Vineet Chopra, MD, MSc; Scott A. Flanders, MD; Sanjay Saint, MD, MPH; Scott C. Woller, MD; Naomi P. O'Grady, MD; Nasia Safdar, MD, PhD; Scott O. Trerotola, MD; Rajiv Saran, MD, PhD; Nancy Moureau, BSN, RN; Stephen Wiseman, PharmD; Mauro Pittiruti, MD; Elie A. Akl, MD, MPH, PhD; Agnes Y. Lee, MD, MSc; Anthony Courey, MD; Lakshmi Swaminathan, MD; Jack LeDonne, MD; Carol Becker, MHSA; Sarah L. Krein, PhD, RN; Steven J. Bernstein, MD, MPH
Portions of this work were presented at the 2015 Annual Society of Hospital Medicine Meeting, Washington, DC, and the 2015 Society for Healthcare Epidemiology of America Meeting, Orlando, Florida.
Acknowledgment: The authors thank Tanya Boldenow, MD, and Aaron Berg, MD, for reviewing early drafts of the appropriateness document; Andy Hickner, MSI, and Marisa Conte, MSI, for assistance with literature searches; and Georgiann Ziegler, their patient panelist, whose views greatly influenced panel discussions.
Disclosures: Dr. Chopra reports grants from the Society of Hospital Medicine and Agency for Healthcare Research and Quality during the conduct of the study. Dr. Flanders reports grants from Blue Cross Blue Shield of Michigan during the conduct of the study and consultancy for the Institute for Healthcare Improvement and the Society of Hospital Medicine; employment by the University of Michigan; one expert review per year as expert testimony; grants or grants pending from the CDC Foundation, Blue Cross Blue Shield of Michigan, Michigan Hospital Association, and Agency for Healthcare Research and Quality; honoraria for various talks at hospitals as a visiting professor; and royalties from Wiley Publishing outside the submitted work. Dr. Saint reports serving on the medical advisory board of Doximity (a social networking site for physicians) and receiving an honorarium for being a member of this medical advisory board, and serving on the scientific advisory board of Jvion (a health care technology company) outside the submitted work. Dr. Woller reports a grant paid by Bristol Myers-Squibb to Intermountain Healthcare, with no financial support to Dr. Woller, outside the submitted work. Dr. Trerotola reports personal fees from University of Michigan during the conduct of the study and grants from Vascular Pathways; personal fees from Bard Peripheral Vascular, B. Braun, Orbimed, Teleflex, Cook, W.L. Gore, and Lutonix outside the submitted work. Dr. Moureau reports PICC Appropriateness Panel reimbursement during the conduct of the study and serving as chief executive officer of PICC Excellence, Inc.; vascular access specialist and team member at Greenville Hospital System, Greenville, South Carolina; and associate adjunct professor and member of Alliance for Vascular Access Device Training and Research (AVATAR), Griffith University, Brisbane, Australia, outside the submitted work. Dr. LeDonne reports personal fees from Teleflex, Ethicon, Bard International, SonoSite, and 3M outside the submitted work. Ms. Becker reports grants from the Society of Hospital Medicine and Blue Cross Blue Shield of Michigan during the conduct of the study. Dr. Bernstein reports grants from Department of Veterans Affairs National Center for Patient Safety and Blue Cross Blue Shield of Michigan during the conduct of the study; in addition, he is a member of the Blue Care Network Clinical Quality Committee, which reviews issues related to quality of care, and although peripherally inserted central venous catheters have not been considered in the past, their use may be reviewed in the future. Dr. Bernstein is also director of quality for the University of Michigan Medical Group; if the appropriateness of peripherally inserted central venous catheter criteria developed as part of this process are widely adopted, they could be applied to the University of Michigan by outside agencies. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOf InterestForms.do?msNum=M15-0744.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.
Grant Support: By a Young Researcher Award from the Society of Hospital Medicine and a career development award (1-K08-HS022835-01) from the Agency for Healthcare Research and Quality to Dr. Chopra and by Blue Cross Blue Shield and Blue Care Network of Michigan, which provided salary support for Drs. Flanders and Bernstein and Ms. Becker through the Michigan Hospital Medicine Safety Consortium.
Requests for Single Reprints: Vineet Chopra, MD, MSc, Institute for Healthcare Policy and Innovation, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 432W, Ann Arbor, MI 48109; e-mail firstname.lastname@example.org.
Current Author Addresses: Dr. Chopra: Institute for Healthcare Policy and Innovation, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 432W, Ann Arbor, MI 48109.
