The Case

A 20-year-old woman with a past medical history of ulcerative colitis was admitted for further evaluation of ongoing diarrhea, severe malnutrition, lower extremity edema, and tachycardia. Diagnostic tests identified a pulmonary embolism and occlusive thrombus in the right brachial vein surrounding the patient’s peripherally inserted central catheter (PICC) line. The type of PICC line and French gauge (diameter in mm, e.g., 4 Fr. single lumen, or 5 Fr. dual lumen) and the length of time the PICC had been in place were not noted.

The patient was started on apixaban for thrombosis and intravenous steroids to control her inflammatory bowel disease. She was discharged home after one week on apixaban, a 30-day taper of prednisone, and oral vancomycin for Clostridioides difficile. Additionally, discharge instructions included a continuation of adalimumab for her ulcerative colitis. The PICC line was left in her right brachial vein, supposedly for ease of future laboratory blood testing. At the time of discharge, the patient was not given any education or supplies for cleaning or flushing the line, or any instructions regarding PICC care and signs of PICC line infection, malfunction, or dislodgement. Discharge follow-up did not include home health services.

On follow-up with a primary care provider several days after discharge, the PICC line was inspected. The PICC dressing was dated six days earlier, which meant that it was due to be changed within one day. The patient confirmed that the line had not been flushed since her discharge date. The primary care provider could not flush the line as the necessary supplies were unavailable in the outpatient office. The provider placed an urgent referral to home health care; however, due to the upcoming three-day holiday weekend, the home health agency could not get the bandage changed or the line flushed until after the holiday. Accordingly, the primary care office staff changed the dressing and instructed the patient to go to the emergency department (ED) before the weekend to assess the line. The ED staff flushed the line and applied a new PICC dressing. The patient was sent home with a two-week supply of flushes and two additional bandages.

The Commentary

By Carla S. Martin, MSN, RN, CIC, CNL, NEA-BC, FACHE, Shannon K. Reese, BSN, RN, VABC, and Margaret Brown-McManus, MSN, RN, CNL

Over the past decade, peripherally inserted central catheters (PICC) have grown in popularity over traditional central venous catheters (CVC) due to their broad applicability across the continuum of care, relative convenience, cost-effectiveness, and continued durable venous access in patients requiring long-term therapies of > 14 days.^1–4 Despite the relative ease of insertion and the availability of specialty vascular access teams, PICC lines carry the potential for increased mortality and morbidity related to serious complications, including venous thrombosis, central line-associated bloodstream infections, and sepsis.^2,3,5,6,7,8  This commentary provides evidence-based information regarding the safety and efficacy of PICC lines compared to other central venous catheters. It is based on the currently available evidence on complications, at-risk populations, duration of access, and important patient education regarding care and maintenance after discharge from the acute care setting.

Significance

A PICC is a central venous access device terminating in the superior vena cava (SVC) or right atrium (RA). Still, unlike other CVCs, it is placed peripherally through the basilic, brachial, cephalic, or medial cubital vein of the arm.^6,9 Over 2.7 million PICC insertions are performed yearly in the United States.¹⁰ This growing trend is driven by several factors. PICC lines can: (i) remain in place for prolonged periods,^1,3 (ii) accommodate a large variety of fluids, including hyperosmolar and vesicants, (iii) be placed by a member of a trained vascular access team,^3–5 and (iv) carry fewer risks (or at least are believed to do so) than other CVCs.^4,5

Safety of PICCs

PICC lines, while relatively safe, carry the potential for complications similar to other CVCs.^1,2,4–6 Systematic reviews and meta-analyses by Johansson et al.⁴ and Chopra et al.^5,7,8 demonstrated that PICC lines are associated with a higher risk of deep vein thrombosis (DVT) compared to CVCs, especially in patients who are critically ill or those with malignancy. This increased risk is thought to be primarily due to the initiation of a triad of factors (Virchow’s triad)–consisting of hypercoagulability, stasis, and endothelial injury–which occurs when the PICC line is placed.^7,11 The overall incidence of upper extremity DVT is low, given a large number of PICCs placed annually; however, these lines account for a significant percentage of overall DVT, which Liem et al. determined to be about 37%.¹²

