Supplementary Material* Supplement. Appropriateness Criteria for Vascular Access in Hospitalized Patients

Transcription

1 Supplementary Material* Chopra V, Flanders SA, Saint S, Woller SC, O'Grady NP, Safdar N, et al. The Michigan Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Method. Ann Intern Med. 205;63(Suppl):S-40. doi:0.7326/m Supplement. Criteria for Vascular Access in Hospitalized Patients * This supplementary material was provided by the authors to give readers further details on their article. The material was reviewed but not copyedited. Annals of Internal Medicine 205 American College of Physicians Downloaded From: on 04/3/208

2 APPROPRIATENESS CRITERIA FOR VASCULAR ACCESS IN HOSPITALIZED PATIENTS GLOSSARY Active cancer: A patient receiving active chemotherapy or admitted to the hospital for a cancer-related diagnosis. Chronic kidney disease (CKD): Any patient who is known have kidney damage on a long-term basis. CKD is divided into non dialysis-dependent and dialysis-dependent, as well as stages through 5. Stages through 3 are usually patients who are non dialysis-dependent and are managing their kidney disease through frequent monitoring and diabetes and blood pressure control, among other techniques. In general, patients begin to become dialysis-dependent and/or need a transplant to survive when stage 4 or 5 CKD develops. Critically ill patients: Those receiving care in an intensive care/critical care setting. Hospitalized medical patients: Those receiving care in an inpatient setting on a general medicine service. Does not include surgical and outpatients/ambulatory patients. Irritant: An agent that induces inflammation, tenderness, warmth or redness along the vein (e.g., vancomycin, cisplatin). Long-term intravenous antibiotics: Antibiotics to be given beyond the period of hospitalization (i.e., at home or an alternate care facility), usually for a duration > 7 days. Multilumen peripherally inserted central catheter (PICC): A PICC with 2 or more lumens. Special populations: A term used to identify patients who often require frequent and long-term vascular access.. Cystic fibrosis: Also known as "mucoviscidosis," this is an autosomal recessive genetic disorder that affects most critically the lungs and also the pancreas, liver, and intestine. It is characterized by abnormal transport of chloride and sodium across an epithelium, leading to thick, viscous secretions; 2. Sickle cell disease: A hereditary blood disorder, characterized by erythrocytes that assume an abnormal, rigid, sickle shape. Sickling decreases the cells' flexibility and results in risk for various complications. The sickling occurs because of a mutation in the hemoglobin gene. 3. Short gut syndrome: A malabsorption disorder caused by surgical removal of the small intestine, or rarely to the complete dysfunction of a large segment of bowel. 4. Inflammatory bowel disease: A group of inflammatory conditions of the colon and small intestine; the major types are Crohn disease and ulcerative colitis. 5. Pancreatitis: Inflammation of the pancreas, occurring when pancreatic enzymes (especially trypsin) that digest food are activated in the pancreas instead of the small intestine. Vascular access device: An instrument, either peripherally or centrally inserted, that provides entry to the venous system. Venous access: An indication for vascular access device placement where access to the venous system is needed solely for short-term infusion of therapeutics and/or laboratory draws or a combination of both during hospitalization. Access can be classified as being central (a venous access device that terminates in the veins of the neck or Downloaded From: on 04/3/208

3 chest) or peripheral (a venous access device that does not enter the veins of the neck or chest). Venous access excludes long-term antibiotic use, chemotherapy, total parenteral nutrition, or hemodynamic monitoring. Vesicant: An agent that induces blistering or redness. These agents can cause a reaction, often called "chemical cellulitis." Examples of vesicants include mitomycin and vincristine. TYPES OF VASCULAR ACCESS DEVICES Midline catheter: A vascular access device that is 7.5 cm to 25 cm in length and is typically inserted into the veins above the antecubital fossa. The tip of a midline catheter resides in the basilic or cephalic vein, terminating just short of the subclavian vein. Midline catheters are therefore peripheral devices and cannot accommodate irritant or vesicant infusions. Nontunneled central venous catheters: Often referred to as "acute" or "short-term" central venous catheters, these are often inserted for durations of 7 to 4 days. They are typically 5 to 25 cm and are placed via direct puncture (often using ultrasonography) and cannulation of the internal jugular, subclavian, or femoral veins. Peripheral intravenous (IV) catheter: A short, usually winged device that provides access to peripheral veins of the arm, foot, or the external jugular vein in the neck. Peripheral IVs can be placed at the patient s bedside by various providers, including nurses, doctors, and paramedical personnel. Peripherally inserted central catheter (PICC): A vascular access device that is inserted in the peripheral veins of an extremity in adults and terminates in a central vein (usually at the cavoatrial junction or lower one third of the superior vena cava) to provide central venous access. PICCs can be placed at the bedside by trained vascular access nurses or in the radiology suite by an interventional radiologist or a trained midlevel provider (physician assistant, nurse practitioner) with fluoroscopic guidance. Port (Mediport or Infusaport): Permanent catheters that are characterized by a subcutaneous reservoir with a diaphragm that acts as a receptacle for infusion. The reservoir is connected to a central vein in the chest with a catheter. Ports always terminate in central veins and are usually placed in the operating room or in the interventional radiology suite by surgeons or radiologists. Tunneled central venous catheter: Permanent or temporary devices that are characterized by the creation of a subcutaneous tunnel between the insertion of the catheter on the skin and the point of puncture in the vein. Tunneled catheters always terminate in central veins and can be cuffed or uncuffed. The cuff is a Dacron- or silicone-based flange that provides tethering to the subcutaneous tissue and prevents the catheter from migrating. The cuff may also provide protection against infection. Tunneled catheters are generally placed in the interventional radiology suite or in the operating room by radiologists or surgeons. Ultrasonography-guided peripheral IV catheter: Inserted in veins of the arm that may be difficult to palpate or localize under ultrasonographic guidance. Such guidance can be used to place standard peripheral IV catheters or specially designed "long" peripheral catheters that are up to 8 cm and can reach deeper veins of the arm. Downloaded From: on 04/3/208