Dr. Flanders: Taubman Medical Center, University of Michigan, 1500 East Medical Center Drive, SPC 5376, Ann Arbor, MI 48109.
Dr. Saint: Institute for Healthcare Policy and Innovation, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 432W, Ann Arbor, MI 48109.
Dr. Woller: Intermountain Medical Center, PO Box 57700, 5169 South Cottonwood Street, Suite 307, Murray, UT 84107.
Dr. O'Grady: Critical Care Medicine Department, Clinical Center, National Institutes of Health, 10 Center Drive, Building 10, Room 2C145, Bethesda, MD 20892.
Dr. Safdar: University of Wisconsin Medical School, MFCB 5221, 1685 Highland Avenue, Madison WI 53705.
Dr. Trerotola: Department of Radiology, University of Pennsylvania Medical Center, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104.
Dr. Saran: Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, 1415 Washington Heights, SPH I, Suite 3645, Ann Arbor, MI 48109-2029.
Ms. Moureau: PICC Excellence, Inc., 1905 Whippoorwill Trail, Hartwell, GA 30643.
Dr. Wiseman: Veterans Affairs Ann Arbor Healthcare System, VISN 11, 2215 Fuller Road, Department of Pharmacy (119), Ann Arbor, MI 48105.
Dr. Pittiruti: Catholic University, Via Malcesine 65, 00135 Rome, Italy.
Dr. Akl: American University of Beirut Medical Center, PO Box 11-0236 Riad-El-Solh 1107 2020, Beirut, Lebanon.
Dr. Lee: Division of Hematology, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, British Columbia V5Z 1M9, Canada.
Dr. Courey: Taubman Medical Center, University of Michigan, 1500 East Medical Center Drive, SPC 3918, Ann Arbor, MI 48109-3918.
Dr. Swaminathan: Division of Hospital Medicine, Oakwood Hospital, 18101 Oakwood Boulevard, Dearborn, MI 48124.
Dr. LeDonne: Department of Surgery, Greater Baltimore Medical Center, 10210 Breconshire Road, Ellicott City, MD 21041.
Ms. Becker: Institute for Healthcare Policy and Innovation, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 476C, Ann Arbor, MI 48109.
Dr. Krein: Department of Veterans Affairs, 2800 Plymouth Road, Building 16, Room 33W, Ann Arbor, MI 48109-2800.
Dr. Bernstein: Institute for Healthcare Policy and Innovation, University of Michigan, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 446E, Ann Arbor, MI 48109.
Author Contributions: Conception and design: E.A. Akl, C. Becker, S.J. Bernstein, V. Chopra, S.A. Flanders, S.L. Krein, J. LeDonne, S. Saint, L. Swaminathan, S. Wiseman, S. Woller
Analysis and interpretation of the data: C. Becker, S.J. Bernstein, V. Chopra, J. LeDonne, A.Y. Lee, M. Pittiruti, S. Trerotola
Drafting of the article: S.J. Bernstein, V. Chopra, A.J. Courey, N. O'Grady, S. Trerotola.
Critical revision for important intellectual content: E.A. Akl, C. Becker, S.J. Bernstein, V. Chopra, A.J. Courey, S.A. Flanders, S.L. Krein, J. LeDonne, A.Y. Lee, N.L. Moureau, N. O'Grady, M. Pittiruti, N. Safdar, S. Saint, R. Saran, L. Swaminathan, S. Trerotola, S. Wiseman, S. Woller.
Final approval of the article: E.A. Akl, C. Becker, S.J. Bernstein, V. Chopra, A.J. Courey, S.A. Flanders, S.L. Krein, J. LeDonne, A.Y. Lee, N.L. Moureau, N. O'Grady, M. Pittiruti, N. Safdar, S. Saint, R. Saran, L. Swaminathan, S. Trerotola, S. Wiseman, S. Woller.
Provision of study materials or patients: V. Chopra, S.A. Flanders, A.Y. Lee.
Statistical expertise: S.J. Bernstein, V. Chopra.
Obtaining of funding: V. Chopra, A.J. Courey, S.A. Flanders, S. Saint.
Administrative, technical, or logistic support: C. Becker, S.J. Bernstein, V. Chopra, S.A. Flanders, R. Saran.
Collection and assembly of data: E.A. Akl, C. Becker, V. Chopra, S.A. Flanders, N.L. Moureau, N. O'Grady, L. Swaminathan, S. Trerotola, S. Wiseman, S. Woller.
Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety.
An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices.
After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters 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.
The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.
Appendix Table 1. Literature Search Strategy
Table 1. Summary of Studies Included in the Literature Review
Appendix Table 2. Characteristics of MAGIC Panel Members
Vascular access devices reviewed to formulate appropriateness ratings.
IV = intravenous; US = ultrasonography. A. Peripheral IV catheter. These devices are typically 3 to 6 cm, enter and terminate in the peripheral veins (cross-section), and are often placed in the upper extremity in veins of the hand. B. US-guided peripheral IV catheter. Ultrasonography may be used to facilitate placement of peripheral intravenous catheters in arm veins that are difficult to palpate or visualize. "Long" peripheral IV catheters (typically ≥8 cm) that are specifically designed to reach deeper veins are also available for insertion under US guidance. C. Midline catheter. These devices are 7.5 to 25 cm in length and are typically inserted in veins above the antecubital fossa. The catheter tip resides in the basilic or cephalic vein, terminating just short of the subclavian vein. These devices cannot accommodate irritant or vesicant infusions. D. Nontunneled central venous catheter. Also referred to as "acute" or "short-term" central venous catheters, these are often inserted for durations of 7 to 14 d. They are typically 15 to 25 cm and are placed via direct puncture and cannulation of the internal jugular, subclavian, or femoral veins. E. Tunneled central venous catheter. These differ from nontunneled catheters in that the insertion site on the skin and site of ultimate venipuncture are physically separated, often by several centimeters, reducing the risk for bacterial entry into the bloodstream and facilitating optimal location of the catheter for care of the exit site. Tunneled devices may be cuffed or noncuffed; the former devices have a polyethylene or silicone flange that anchors the catheter within the subcutaneous tissue and limits entry of bacteria along the extraluminal surface of the device. F. Implanted port. Ports are implanted in the subcutaneous tissue of the chest and feature a reservoir for injection or aspiration (inset) and a catheter that communicates from the reservoir to a deep vein of the chest, thus providing central venous access. Ports are cosmetically more desirable than other types of central venous catheter and can remain in place for months or years. G. Peripherally inserted central catheter. These long vascular access devices (>45 cm) are inserted into peripheral veins of the upper arm in adults and advanced so that the tip of the catheter resides in the lower portion of the superior vena cava or upper portion of the right atrium. They are similar to central venous catheters in that they provide access to the central circulation, but they do so without the insertion risks associated with direct puncture of deep veins in the neck, chest, or groin.
Appendix Table 3. Sample Lists of Thematic Concerns Raised by Panelists*
Conceptual framework used for the development of scenarios and indications of appropriateness.
To develop a conceptual framework, systematic reviews of the literature were conducted to determine the evidence base. With input from panelists, areas of controversy and ambiguity were identified and contextualized within clinical paradigms and lists of common problems associated with peripherally inserted central catheters. By methodologically pairing selection of venous access device with indication, duration, and nature of venous access and specific patient, device, and provider variables (center boxes), scenarios for panelists were created. These scenarios formed the basis for the appropriateness indications.
Appendix Table 4. Example Scenarios From Ratings Material
Venous access device recommendations for infusion of peripherally compatible infusate.
IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.
Venous access device recommendations for infusion of non–peripherally compatible infusates.
Venous access device recommendations for patients with difficult venous access.
Venous access device recommendations for patients who require frequent phlebotomy.