Risk of Infection  

The Centers for Disease Control and Prevention (CDC) estimates that approximately 250,000 central line-associated bloodstream infections (CLABSI) occur each year, with most related to an indwelling intravascular device.¹³ PICC lines were initially believed to be associated with a lower incidence of bloodstream infections because they are placed peripherally rather than centrally; however, there is a growing body of evidence indicating that PICC lines can contribute to bloodstream infections as much as other CVCs.² For example, Chopra et al.¹⁴ found that PICCs in outpatient settings were associated with a lower risk for CLABSI than PICCs in hospitalized patients. Still, among hospitalized patients, the risk of developing a CLABSI from a PICC line was similar to that of other CVCs. ^2,15 The increased risk to inpatients highlights the need for vigilance by hospital staff in appropriate line selection and adherence to sound infection prevention strategies, which include maximizing sterile barriers during insertion, adhering to good hand hygiene practices, and changing sterile dressings every two days for gauze dressings and at least every seven days for transparent dressings.^8,15 Additionally, the insertion site should be assessed daily for any signs of redness or oozing, and the dressing should be replaced as soon as it becomes loose or soiled.¹⁵ 

Other Factors for Consideration

Many other variables have been associated with an increased risk of infection or thrombus in patients with a PICC line, including:                                                                                   

• patient having cancer (increased risk of both thrombus and infection)^2,6–8,16
• the patient is a child (thrombus)^4,16
• diameter (Fr.) of the catheter (smaller is better)^7,8,12
• number of lumina (fewer is better)^2,7,8,12,15
• location of the catheter tip should terminate in the lower one-third of the superior vena cava to reduce the risk of thrombus^1,17
• catheter material (silicon vs. polyurethane). Polyurethane catheters are associated with lower rates of infection, dislodgment, thrombus, and rupture compared to silicon ^3,18

Duration of Access

Duration of access is one of the primary clinical considerations in selecting the most appropriate vascular access device.¹ Perhaps the most attractive feature of a peripherally inserted central catheter is the freedom to allow patients to be discharged home while continuing durable venous access. A PICC can remain in place for prolonged periods and thus support a wide array of continued therapies, including administration of intermittent fluids, parenteral nutrition, chemotherapy, and other therapies, including phlebotomy in patients for which venous access is difficult. The suitability of PICC lines for such a broad range of clinical situations has led to highly variable practices in selecting appropriate intravenous catheters for patients. In 2015, Chopra et al.¹ published The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). These published guidelines incorporate evidence-based practices, and the authors applied the guidelines to 665 different clinical scenarios. Each scenario was rated as appropriate, neutral/uncertain, or inappropriate. This exercise served as a first step toward establishing a standard of care based on the best available evidence. The MAGIC criteria address PICC practices related to appropriate line selection, duration of access, care and maintenance, specific patient populations, management of complications, and PICC removal.¹ The MAGIC guidelines recommend that removal of PICC lines in hospitalized patients is appropriate when (i) the PICC has not been used for a clinical purpose for more than 48 hours, (ii) when the clinical indication for the line is completed, i.e., parenteral nutrition, or (iii) when the line is only being used for routine blood sampling in a hemodynamically stable patient when peripheral veins are present.¹ Based on the evidence as it applies to this clinical scenario, discharging this person home with a PICC line solely to avoid the discomfort associated with future blood draws would not be an appropriate use of a PICC line.

Patient Education

Lengths of stay in hospitals have decreased steadily over the past 40 years.¹⁹ Increasing complexity of healthcare, higher patient acuity, and nursing shortages have contributed to less time available to ensure safe discharges as patients move from one care setting to another. Communication between care teams and patients must be well coordinated and individualized based on the patient's preferred language, culture, and educational level, which will help ensure safety during each care transition.²⁰ Providing culturally competent patient education and coordination of care activities, such as ensuring home health services, making follow-up appointments with medical providers, and obtaining durable medical supplies and medications at discharge, are critical to patient safety and well-being. Patients who do not receive enough information at discharge tend to adhere poorly to their treatment plan, experience more patient safety-related issues, and visit emergency departments more often.²¹

This case illustrates the fragmentation of care resulting from our siloed and complex care systems in this country. These barriers can be overcome through good communication and coordination between the healthcare teams and their patients. The care team must be attentive when discharging patients with central venous access devices to ensure that patients have the information and tools they need to keep the device safe and infection-free after discharge. Education on PICC care should begin with members of the vascular access teams, who should then ensure that patients being discharged have the knowledge, skills, and supplies they will need to maintain the central venous line independently at home or semi-independently in a lower acuity setting.

