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HMS PICC Tier II CLABSI Toolkit

The CLABSI Tier II toolkit steps focus on the life-cycle of the catheter: appropriate insertion, care and maintenance, technology-based solutions, line necessity evaluations and culturing stewardship. For each of these elements, specific guidance and recommendations are provided.

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  5. Step 2a: Device Selection and Proper Insertion Practices

Step 2a: Device Selection and Proper Insertion Practices

You should complete this section if a majority of CLABSIs occur within six days of line insertion.

If CLABSIs at your facility occur equally within 6 days of line insertion and  ≥ 7 days of line insertion, you should also work through Step 2B: Care and Maintenance. If CLABSIs at your facility occur mainly ≥ 7 days of line insertion, you should focus on Step 2B: Care and Maintenance.

Key institutional partners to engage in this step: HMS PICC Team, Abstractor, QI Department, Providers, IR, Vascular Access Team

Elements:
  • Perform an audit for compliance with a checklist for proper insertion
    • Hand hygiene before insertion
    • Gloves, Gowns, Drapes, Maximal Sterile Barriers
    • 2-4% Chlorhexidine Gluconate (CHG) with alcohol for skin antisepsis
    • Use of ultrasound for vein mapping/insertion
    • Secure line with sutureless securement device
    • Competencies for insertion for all inserters
      • Audit should include at least 20% of all insertions
  • Only use a CVC if necessary
  • Use MAGIC or another validated decision tool to guide your decisions for PICCs
    • Make MAGIC app available to providers
    • Consider integrating use of the MAGIC app into your policy so that providers cannot order a PICC line unless it is first deemed appropriate through the app
    • Design electronic order sets that map to MAGIC criteria
  • Evaluate who is determining appropriateness/number of lumens
    • Consider if another clinician type should be involved (i.e. Vascular Access Teams)
    • Ensure those identified as most appropriate to determine appropriateness/number of lumens are educated on appropriate device choice/insertion
  • Place the minimum number of lumens
  • Avoid PICCs in patients at high risk of CLABSI
    • Provide education on the Michigan PICC CLABSI (MPC) Score to Providers and/or PICC Inserters at your facility
    • Use the MPC Score to determine risk of CLABSI prior to selecting a PICC
    • If a patient is at high risk of CLABSI, consider advanced approaches (i.e. Chlorhexidine gluconate impregnated catheters) to device insertion or use another device
  • Assessment of Catheter-to-Vein Ratio
    • Use Catheter to Vein (CVR) App or Tool
      • CVR is associated with PICC related UE DVT. Thrombosis in the catheter or around the vein increases risk of infection
    • Document CVR measurement in the chart
    • Audit of CVR documentation
Resources/Tools

Presentations:

National/International Guidelines:

Articles/References

Bozaan D, et al. Less lumens-less risk:  A pilot intervention to increase the use of single-lumen peripherally inserted central catheters. Journal of Hospital Medicine 2019

  • An intervention involving setting PICC default orders to single-lumen devices, establishing criteria of when multi-lumen PICCs are appropriate, and provider, nursing, and pharmacy education resulted in significant decrease in inappropriate PICC use as well as an overall increase in single lumen PICC use

Chaiyakunapruk N, et al. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Annals of Internal Medicine 2002

  • Incidence of bloodstream infections is significantly reduced in patients with central vascular lines who receive chlorhexidine gluconate versus povidone-iodine for insertion-site skin disinfection
Chopra V, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of Internal Medicine 2015
  • Criteria for the use of PICCs was developed, adopting the RAND/UCLA Appropriateness Method. After a review of 665 scenarios, 43% of PICCs were flagged as inappropriate. Applying these criteria as a guide can help decrease the likelihood of an inappropriate catheter, improve care, and inform quality improvement efforts

Chopra V, et al. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults:  A systematic review and meta-analysis. Infection Control and Hospital Epidemiology 2013