4 Final Rating Document Scenarios for Considering Vascular Access Device : Summary Results Key ) The number in parenthesis after the numbered responses is the median response 2) =Highly Inappropriate, 5=Neutral or Uncertain, =Highly Appropriate 3) Color codes Green Appropriate (median of 7-) Orange Neutral (median of 3-6) Red Inappropriate (median of -3) Yellow Disagreement (at least 5 rated appropriate and 5 rated inappropriate) The consensus panel ratings are divided into three sections with specific clinical scenarios in each section: Section : Clinical scenarios for rating the appropriateness of vascular access devices (peripheral IVs, PICCs, midlines, tunneled-cuffed catheters and ports) in hospitalized medical patients, critically ill patients, cancer patients and special populations. Section 2: Clinical scenarios for rating the appropriateness of PICC-related consultations, insertion practices, device characteristics, maintenance, complications and removal. Section 3: Clinical scenarios for rating the appropriateness of strategies associated with peripheral IV catheter placement, removal and management. Downloaded From: on 04/3/208

5 Section : Clinical Scenarios for rating the appropriateness of vascular access devices (peripheral IVs, PICCs, midlines, tunneled-cuffed catheters and ports) in hospitalized medical patients, critically ill patients, cancer patients and special populations. INDICATIONS FOR VASCULAR ACCESS DEVICE HOSPITALIZED MEDICAL PATIENTS*. How appropriate is the use of each of the following vascular access devices for infusion of therapeutics that can be administered through a peripheral vein in a hospitalized medical patient for a proposed duration of: Peripheral IV US Guided Peripheral IV Midline PICC Tunneled-Cuffed Catheter Port a. <5 days? b. 6-4 days? c days? How appropriate is the use of each of the following vascular access devices for infusion of therapeutics that cannot be administered through a peripheral vein (e.g., irritants, vesicants) in a hospitalized medical patient for a proposed duration of: Peripheral IV or US Guided Peripheral IV Midline Non-Tunneled CVC PICC Tunneled-Cuffed Catheter Port a. <5 days? 8 7 b. 6-4 days? 7 5 c days? * Hospitalized medical patients do not include patients who are on chemotherapy or admitted for a cancer-related diagnosis. Unless otherwise specified, assume that venous access is only required during hospitalization Downloaded From: on 04/3/208

6 3. How appropriate is the use of each of the following vascular access devices to obtain venous access solely for frequent blood draws (e.g., hemoglobin every 8 hours) in a hospitalized medical patient for a proposed duration of: Peripheral IV or US Guided Peripheral IV Midline Non-Tunneled CVC PICC Tunneled-Cuffed Catheter Port a. <5 days? b. 6-4 days? c days? Is it appropriate to place a PICC in a hospitalized medical patient when peripheral venous access is difficult to obtain (e.g., frequent IV infiltration, no palpable or accessible peripheral veins) but central venous access is not needed, in order to obtain infrequent blood draws or infuse fluids and therapies for a proposed duration of: a. < 5 days? b. 6-4 days? c days of PICC Is it appropriate to place a PICC in a hospitalized medical patient when peripheral venous access is difficult to obtain (e.g., frequent IV infiltration, no palpable or accessible peripheral veins) but central venous access is not needed, in order to obtain frequent blood draws or infuse fluids and therapies for a proposed duration of: a. < 5 days? b. 6-4 days? c days of PICC Compared to PICCs, how preferable is the use of a midline or USGPIV in a hospitalized medical patient who requires venous Preference of Midline vs. PICC Preference of US Guided PIV vs. PICC Downloaded From: on 04/3/208

7 access for infusion of non-irritant, non-vesicant therapies for a proposed duration of: (Prefer Midline=, Neutral 4-6, Prefer PICC=) (Prefer US Guided PIV=, Neutral 4-6, Prefer PICC=) a. < 5 days? b. 6-4 days? c days? Compared to PICCs, how preferable is the use of a midline or USGPIV in a hospitalized medical patient who requires venous access mainly for daily laboratory testing for a proposed duration of: Preference of Midline vs. PICC (Prefer Midline=, Neutral 4-6, Prefer PICC=) Preference of US Guided PIV vs. PICC (Prefer US Guided PIV=, Neutral 4-6, Prefer PICC=) a. < 5 days? b. 6-4 days? c days? Compared to PICCs, how preferable is the use of a midline or USGPIV in a hospitalized medical patient who requires venous access for both infusion of non-irritant, non-vesicant therapies and daily laboratory testing for a proposed duration of: Preference of Midline vs. PICC (Prefer Midline=, Neutral 4-6, Prefer PICC=) Preference of US Guided PIV vs. PICC (Prefer US Guided PIV=, Neutral 4-6, Prefer PICC=) a. < 5 days? b. 6-4 days? c days? Compared to PICCs, how preferable is the use of a midline in a hospitalized medical Preference of Midline vs. PICC Downloaded From: on 04/3/208

