Guide for Appropriate Use of PICCs

Medscape Medical News
Panel Releases Guide for Appropriate Use of PICCs

Susan London
September 15, 2015


Clinicians can now refer to a new tool, the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), to help determine when and how to use peripherally inserted central catheters (PICCs) and related venous access devices. The guide is published as a supplement to the Annals of Internal Medicine.

"[Intravenous] access and getting an [intravenous drip] is the most commonly performed procedure in any hospitalized patient in the world. And yet it's the least studied, for a number of different reasons," lead author Vineet Chopra, MD, an assistant professor of medicine at the University of Michigan and a research scientist with the VA Ann Arbor Healthcare System, told Medscape Medical News.

Meanwhile, "the use of PICCs in hospitalized patients has just exploded," he said. In addition, "there was really no good...unifying document that instructed physicians or provided guidance as to when one device is better than the other, or when the use of one device is potentially harmful. All of that exists in fragmented spaces and in different disciplines, but not in the mainstream view of a typical inpatient doctor.

"We thought it was really important, given the growing use of PICCs and other devices in mainstream medicine, to have something that would help coordinate the literature in a way that was a lot more systematic and a lot more practical for the everyday doctor," Dr Chopra summarized. "I think there was a huge need that never existed before, especially with the rise of hospitalists and the rise of PICCs in hospitalized patients."

To create MAGIC, he and other members of an international, multispecialty panel of experts applied the RAND/University of California, Los Angeles, Appropriateness Method to develop criteria for the use, care, and management of PICCs and related venous access devices in adults. They performed a systematic review of the literature and created clinical scenarios based on patient population, indication for insertion, and duration of use. For each scenario, they compared the appropriateness of PICC use with that of other venous access devices.

A noteworthy aspect of the panel was inclusion of a patient who had undergone placement of several different venous access devices over time and was able to contribute that perspective, which is a rare practice in guideline development, according to Dr Chopra.

"We wanted to be different, first, because the evidence here is not very mature, there are very few randomized trials to guide us on our decision making and, second, because when there is uncertainty, it's imperative to have that conversation with the patient," he elaborated. "A lot of the recommendations that we ended up with that were not evidence driven were really based on the patient being on our panel, who actually [said], 'Listen, if this were me, this is what I would want.' "

Dr Chopra enumerated three key take-home points from MAGIC for clinicians. First, "think about the device before you place it," he recommended. "Too often, in medicine we are so focused on the clinical moment or moving the patient through processes of care, and we don't think of the device as being potentially harmful. So I think that a moment of pause needs to be interjected right before an operation, to slow down and...reflect, 'Is this the right choice for the patient?' "

Second, "choose wisely," Dr Chopra advised. To that end, the guide details specific risks and benefits of each device. Clinicians can then consider their individual patient and goals of treatment in deciding the best way to move forward.

"Third, I am hoping this will become a tool that will actually help improve quality of care," he said. "I am hoping MAGIC becomes an instrument that can be tested in real-world scenarios, whether it's through [electronic medical records] or through quality improvement initiatives like we have in Michigan, where we can actually think about how can you utilize this in an everyday fashion, so that it doesn't become more of an obstacle, but rather a great benefit to have on your side."

The MAGIC panelists reviewed a daunting 665 scenarios for the use of PICCs, rating 38% as appropriate, 19% as neutral/uncertain, and 43% as inappropriate. But time-strapped clinicians can simply refer to the color-coded figures that summarize the findings in a way that makes them easy to apply at the bedside, according to Dr Chopra.

"Think of those as pocket cards," he suggested. "All that physicians need to do is have those in your pocket because you can literally think about your patient and what you need, and run through that list of devices and how long you will need it for to come up with a handy way of saying, 'Yup, these are my options, and this one seems to be the preferred device or the best device.' "

"We are working on creating smart phone apps and other handy dandy tools that make this a lot easier, so hopefully this will become a lot more manageable when you are taking care of many patients, so that you don't have to dig through the paper or find the [figures]," Dr Chopra added.

The timing of MAGIC's publication works out well for teaching institutions, as it coincides with the beginning of the academic year, he noted. "It's a great educational tool that I would sort of love to be able to walk around with the new interns and say, 'Look, this is a new tool out there for you to start thinking about,' " he elaborated.

Dr Chopra reports receiving grants from the Society of Hospital Medicine and Agency for Healthcare Research and Quality during the conduct of the study. Several coauthors report various financial relationships with Blue Cross Blue Shield of Michigan, the Institute for Healthcare Improvement, the Society of Hospital Medicine, the University of Michigan, the CDC Foundation, Michigan Hospital Association, Agency for Healthcare Research and Quality, Wiley Publishing, Doximity, Jvion, BMS, Vascular Pathways, Bard Peripheral Vascular, B. Braun, Orbimed, Teleflex, Cook, W.L. Gore, Lutonix, PICC Excellence Inc, Greenville Hospital System, Alliance for Vascular Access Device Training and Research, Griffith University, Teleflex, Ethicon, Bard International, SonoSite, 3M, Department of Veterans Affairs National Center for Patient Safety, University of Michigan Medical Group.

Ann Intern Med. 2015;163:S1-S42. Abstract