicrobial therapy were not found to be predictors of the outcome.
Conclusion: ESBL-PE native BJIs are often polymicrobial and fluoroquinolones-resistant infections caused by K. pneumoniae, highlighting the need for expert centers with pluridisciplinary meetings with experienced surgeons.