8 patient who will require vascular access for continued outpatient intravenous antibiotic therapy, with an antibiotic that can be infused through a peripheral vein (e.g., appropriate ph and osmolarity) for a proposed duration of: a. < 5 days? b. 6-4 days? c days? (Prefer Midline=, Prefer PICC=) 7. How appropriate is it to place an advanced venous access device in a hospitalized medical patient who does not require central venous access, but has difficult peripheral IV access who has required: a. -3 peripheral IV placements in <48 hours? b. >4 peripheral IV placements in <48 hours? of PICC 4 6 Downloaded From: on 04/3/208

9 2. How appropriate is it to consider placement of a PICC or midline in a hospitalized medical patient who has reliable peripheral venous access, does not require central venous access, but specifically requests the placement of a PICC: of PICC of Midline a. for comfort from routine lab draws (once/day)? b. for comfort from frequent lab draws (3 or more times/day)? c. for comfort/ease of intermittent (2 or more times/day) intravenous medication administration (opiates, antiemetics) with objective evidence/clinical necessity of the same? d. for comfort from frequent lab draws (3 or more times/day) and intermittent intravenous medication administration (opiates, anti-emetics)? e. during end of life/comfort care? In a hospitalized medical patient admitted with a diagnosis that is likely to require 4-6 weeks of intravenous antibiotic treatment for a chronic infection (osteomyelitis, endocarditis), how appropriate is it to transition from a peripheral IV catheter to a PICC within: of PICC with bacteremia of PICC without bacteremia a. < day of admission? b. 2-3 days of admission? c. 4-6 days of admission? d. greater than a week (7 days) of admission? Downloaded From: on 04/3/208

10 INDICATIONS FOR VASCULAR ACCESS DEVICE PATIENTS WITH CHRONIC KIDNEY DISEASE (CKD) 4. How appropriate are each of the following vascular access devices in a hospitalized medical patient with stage -3A CKD who is not on dialysis but needs intravenous antibiotics following discharge from the hospital for a proposed duration of: Peripheral IV (dorsum of hand) US Guided PIV Midline PICC Small Bore Tunneled Catheter Port a. <5 days? b. 6-4 days? c days? How appropriate are each of the following vascular access devices in a hospitalized medical patient with stage 3B 5 CKD who is not on dialysis but need intravenous antibiotics following discharge from the hospital for a proposed duration of: Peripheral IV in dorsum of hand US Guided PIV Midline PICC Small Bore Tunneled Catheter Port a. <5 days? b. 6-4 days? c days? Downloaded From: on 04/3/208

11 6. How appropriate are each of the following vascular access devices in a medical patient with Stage 5 CKD on dialysis who needs intravenous antibiotics that cannot be given with dialysis, following discharge from the hospital for a proposed duration of: Peripheral IV in dorsum of hand US Guided PIV Midline PICC Small Bore Tunneled Catheter Port a. <5 days? b. 6-4 days? c days? How appropriate is the placement of a small bore tunneled catheter or a port rather than a PICC in a hospitalized medical patient with stage -3A CKD who requires central venous access for a proposed duration of: of Small Bore Catheter vs. PICC (Prefer Small Bore Tunneled Catheter=, Neutral 4-6, Prefer PICC=) of Port vs. PICC (Prefer Port=, Neutral 4-6, Prefer PICC=) a. <5 days? b. 6-4 days? c days? Downloaded From: on 04/3/208

12 8. How appropriate is the placement of a small bore tunneled catheter rather than a PICC in a hospitalized medical patient with stage 3B - 5 CKD, not on dialysis, who requires central venous access for a proposed duration of: a. <5 days? b. 6-4 days? c days? of Small Bore Tunneled Catheter vs. PICC (Prefer Small Bore Tunneled Catheter=, Neutral 4-6, Prefer PICC=). How appropriate is the placement of a small bore tunneled catheter rather than a PICC in a hospitalized medical patient with Stage 5 CKD currently on dialysis who requires central venous access for a proposed duration of: a. <5 days? b. 6-4 days? c days? of Small Bore Tunneled Catheter vs. PICC (Prefer Small Bore Tunneled Catheter=, Neutral 4-6, Prefer PICC=) Downloaded From: on 04/3/208

13 20. Among patients with stages -3A CKD, in whom peripheral venous access is difficult to obtain but who do not otherwise require central venous access, how appropriate is the insertion of a PICC to obtain blood for laboratory testing and infusion of therapeutics for a proposed duration of: of PICC a. < 5 days? b. 6-4 days? c days? Among patients with Stage 3B 5 CKD, who are not on dialysis in whom peripheral venous access is difficult to obtain but who do not otherwise require central venous access, how appropriate is the insertion of a PICC to obtain blood for laboratory testing and infusion of therapeutics for a proposed duration of: a. < 5 days? b. 6-4 days? c days? of PICC 22. Among patients with CKD (Stage 5) in whom peripheral venous access is difficult to obtain and are currently on hemodialysis, how appropriate is the insertion of a PICC to obtain blood for laboratory testing and infusion of therapeutics for a proposed duration of PICC Downloaded From: on 04/3/208

