Safe and reliable venous access is paramount when administering medications in critically ill and ICU patients. “Central venous access devices (CVADs) are commonly used in ICUs and pose significant infectious and thrombotic risk to patients,” explains Vineet Chopra, MD, MSc. Underlying disease, immobility, sedation, and the number, type, and duration of catheters used are just some of the risk factors associated with catheter-related complications in ICU patients. Studies show that the risk for complications associated with central venous catheters (CVCs) is higher in ICUs when compared with other hospital departments.

“It’s important to balance the clinical needs of patients with risks associated with any vascular device,” says Dr. Chopra. “This requires having processes in place for selecting devices, inserting the devices aseptically, and caring for, managing, and removing devices when they’re no longer necessary.” He adds that the association between thrombosis, infections and devices highlights why use of devices, such as peripherally inserted central catheters (PICCs), should be considered carefully. Despite this knowledge, some PICCs may not be placed for clinically valid reasons. “Defining appropriate indications for PICC use is an important patient safety issue,” Dr. Chopra says.


A New Approach

Several professional organizations have issued recommendations to help guide the selection of CVADs. For example, the Society of Healthcare Epidemiology of America recommends providing clinicians an evidence-based list of indications for CVCs prior to placement. The Infusion Nursing Standards recommend using the least invasive device to meet patients’ specific needs. The CDC’s central line-associated bloodstream guidelines recommend reserving PICCs when duration of IV therapy is projected to last 7 or more days. While helpful, none of these documents provide a method to achieve this goal.

In an effort to address this unmet need, Dr. Chopra and colleagues convened a multidisciplinary panel of national and international experts to examine criteria for appropriate placement of PICCs in comparison with other peripheral and central venous devices. The result of this collaboration was the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC), a tool that reflects the in-depth evaluation of vascular access devices to provide the evidence needed to guide selection (Table). MAGIC was formulated using the RAND Corporation and UCLA’s Appropriateness Method.

 

A Closer Look

In order to create and publish MAGIC in Annals of Internal Medicine, Dr. Chopra and colleagues conducted systematic reviews of the literature and compiled available evidence. “We created numerous clinical scenarios to rate the appropriateness of insertion, maintenance, and care of PICCs as compared with other peripheral and CVADs,” says Dr. Chopra. “Our purpose wasn’t to reach consensus. Instead, we wanted to evaluate why disagreements occurred so that we could minimize misunderstandings when rating each scenario.”

The research team examined the use of several devices, including PICCs, ultrasound-guided peripheral intravenous catheters, midline, peripheral intravenous catheters, non-tunneled CVCs, tunneled CVCs, and ports. After reviewing of 665 scenarios, 38% were rated as appropriate, 19% were deemed neutral or uncertain, and 43% were rated as inappropriate.

For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 days or less. Although appropriate when more than 6 days of use were anticipated, midline catheters and ultrasound-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. Among critically ill patients, non-tunneled CVCs were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration.

A Top Priority

“Our work highlights the importance of vascular access when treating ICU patients,” says Dr. Chopra. “When we select vascular access devices for critically-ill patients, we need to consider the many factors that impact patient risk and safety. Important considerations include the potential for prolonged immobility and critical illness as well as the risk of thrombosis and infection. The selection criteria established within the MAGIC guide can help physicians determine which devices are associated with least risk while meeting the treatment needs of patients.”

MAGIC can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients. Several institutions throughout the United States have implemented MAGIC and are testing its efficacy. “MAGIC provides guidance and measurement criteria where none existed, allowing for assessment of appropriateness of PICCs and other vascular access devices,” Dr. Chopra says. “Ultimately, applying MAGIC in the ICU setting may help hospitals establish reliable venous access and improve outcomes. It may also assist hospitals in achieving their infection prevention goals and reducing the burden of thrombosis.”

References

Chopra V, Flanders SA, Saint S, et al; Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) Panel. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(Suppl):S1-S40.

Moureau N, Chopra V. Indications for peripheral, midline and central catheters: summary of the MAGIC recommendations. Br J Nurs. 2016;25:S15-S24.

Ratz D, Hofer T, Flanders SA, Saint S, Chopra V. Limiting the number of lumens in peripherally inserted central catheters to improve outcomes and reduce cost: a simulation study. Infect Control Hosp Epidemiol. 2016;37:811-817.

Ajenjo MC, Morley JC, Russo AJ, et al. Peripherally inserted central venous catheter–associated bloodstream infections in hospitalized adult patients. Infect Control Hosp Epidemiol. 2011;32:125-130.

Chopra V, Anand S, Krein SL, et al. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med. 2012;125:733-741.

Simonov M, Pittiruti M, Rickard CM, Chopra V. Navigating venous access: a guide for hospitalists. J Hosp Med. 2015;10:471-478.