  • Risk for CLABSI may be similar for hospitalized patients with PICCs vs CVCs

Chopra V, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Annals of Internal Medicine 2015

  • Criteria for the use of PICCs was developed, adopting the RAND/UCLA Appropriateness Method. After a review of 665 scenarios, 43% of PICCs were flagged as inappropriate. Applying these criteria as a guide can help decrease the likelihood of an inappropriate catheter, improve care, and inform quality improvement efforts

Herc E, et al.  Model to Predict Central-Line-Associated Bloodstream Infection Among Patients With Peripherally Inserted Central Catheters: The MPC Score. Infection Control & Hospital Epidemiology 2017

  • Risk factors for CLABSI in patients with PICC lines include:  hematological cancer, history of CLABSI within 3 months of PICC insertion, multi-lumen PICCs, solid cancers with ongoing chemotherapy, receipt of total parenteral nutrition through the PICC, and the presence of another central venous catheter (CVC)

Hu KK, et al. Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review. American  Journal of Infection Control 2004

  • Studies suggest maximal sterile barriers may reduce infectious complications; however, further research is needed to support this conclusion. Current literature is limited

Kramer R, et al. Are Antimicrobial Peripherally Inserted Central Catheters Associated with Reduction in Central Line–associated Bloodstream Infection? A Systematic Review and Meta-analysis. American Journal of Infection Control 2017

  • Antimicrobial PICCs may reduce CLABSI, especially in high-risk subgroups

Lam PW, et al. Impact of defaulting to single-lumen peripherally inserted central catheters on patient outcomes:  An interrupted time series study. Clinical Infectious Diseases 2018

  • Defaulting non-ICU PICC orders to single-lumen devices resulted in a sustained decrease in PICC-associated complications

Micic D, et al. Choosing the right central venous catheter for parenteral nutrition. The American Journal of Gastroenterology 2018

  • Review of appropriate venous access device selection for patients requiring total parenteral nutrition (TPN)

Raad II, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infection Control & Hospital Epidemiology 1994

  • Maximal sterile barrier precautions during the insertion of non-tunneled catheters reduce the risk of catheter infection

Ratz D, et al. Limiting the Number of PICC Lumens to Improve Outcomes and Reduce Cost: A Simulation Study. Infection Control & Hospital Epidemiology 2016

  • Every 5% increase in single-lumen PICC use would prevent 0.5 PICC-related central line-associated bloodstream infections and 0.5 PICC-related deep vein thrombosis events, while saving $23,500

Spencer T, et al. Reducing catheter-related thrombosis using a risk reduction tool centered on catheter to vessel ratio. Journal of Thrombosis and Thrombolysis 2017

  • Increasing the understanding and utilization of CVRs will lead to a safer, more consistent approach to device placement, with potential thrombosis reduction strategies

Stone PW, et al. State of infection prevention in US hospitals enrolled in NHSN. American  Journal of Infection Control 2014

  • Gap in compliance with evidence-based infection control policies for CLABSI prevention related to insertion and catheter site selection in ICUs

Swaminathan L, et al. Improving PICC use and outcomes in hospitalized patients:  An interrupted time series study using MAGIC criteria. BMJ Quality & Safety 2018

  • A multi-modal intervention based on MAGIC resulted in a modest decrease in inappropriate PICC use

Thornburg CD, et al. Association between thrombosis and bloodstream infection in neonates with peripherally inserted catheters. Thrombosis Research 2008

  • There was a positive association between thrombosis and bloodstream infection in infants who did not have lines removed for infection. Further research must be done to understand the pathophysiology between these two complications

Timsit JF, et al. Central vein catheter-related thrombosis in intensive care patients:  Incidence, risk factors, and relationship with catheter-related sepsis. Chest  1998

    • Catheter-related venous thrombosis is associated with higher rates of septicemia and catheter-related sepsis
  • Interventions aimed at improving CVC appropriateness and prompt device removal significantly reduce CLABSI rates. CLABSI reduction interventions should include focus on CVC appropriateness and device assessment/removal