14 of: a. < 5 days? b. 6-4 days? c days? INDICATIONS FOR VASCULAR ACCESS DEVICE CANCER PATIENTS* Downloaded From: on 04/3/208

15 23. How appropriate is the use of each of the following vascular access devices in a patient with active cancer who may require multiple cycles of non-irritant, non-vesicant chemotherapy that can be delivered through a peripheral vein for a proposed duration of: Peripheral IV PICC Tunneled-Cuffed Catheter Port a. < 3 months? b. 3-6 months? c. > 6 months? How appropriate is the use of each of the following vascular access devices in a patient with active cancer who may require multiple cycles of irritant or vesicant chemotherapy that cannot be delivered through a peripheral vein for a proposed duration of: Peripheral IV PICC Tunneled-Cuffed Catheter Port a. < 3 months? 7 5 b. 3-6 months? 8 6 c. > 6 months? *Active cancer patients = patients that are currently receiving chemotherapy or hospitalized for a cancer-associated diagnosis Downloaded From: on 04/3/208

16 25. How appropriate is the use of each of the following vascular access devices in a patient with active cancer who requires frequent blood draws for a proposed duration of: Peripheral IV US Guided PIV Midline Non-Tunneled Catheter PICC Tunneled-Cuffed Catheter Port a. < 5 days? b. 6-4 days? c days? d. greater than 30 days? Among patients with active cancer in whom peripheral venous access becomes difficult to obtain but central venous access is not required, how appropriate is the insertion of a PICC for obtaining blood for laboratory testing or infusion of therapeutics for a proposed duration of: a. < 5 days? b. 6-4 days? c days? of PICC Downloaded From: on 04/3/208

17 27. Among patients with active cancer in whom peripheral venous access becomes difficult to obtain and central venous access is required, how appropriate is the insertion of a PICC for obtaining blood for laboratory testing or infusion of therapeutics for a proposed duration of: a. < 5 days? b. 6-4 days? c days? of PICC Downloaded From: on 04/3/208

18 INDICATIONS FOR VASCULAR ACCESS DEVICE CRITICALLY ILL PATIENTS* 28. How appropriate is the use of each of the following vascular access devices to obtain venous access in a critically ill patient who does not require centrally administered medications or invasive hemodynamic monitoring for a proposed duration of: Peripheral IV US Guided PIV Midline PICC Non-Tunneled Catheter Tunneled-cuffed Catheter/Port a. < 5 days? b. 6-4 days? c days? How appropriate is the sole use of each of the following vascular access devices to obtain venous access in a critically ill patient who needs centrally administered medications but not invasive hemodynamic monitoring for a proposed duration of: Peripheral IV US Guided PIV Midline PICC Non-Tunneled Catheter Tunneled-cuffed Catheter/Port a. < 5 days? b. 6-4 days? c days? *Critically ill patients are those that are receiving care in an intensive care (ICU) setting (examples include cardiac ICU, surgical ICU, trauma ICU, etc.) Downloaded From: on 04/3/208

19 3. Compared to a non-tunneled catheter, how preferable is the use of a PICC for central venous access in a critically ill patient who: a. may, but has not yet, developed hemodynamic instability? b. has documented instability in hemodynamic status? c. is actively receiving vasopressors to maintain hemodynamic status? d. has an absolute platelet count less than 50,000? e. has an absolute platelet count less than 0,000? f. has an INR >3.0 and requires central venous access? g. will need central venous access for >5 days? Preference of Non-tunneled CVC vs. PICC (Prefer Non-tunneled CVC=-3, Neutral 4-6, Prefer PICC=) Among critically ill patients in whom peripheral venous access is difficult to obtain but who do not otherwise require central venous access, how appropriate is the insertion of a PICC for obtaining blood for laboratory testing and infusion of fluids/iv therapies for a proposed duration of: a. < 5 days? b. 6-4 days? c days? of PICC Downloaded From: on 04/3/208

20 INDICATIONS FOR VASCULAR ACCESS DEVICES IN SPECIAL POPULATIONS *, HOME-BASED AND SKILLED NURSING SETTINGS $ 33. How appropriate is the use of each of the following vascular access devices in hospitalized medical patients who belong to a special population and are not frequently admitted (<5 hospital admissions per year) when the current hospitalization is expected to last for: Peripheral IV US Guided PIV Midline PICC Tunneled-Cuffed Catheter Port a. <5 days? b. 6-4 days? c days? How appropriate is the use of each of the following vascular access devices in hospitalized medical patients who belong to a special population and are frequently admitted (>6 hospital admissions per year) when the current hospitalization is expected to last for: Peripheral IV US Guided PIV Midline PICC Tunneled-Cuffed Catheter Port e. <5 days? f. 6-4 days? g days? h. greater than 30 days? *Special populations include patients that require frequent and/or long-term or lifelong vascular access. This category typically includes the following conditions: cystic fibrosis, sickle cell disease, short-gut syndrome, inflammatory bowel disease, and patients with chronic pancreatitis. $These settings include patients who are receiving ongoing treatments following acute hospitalization either at their home or in nursing homes, skilled nursing facilities or extended care facilities. Downloaded From: on 04/3/208