Essential education for ensuring PICC safety should include the following:

• Simple PICC line explanation 
  • central lines require a higher level of care and maintenance and have higher risks compared with peripheral lines
• Care and Maintenance of the Line
  • the line is central, meaning it is about 24 inches long and thread up the arm until it reaches the large vein sitting right above the heart ²²
  • a plan for the line after discharge, including who will be caring for it;
  • confirming that the patient has enough supplies to last until the follow-up appointment with the provider or until a home health visit occurs;
  • ensuring that the patient knows how to change the dressing if it becomes soiled or loose and the importance of keeping the dressing clean and dry;²² and
  • reinforcing the importance of good hand hygiene before touching the line and preventing it from getting wet in the shower.
• When to Call your Healthcare Provider or go to the Emergency Department
  • if you develop a fever;
  • if you become short of breath or develop a cough;
  • if blood or other fluids leak from the insertion site;
  • if you develop pain or swelling in the arm, chest, or face;
  • if you develop redness, warmth, or a lump at the insertion site;
  • if there is a change in the length of the tube; or
  • if you have any other pain or discomfort when receiving medications in your line.²²

Systems Change Needed/Quality Improvement Approach

Loop Closure

PICC lines provide essential long-term central venous access for many clinical conditions and therapies. However, the ease and convenience of using these devices should not lead health care providers to downplay the risks associated with this type of central line. Good communication, including “closing the loop” between caregivers and patients, is vital to promoting the safe use of PICC lines.

Written communication is important. As with any central line, having clear documentation of the type of PICC line–i.e., single, dual, or triple lumen, location, and date of insertion–is essential to helping the provider make critical safety decisions regarding the PICC line.

Ensuring patients understand their part in keeping the PICC line safe is crucial. Patients have different learning styles. Assessment of whether the patient prefers written or video instructions, e.g., should be made. Patient participation during dressing changes and line flushes through return demonstration allows the nurse to assess the patient's understanding and proficiency in performing the skill. This type of hands-on, guided learning promotes confidence and enhances the patient’s ability to correctly perform the skill after discharge.²³

Anticipating the patient's needs at the time of discharge is essential. At discharge, provide the patient with the supplies necessary to maintain the line. Review with them their plan for follow-up care. Finally, providing verbal and written instructions on when to notify a healthcare provider or go to the emergency department is key to improving patient experience and preventing serious patient harm. Caring for your PICC line at home.

Conclusion

There are several keys to minimizing the risks associated with using PICC lines. Providing healthcare staff and patients with fundamental knowledge of PICC lines is one way to help mitigate the potential risks. Another important quality improvement approach to take is to anticipate patients' discharge needs and provide them with the supplies and information they will require. Good communication and coordination of care among the healthcare teams will also improve the likelihood that the PICC line can remain in place for an extended period and thus support the patient's clinical needs.

Take-Home Points

• A PICC line is a central line and is associated with an increased risk of upper extremity DVT and infection, especially in critically ill patients or those with malignancy^4,5,10.
• PICCs and other CVCs carry equal risk of developing CLABSI in inpatient settings¹⁴
• Attention to good infection-prevention practices during line insertion, when performing line care, or when accessing the line is key to reducing the risk of CLABSI.¹⁵
• Culturally competent education and testing of individual patient knowledge and skills through return demonstration of PICC line care and maintenance will reduce risks and ensure the PICC functions as intended and for the length of time needed²⁴
• Healthcare personnel should ensure patients understand the risks associated with a central line and under what circumstances they should contact a healthcare provider or seek immediate medical attention²²
• MAGIC criteria can assist healthcare providers in selecting the appropriate vascular access device based on the risk/benefit to an individual patient¹

Carla S. Martin, MSN, RN, CIC, CNL, NEA-BC, FACHE
Executive Director
Patient Care Services, Quality & Safety, Hospital Infection Prevention and Epidemiology
UC Davis Health
carmartin@ucdavis.edu

Shannon K. Reese, BSN, RN, VABC
Assistant Nurse Manager
Vascular Access Team
UC Davis Health
sreese@ucdavis.edu

Margaret Brown-McManus, MSN, RN, CNL
Unit Director
Patient Care Services, Radiology Nursing, AIM, & PICC Services
UC Davis Health
mbrownemcmanus@ucdavis.edu

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