Table 2. Guide for PICC Use
Table 3. Guide for PICC Insertion, Care, and Maintenance Practices
Table 4. Guide for Peripheral Intravenous Catheter Practices
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Lakshmipathi Chelluri MD
Professor, Deprtment of Critical Care Medicine, University of Pittsburgh School of Medicine
October 13, 2015
Peripheral venous access
Dear Sir, The recent guidelines on Intravenous Access (IV) published in Annals of Internal Medicine are comprehensive and educational1. Occasionally, IV access for patients on the wards may be difficult. The guidelines provide a step wise approach, and may decrease use of Central Venous Catheters (CVC) and Peripherally Inserted Central Catheters (PICC). As an intensivist, it is not uncommon for me to be called to place a CVC on the ward for IV access. There seem to be a bias on the part of the panelists for CVC, and against PICC lines for IV access for ≤14 days, particularly if the duration is ≤ 5 days (figure 6, ref 1), but the rationale is not clear. From a safety perspective, a PICC is safer compared to CVC because there should be no mechanical complications (Pneumo/hemothorax) related to insertion with PICC, compression of brachial artery is easier in case of arterial puncture (compared to carotid or subclavian arterial puncture), infectious complications may be similar, patient may tolerate a PICC line better, and may need less sedation. Although PICC are associated with thrombosis, the incidence with short –term use is not well studied, and may be similar to CVC. The financial cost of PICC is about 2-3 times higher than standard triple lumen CVC, but the insertion complications associated with CVC may off set it. The panelists also suggest use of external jugular vein for IV access of duration ≤ 96 hours when a nurse cannot get peripheral IV access (Q 72, Supplement, ref 1). Although external jugular vein is easy to identify, it is sometimes difficult place an IV catheter, secure it for prolonged period and should be considered temporary, while a plan for better IV access is being considered2. Infusion Nurses Society suggested guidelines for external jugular vein access, and they could be considered for credentialing both nurses as well as physicians.1.Chopra V, Flanders SA, Saint S, O’Grady NP, Safdar N, Trerotola SO, et al; The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using RAND/UCLA Appropriateness Method. Ann Intern Med. 2015;163:S1-S392. INS Position Paper: The Role of the Registered Nurse in the Insertion of External Jugular Peripherally Inserted Central Catheters (EJ PICC) and External Jugular Peripheral Intravenous Catheters (EJ PIV) http://www.ins1.org/files/public/08_26_08_ins_position_paper.pdf. Accessed October 13, 2015
Benjamin T. Galen, MD
Albert Einstein College of Medicine, Division of Hospital Medicine
November 12, 2015
The definition and duration of "US-guided peripheral IV catheter" are not clear
In their extensive review of intravenous catheters, Chopra et al. make helpful recommendations about the use of venous access devices (1). However, there is insufficient evidence to justify separating “US-guided peripheral IV catheter” from “peripheral IV catheter” in recommendations for catheter duration as the authors do in Figures 3-6. While the authors state in Figure 1 that longer peripheral IV catheters can be inserted with US guidance, their category of “US-guided peripheral IV catheter” includes placing a standard-sized catheter (1,2). Using ultrasound to insert a peripheral IV might be helpful in patients with challenging venous access, but Chopra et al. do not cite any evidence for the recommendation that an “US-guided peripheral IV catheter” can be safely used for longer than a “peripheral IV catheter” placed without ultrasound (6-14d compared to <5d in figures 3 and 5). While catheter length and larger / deeper veins might theoretically permit a safe extension of catheter duration, Chopra et al. do not discuss these factors in their recommendations for peripheral catheters. The authors cite one study in which 8 cm catheters were placed in the cephalic and basilic veins, but these “longer” peripheral catheters were observed for a maximum of only seven days without a comparison group (3). The only other primary study cited by Chopra et al. that evaluated “US-guided peripheral IV catheter” duration is a trial comparing a 12 cm catheter to a 5cm catheter. Catheters were removed on clinical grounds and lasted an average of 6.2 and 3.4 days, respectively (4). Chopra et al. define a “midline catheter” as a peripheral device >7.5 cm; thus, the distinction between “US-guided peripheral IV catheter” and “midline catheter” is also not clear (1). Further guidelines for “US-guided peripheral IV catheters” should be more precise about device definitions and provide better evidence to support catheter duration recommendations. 1. Chopra V, Flanders SA, Saint S, O’Grady NP, Safdar N, Trerotola SO, et al; The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using RAND/UCLA Appropriateness Method. Ann Intern Med. 2015; 163:S1-S392. Joing S, Strote S, Caroon L, Wall C, Hess J, Roline C, et al. Videos in clinical medicine. Ultrasound-guided peripheral IV placement. N Engl J Med. 2012;366:e38.3. Meyer P, Cronier P, Rousseau H, Vicaut E, Choukroun G, Chergui K, et al. Difficult peripheral venous access: clinical evaluation of a catheter inserted with the Seldinger method under ultrasound guidance. J Crit Care. 2014;29:823-7. 4. Elia F, Ferrari G, Molino P, Converso M, De Filippi G, Milan A, et al. Standard-length catheters vs long catheters in ultrasound-guided peripheral vein cannulation. Am J Emerg Med. 2012;30: 712-6.
Chopra V, Flanders SA, Saint S, Woller SC, O'Grady NP, Safdar N, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method. Ann Intern Med. 2015;163:S1–S40. doi: 10.7326/M15-0744
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Published: Ann Intern Med. 2015;163(6_Supplement):S1-S40.
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