21 35. How appropriate is the use of each of the following vascular access devices to administer non-irritant, nonvesicant intravenous therapies in a home-based setting following hospitalization, for a proposed duration of: Peripheral IV Midline PICC Tunneled-Cuffed Catheter Port a. < 5 days? b. 6-4 days? c days? How appropriate is the use of each of the following vascular access devices to administer irritant, or vesicant intravenous therapies in a home-based setting following hospitalization, for a proposed duration of: Peripheral IV Midline PICC Tunneled-Cuffed Catheter Port a. < 5 days? b. 6-4 days? c days? How appropriate is the use of each of the following Peripheral IV Midline PICC Tunneled-Cuffed Catheter Port Downloaded From: on 04/3/208

22 vascular access devices to administer non-irritant, nonvesicant intravenous therapies at a skilled nursing facility following hospitalization for a proposed duration of: a. < 5 days? b. 6-4 days? c days? How appropriate is the use of each of the following vascular access devices to administer irritant, or vesicant intravenous therapies at a skilled nursing facility following hospitalization for a duration of: Peripheral IV Midline PICC Tunneled-Cuffed Catheter Port a. < 5 days? b. 6-4 days? c days? Downloaded From: on 04/3/208

23 Section 2: Clinical scenarios for rating the appropriateness of PICC-related consultations, insertion practices, device characteristics, maintenance, complications and removal. 3. APPROPRIATENESS OF CONSULTATION FOR PICC PLACEMENT of Consultation/Involvement a. How appropriate is it to consult/involve infectious disease specialists prior to ordering a PICC for long- term intravenous antibiotic therapy? b. In patients with stage -3A CKD who are not currently on dialysis, how appropriate is it to consult/involve a nephrologist prior to ordering a PICC for any reason? c. In patients with stage 3B-5 CKD who are not currently on dialysis, how appropriate is it to consult/involve a nephrologist prior to ordering a PICC for any reason? d. In patients with stage 5 CKD, who are currently on dialysis, how appropriate is it to consult/involve a nephrologist prior to ordering a PICC for any reason? e. In patients with active cancer, how appropriate is it to discuss placement of a PICC with an oncologist or hematologist prior to ordering the PICC for chemotherapy? f. How appropriate is it to routinely discuss the rationale and indication for placement of a PICC with vascular access specialists (nurse or physician) prior to ordering a PICC for any reason? How appropriate is it to automatically refer patients to or consult interventional radiology for PICC placement if bedside PICC insertion is unsuccessful because: a. a suitable vein for PICC placement cannot be localized by ultrasound? b. the PICC coils or fails to advance despite 2 or more attempts? c. the patient requests sedation for the procedure due to anxiety? d. the patient specifically requests vascular access specialists to perform the procedure? e. the patient has bilateral mastectomies or altered chest anatomy? f. the patient is known to have a superior vena cava filter in place? g. the patient has a permanent pacemaker or defibrillator in place, and the contralateral arm is not suitable for access? 8 8 Downloaded From: on 04/3/208

24 PICC INSERTION AND PLACEMENT 4. How appropriate is it to request urgent PICC insertion (placement of a PICC within a few hours of the order) in a patient who lacks venous access and is: a. hemodynamically stable, but receiving care in an ICU-setting? b. hemodynamically unstable emergent patient in an ICU-setting? c. scheduled for hospital discharge, but needs a PICC prior to discharge for long-term intravenous treatment at a skilled nursing facility? d. due for their next dose of IV antibiotics and has missed 2 or more doses of the antibiotic due to problems with venous access? When inserting a PICC, how appropriate is it to: when Other Arm Not Available when Other Arm Available a. avoid insertion over a bruised or corded venous segment? b. avoid insertion over an area of the skin that has a burn or open wound? c. avoid insertion in an arm that has experienced a recent (< 30 days) DVT? d. avoid insertion in an arm that has experienced a distant (> 3 days) DVT? e. avoid insertion in a hemiparetic or immobile arm, which is otherwise amenable to placement? f. ensure that the target vein lumen is at least two to three folds greater than the maximal PICC diameter using ultrasound? g. avoid insertion in veins below the elbow? h. avoid insertion in the right arm when patients are right-handed or vice-versa? i. incorporate patient preference when placing a PICC? Downloaded From: on 04/3/208

25 43. Assuming clinical stability, how appropriate is it to avoid PICC insertion in the following patients or circumstances, regardless of the relative indication for PICC use? a. A patient with chronic kidney disease currently receiving hemodialysis? b. A patient receiving anticoagulation for a recent DVT (< month) related to a PICC? 5 c. A patient who has undergone breast surgery, extensive lymph node dissection, or has severe burns in an arm that is otherwise amenable to PICC placement? d. A dying patient on comfort care measures who has PIV access, but could benefit from additional IV access for drug infusion or administration of pain medications Assuming clinical stability, how appropriate is it to avoid PICC insertion in the following patients or circumstances, regardless of the relative indication for PICC use? Outpatient Hospitalized/SNF a. A patient with remote history of intravenous drug abuse who has difficult peripheral IV access? b. A patient with active intravenous drug abuse who has difficult peripheral IV access? How appropriate is chest x-ray verification of PICC tip position prior to use: a. following insertion at the bedside by a vascular access nurse/consultant without EKG guidance? b. following insertion at the bedside by a vascular access nurse/consultant with EKG guidance who has demonstrated proficiency with this technique? c. following fluoroscopy-guided placement in the interventional radiology suite? d. following admission to the hospital with a PICC placed during a prior hospitalization? e. following admission to the hospital with a PICC placed at an outside facility? 8 Downloaded From: on 04/3/208

