WHAT DO WE DO ABOUT

ALL THESE PICCS

KYLE W SANDERS, MD
MAY 2019
CURRENT PICC PATHWAY AT SJRMC

• PATIENT PRESENTS TO THE HOSPITAL

• DIFFICULT ACCESS, VASOPRESSORS, VESICANTS,
CRITICALLY ILL, CHEMO, DURATION OF STAY = PICC
PLACED WITHIN HRS
• NEARLY 900 PLACED A YEAR AT SJRMC 24/7
• PICCS REGULARLY PLACED IN HOSPITAL FOR DC
HOME
OVER UTILIZATION OF PICCS AT SJRMC

• COMPARISON HOSPITAL
• COVENANT MEDICAL CENTER HARRISON, MI). A 516-
BED HOSPITAL (SJRMC 184-BEDS)
• 5 PICC RNS WORKING MON TO SAT 9A TO 530P
• NO PICCS OUTSIDE OF THESE HOURS
MICHIGAN APPROPRIATENESS GUIDE FOR
INTRAVENOUS CATHETERS (MAGIC):
RAND/UCLA APPROPRIATENESS METHOD 2015

• PERIPHERALLY COMPATIBLE INFUSIONS - PICC INAPPROPRIATE WITH

EXPECTED DURATION WAS 5 OR FEWER DAYS.
• MIDLINE CATHETERS AND ULTRASONOGRAPHY - GUIDED IVS WERE
PREFERRED TO PICCS FOR USE BETWEEN 6 AND 14 DAYS.
• IN CRITICALLY ILL PATIENTS, CENTRAL LINES WERE PREFERRED OVER
PICCS WHEN 14 OR FEWER DAYS OF USE WERE LIKELY. SAME INFECTION
RATE WITH BETTER ACCESS.
• IN PATIENTS WITH CANCER, PICCS WERE RATED AS APPROPRIATE FOR
IRRITANT OR VESICANT INFUSION, REGARDLESS OF DURATION.
PICCS
• PROS
• LOW COMPLICATION RATE
• EASE OF PLACEMENT (JUST PLACE THE ORDER, RNS / MDS HAVE LOST SKILLS)
• CONS
• LOSS TO HOSPITAL OF $700 TO $1300 PER PICC VS IV COST OF $32
• PICCS BUNDLED INTO DRG FOR GOV BILLING AND PRIVATE INSURANCE =
ZERO PAY
• PHLEBITIS
• STENOSIS (7 TO 10%)
• THROMBOSIS (11 TO 85%)
PICCS COST / REVENUE 2019
• INPATIENT REIMBURSEMENT
• CATH FLOW – NONE DRG
• PICC – NONE DRG
• MIDLINE – NONE DRG
• BEDSIDE CENTRAL LINE U/S -
$105
• TUNNELED CATHETER –
NONE DRG
• OUTPATIENT REIMBURSEMENT
• CATH FLOW – SALES PRICE + 6%
• PICC – $1,631(2020) ($1,094
2019)
• MIDLINE – NONE
• TUNNELED CENTRAL LINE -
$2,771(2020) ($2,642 2019)
PERIPHERAL IV
VASOPRESSORS

The development of a nurse-driven protocol

for the safe administration of vasopressors
through peripheral intravenous catheters.
International Journal of Healthcare 2018,
Vol. 4, No. 1 Laura Padrone1 , Janet
Galiczewski∗1,2, Bernadette Amitrano1 ,
Seth Koenig1,3, Mangala Narasimhan1,3,
Paul H. Mayo3,4
 META-ANALYSIS CENTRAL LINE OR PICC
GREATER RISK OF INFECTION IN HOSPITAL

• HOSPITALIZED PATIENTS JUST AS LIKELY TO EXPERIENCE CATHETER

RELATED INFECTIONS
WITH PICCS AS WITH CVCS

Infect Control Hosp Epidemiol. 2013 Sep;34(9):908-18. doi: 10.1086/671737. Epub 2013 Jul 26.
The risk of bloodstream infection associated with peripherally inserted central catheters
compared with central venous catheters in adults: a systematic review and meta-analysis.
Chopra V1, O'Horo JC, Rogers MA, Maki DG, Safdar N.
NO PICCS IN PTS “AT RISK” FOR CKD

• “AT RISK” INCLUDES DM, UNCONTROLLED HTN, AKI, NEPHROTOXIC

MEDS, HEAVY SMOKERS, ADVANCED AGE, FAMILY HISTORY, ETHNICITY.
• STAGE 1 CKD – NORMAL GFR WITH ANY RENAL DAMAGE

• FISTULA FIRST BREAKTHROUGH INITIATIVE 

• AMERICAN BOARD OF INTERNAL MEDICINE 
• AMERICAN SOCIETY OF NEPHROLOGY
• KDOQI GUIDELINES NATIONAL KIDNEY FOUNDATION
WHY AVOID PICCS
IN AT RISK CKD PTS
MIDLINES
GUIDELINE COMPLIANT
RN Midlines, ultrasound guided
IMPROVED PATHWAY -Difficult IV
-Frequent blood draws
IV FIRST -tx 3 to 14 days
-Stress importance of IVs -Vasopressors Δ to CL within 48 hrs
-Empower nursing
(vein finder, ultrasound) IV: upper arm, ≥ 20g, confirm w U/S
-Req multiple providers fail at -Vasopressors:
IV -Δ to CL within 48 hrs
CENTRAL LINE -Δ to PICC within 48 hrs if
-Emergent need (within 6 hrs) expected duration ≥ 14 days
-Large volume
Eliminates need for overnight PICC
-CVP monitoring service
Eliminates need for overnight PICC
service PICC within 48 hrs
-Vesicant medications
Changes Required -Chemotherapy
-Policy change -Tx duration ≥ 30 days
-Increased MD skills
-RN training Tunneled PICC within 48 hrs
-Increased equipment – U/S -Renal compromise
and vein finders -Pediatrics
TAKE AWAY CONSIDERATIONS
• ADD U/S GUIDED IVS AND U/S CONFIRMATION OF IVS WITH
VASOPRESSORS
• ADD MIDLINE IVS – IMPORTANT IN GUIDELINES, DIFFICULT TO
GET RNS TO DO AS PICC TEAM FREQUENTLY MORE SKILLED.
LOSS OF RN PRODUCTIVITY – TIME CONSUMING.
• UNDERUTILIZATION OF CVCS – MANDATE MD/NP/PA MAINTAIN
THIS SKILL
• UNDER CURRENT GUIDELINES MANY PICCS / TUNNELED PICCS
CAN BE PLACED OUTPATIENT AFTER DISCHARGE (↑ HOSP
PROFIT 200K)
• UNDERUTILIZATION OF TUNNELED SMALL-BORE CENTRAL
CATHETERS PLACEMENT DIALYSIS PATIENTS AT RISK