26 45. How appropriate is it to adjust the PICC tip to an alternative position, if the tip has been determined by chest x-ray to reside at the: a. upper /3 of the superior vena cava? b. middle /3rd of the superior vena cava? c. lower /3 of the superior vena cava? d. cavo-atrial junction? e. right atrium? f. right ventricle? 7 Downloaded From: on 04/3/208

27 CHARACTERISTICS AND CONSIDERATIONS FOR SELECTING PICCS, PERFORMING CARE AND MAINTAINING DEVICES 46. When considering the appropriate number of lumens for a PICC in a hospitalized patient, how appropriate is it to: a. always order a single lumen PICC unless specific reasons for a PICC with more than one lumen (e.g., incompatible infusions) exist? b. always order a PICC with more than one lumen in case a single-lumen device fails? c. always order a multi-lumen PICC so that infusion and blood collection can be separated? d. always order a multi-lumen PICC for patients who need parenteral nutrition, with a dedicated lumen for use with lipid emulsions/tpn? 48. Is it appropriate for the physician or clinical provider who orders placement of the PICC to collaborate in making the final decision with: a. the operator/inserter (vascular access specialist)? b. an appropriate specialist (nephrologist, infectious disease, oncologist) in cases involving patient who have specialty specific disease (e.g., chronic kidney disease, infections or malignancies)? c. the hospital pharmacist? 8 4. How appropriate are each of the following measures to maintain a dressing in a patient who has oozing from the PICC insertion site: a. routinely place sterile gauze between the entry site and the adhesive dressing to absorb any sweat, oozing or moisture beyond the first -2 days of insertion? b. exchange the transparent semi-permeable dressing whenever it becomes loose or soiled? c. use cyanoacrylate (or "super-glue") at the exit site to decrease oozing/bleeding? d. apply a chlorhexidine-impregnated sponge dressing around the catheter entry site in order to prevent infection, even if institutional rates of CLABSI are not high? 6 3 Downloaded From: on 04/3/208

28 50. How appropriate are each of the following protocols to flush/maintain the patency of the PICC: a. flush each lumen of the PICC with 5-0 cc of sterile saline each day regardless of use? b. flush each lumen with a solution of 5-0 cc of heparin (0U/ml) each day regardless of use? 5. If there is catheter migration, how appropriate is the use of the following techniques to reconfirm the position of the PICC tip: a. Chest X-ray? b. Intra-cavitary EKG? c. Fluoroscopy? d. Ultrasonography? Assuming a PICC was centrally positioned and was functioning for at least 7 days, how appropriate is it to advance the PICC when examination of the catheter reveals migration on the skin by: a. 2-4 cm? b. 5-8 cm? c. > cm? Downloaded From: on 04/3/208

29 53. How appropriate are exchanges of an existing PICC over a guide-wire (replacement in the same vein or site) in each of the following scenarios: a. exchange of a single lumen PICC to a multi-lumen PICC? b. exchange of a multi-lumen PICC to a single lumen PICC prior to discharge on IV antibiotics? c. exchange from a non-power PICC to a POWER PICC for an intravenous contrast procedure? d. exchange of a PICC that has been partially dislodged by patient or provider such that the PICC has externally migrated by 2-4cm? e. exchange of a PICC that has been partially dislodged by patient or provider such that the PICC has externally migrated by 5-8cm? f. exchange of a PICC that has been partially dislodged by patient or provider such that the PICC has externally migrated by >cm? g. exchange of a PICC that is not functional (no longer allowing for blood draws or infusions reliably)? 7 8 MANAGEMENT OF PICC-RELATED COMPLICATIONS Downloaded From: on 04/3/208

30 . Deep Vein Thrombosis (DVT) 54. In a hospitalized medical patient who has experienced recent PICC-related DVT (<30 days), but who does not otherwise need central venous access, how appropriate is it to place a PICC: of PICC a. when no compelling reason for central venous access exists, but peripheral IV access becomes difficult (e.g., repeated IV infiltration, no palpable or accessible peripheral veins)? b. when frequent blood draws are required (acute coronary syndromes, gastrointestinal bleeding) but peripheral veins to draw labs are available? c. when frequent blood draws are required (acute coronary syndromes, gastrointestinal bleeding) but peripheral veins to draw labs are difficult to find? d. when infusion of parenteral antibiotics for > 0 days is necessary? e. when the patient is likely to require surgery that will last > hour? f. when the patient is likely to require surgery that will last > hour but will need central venous access for TPN after surgery? g. when the patient requests a PICC for comfort without other indications for use or non-end of life settings? In a hospitalized medical patient who has experienced recent PICC-related DVT, PICC was removed, and now requires central venous access for infusions, how appropriate is placement of a PICC: of PICC a. in the ipsilateral arm within 7 days of the DVT? b. in the contralateral arm within 7 days of the DVT? c. in the ipsilateral arm within one month of the DVT? d. in the contralateral arm within one month of the DVT? e. in the ipsilateral arm within three months of the DVT? f. in the contralateral arm within three months of the DVT? Downloaded From: on 04/3/208

31 58. When managing symptomatic PICC-related DVT in a patient who has no other indication or contraindication for anticoagulation, has a centrally located PICC that is functional and needs to keep the PICC in place several weeks to complete therapy, how appropriate is it to: a. not provide an anticoagulant at a treatment dose despite no contraindications? b. provide one month of an anticoagulant at a treatment dose from the date of DVT diagnosis? c. provide a minimum of three months of an anticoagulant at a treatment dose from the date of DVT diagnosis or longer if the PICC remains in place? d. assuming at least three months of anticoagulation was provided, provide an anticoagulant at a treatment dose for an additional month beyond the date of PICC removal? 60. When treating a patient with PICC-related DVT who has active cancer but has not experienced a prior DVT, how appropriate is: a. targeting treatment to an INR range of 2-3 for the entire duration of anticoagulation (warfarin)? b. targeting treatment to INR range of 3-4 for the entire duration of anticoagulation (warfarin)? c. preferential use of low-molecular weight heparin over warfarin? d. use of novel oral anticoagulants (rivaroxaban, dabigatran) over low molecular weight heparin (LMWH)? Downloaded From: on 04/3/208

32 64. When proceeding with placement of a PICC in a patient who has recently experienced a PICCrelated DVT (< 30 days), how appropriate are each of the following statements when considering site and device selection: a. use a vein other than the one associated with thrombosis? b. use a vein on the contralateral arm whenever possible? c. choose a catheter with the smallest gauge or thickness? d. choose a catheter with the least number of lumens? e. ensure that the catheter: vein ratio is at least :3? f. confirm that the PICC tip is placed in the lower /3rd of the SVC or at the cavo-atrial junction? Downloaded From: on 04/3/208

33 65. How appropriate is it to remove a centrally positioned, otherwise well-functioning PICC that is associated with image-confirmed arm DVT: a. in a hospitalized medical patient who only needs peripheral venous access and has a working peripheral IV in place? b. in a hospitalized medical patient who still needs central venous access for administration of an irritant or vesicant? c. in a hospitalized medical patient who does not have a clinical indication for venous access other than routine lab draws and peripheral veins are accessible? d. in a patient who cannot receive systemic anticoagulation (severe GI bleed, recent eye or intracranial surgery)? e. in a patient who has no improvement in symptoms of venous occlusion (arm pain, swelling) despite therapeutic anticoagulation for <48 hours? f. in a patient who has no improvement in symptoms of venous occlusion (arm pain, swelling) despite therapeutic anticoagulation for >48-7 hours? g. in a patient who has no improvement in symptoms of venous occlusion (arm pain, swelling) despite therapeutic anticoagulation of >72 hours? h. in a patient with active cancer who still requires central venous access for chemotherapy and frequent lab draws? How appropriate is it to remove a centrally positioned, otherwise well-functioning PICC that is associated with image-confirmed arm DVT: a. in a patient with bacteremia that is suspected to be line-related with poor venous access? b. In a patient with bacteremia that is a confirmed line related infection with poor venous access? 5 Downloaded From: on 04/3/208

34 66. Among patients with PICC-related DVT, when is it appropriate to consider referral to a vascular access specialist for catheter-directed treatments? a. Whenever a patient has symptoms suggestive of venous occlusion (arm pain, swelling)? b. Whenever a patient has symptoms of venous occlusion (arm pain, swelling) and also develops limitations in arm movement of function? c. When a patient experiences symptoms of phlegmasia cerula dolens (limb that is swollen, enlarged, painful and often purplish in color) at any time? 8 Downloaded From: on 04/3/208

35 2. PICC-Associated Bloodstream Infections 67. In a hemodynamically stable, hospitalized medical patient who has experienced a recent (<30 days) central line-associated bloodstream infection, who has documented clearance of bacteremia, but needs another PICC for continued antibiotics, how appropriate is the placement of a: of PICC a. single lumen PICC when placement of peripheral IV catheters is difficult, but no compelling reason for venous access exists? b. multi-lumen PICC when placement of peripheral IV catheters is difficult, but no compelling reason for venous access exists? In a critically ill patient who has been diagnosed with a PICC-related bloodstream infection yet still needs central venous access, how appropriate is: a. continued treatment using the affected PICC? b. removal of the affected PICC and placement of a new PICC on the contralateral arm without a line-free interval? c. removal of the affected PICC and placement of a new PICC on the contralateral arm following a line-free interval (e.g., a variable number of days with no central venous access) with documented negative cultures? d. removal of the affected PICC and placement of a temporary non-tunneled catheter in either the internal jugular or subclavian vein without a line-free interval? e. removal of the affected PICC and placement of a temporary non-tunneled catheter in either the internal jugular or subclavian vein with a line-free interval and documented negative cultures? f. removal of the affected PICC and placement of a non-tunneled catheter in the femoral vein following a line-free interval with negative cultures? g. removal of the affected PICC and placement of a tunneled catheter following a line-free interval with documented negative cultures? Downloaded From: on 04/3/208

36 6. In a patient with active cancer who needs long-term central venous access but has been diagnosed with PICC-related bloodstream infection, how appropriate is: a. continued treatment using the affected PICC? b. removal of the affected PICC and placement of a new PICC on the contralateral arm without a line-free interval? c. removal of the affected PICC and placement of a new PICC on the contralateral arm following a line-free interval (e.g., a variable number of days with no central venous access) with documented negative cultures? d. removal of the affected PICC and placement of a temporary non-tunneled catheter in either the internal jugular or subclavian vein without a line-free interval? e. removal of the affected PICC and placement of a temporary non-tunneled catheter in either the internal jugular or subclavian vein with a line-free interval and documented negative cultures? f. removal of the affected PICC and placement of a non-tunneled catheter in the femoral vein following a line-free interval with negative cultures? g. removal of the affected PICC and placement of a tunneled catheter following a line-free interval with documented negative cultures? Downloaded From: on 04/3/208

37 PICC REMOVAL 70. How appropriate is the removal of a PICC with notification/approval of a physician, in a hospitalized medical patient who: a. has not had any documented use of the PICC (blood draws or infusions) for at least 48 hours and peripheral IV access is available? b. has not had any documented use of the PICC (blood draws or infusions) for at least 48 hours but peripheral IV access is not available? c. no longer has an active clinical indication for the PICC (e.g., completed chemotherapy, no longer needs antibiotics, etc.) and peripheral venous access is available? d. no longer has an active clinical indication for the PICC (e.g., completed chemotherapy, no longer needs antibiotics, etc.) but peripheral venous access is difficult to obtain? e. is hemodynamically not stable but only needs a PICC for routine blood collection for daily laboratory testing? 5 7. How appropriate is removal of a PICC by: a. individuals who have not received specific training on how to remove a PICC or CVC? b. bedside registered nurses who have received specific training on how to remove a non-tunneled central venous catheter, but not a PICC? c. bedside registered nurses who have received specific training on how to remove a PICC? d. house-officers and physicians who have not received specific training on how to remove a PICC, but have received training on removal of non-tunneled central venous catheters? e. house-officers (interns, residents) and physicians who have received specific training on how to remove a PICC? 3 3 Downloaded From: on 04/3/208

38 Section 3: Clinical scenarios for rating the appropriateness of strategies associated with peripheral IV catheter placement, removal and management. The following scenarios relate to the use of peripheral IV s. 72. Assuming that there is no indication for central access and bedside nurses cannot place a peripheral IV in the arm, how appropriate is the placement of a peripheral IV in the external jugular vein if no other, suitable peripheral access site can be found: a. in a non-urgent situation? b. in an emergent/life-threatening situation? c. for a proposed duration < 6 hours? d. for a proposed duration > 6 hours? Assuming that there is no indication for central access and bedside nurses cannot place a peripheral IV in the arm, how appropriate is the placement of a peripheral IV in a leg or foot vein if no other, suitable peripheral access site can be found: a. in a non-urgent situation? b. in an emergent/life-threatening situation? c. for a proposed duration < 6 hours? d. for a proposed duration > 6 hours? 5 Downloaded From: on 04/3/208

39 74. Assuming that there is no indication for central access and bedside nurses cannot place a peripheral IV in the arm, how appropriate is the use of ultrasound to guide placement of peripheral intravenous catheters in the arm: a. before considering placement of a peripheral IV in the neck? b. before considering placement of a peripheral IV in the leg or foot? c. before ordering placement of a PICC? d. in a critically ill patient in an ICU setting? e. in patients with active cancer (on chemo- or radiation therapy or admitted for a cancer-related diagnosis)? f. in patients with Stage 3a or lower CKD? g. in patients with Stage 3b or greater CKD? How appropriate is it to remove a peripheral IV that was started in the field (e.g., ambulance or non-hospital site) upon admission to a hospital setting: a. if there are no signs of redness or swelling and the device is working? b. if there is redness or swelling around the entry site? c. if there are no signs of redness or swelling, but another peripheral IV has been placed in the hospital? d. if there is no immediate or apparent need for venous access? 3 Downloaded From: on 04/3/208

40 76. How appropriate is it to remove or replace a peripheral IV that was started in the emergency department upon admission to an inpatient unit: a. if there are no signs of redness or swelling and the device is working? b. if there is redness or swelling around the entry site? c. if there are no signs of redness or swelling, but another peripheral IV has been placed and is working? d. if there is no immediate or apparent need for venous access? 77. Assuming other upper extremity peripheral veins are accessible and central venous access is not indicated, how appropriate is it to place a peripheral IV in: a. an arm on the same side as breast surgery or axillary node dissection? b. an arm with an existing, functional arteriovenous fistula? c. an arm with an existing, but nonfunctional (e.g., non-working) arteriovenous fistula in a patient not currently on dialysis? d. an arm that has been paralyzed or immobilized (e.g., stroke or injury)? e. forearm veins in a patient with Stage -3A chronic kidney disease not currently on dialysis? f. forearm veins in a patient with Stage 3B - 5 chronic kidney disease not currently on dialysis? g. forearm veins in a patient with chronic kidney disease on dialysis? 5 Downloaded From: on 04/3/208

41 78. When long-term therapy with an infusion containing extremes of ph or osmolarity (e.g., vancomycin, metronidazole, amphotericin-b) is considered likely, how appropriate is it to transition from a peripheral IV to a PICC: a. within <5 days of this decision point? b. within 6-4 days of this decision point? c. within 5-30 days of this decision point? d. > 30 days from this decision point? 7 Downloaded From: on 04/3/208