From the 2018 HVPAA National Conference
Katherine Hochman (NYU Langone Health), Nicole Adler (NYU Langone Health), Frank Volpicelli (NYU Langone Health), Brian Bosworth (NYU Langone Health)
Peripherally inserted central catheters are routinely placed in hospitalized patients. Prior to our intervention, 1 in 12 patients on the Medicine service received a PICC. The 90-day mortality in patients who received a PICC was 13.4%, suggesting that providers are not considering prognosis in the role of long-term therapy.
The goal was to reduce the number of PICCs, PICC days, central line associate blood stream infections and line-associated venous thromboembolisms on Medicine patients. Like antibiotic stewardship, a goal of vascular access stewardship was to educate and advise the safest access for each patient.
The strategy for the VAS initiative was simple: every PICC required approval from the on-call VAS attending prior to insertion. The initiative was championed by Medicine leadership who partnered with the vascular access nurses to create a seamless workflow. Housestaff, nurse practitioners, physician assistants and attendings were educated on the importance of carefully considering the method of vascular access, the alternative to PICC placement as well as the new policy requiring approval. If a PICC was approved, the ordering provider was instructed to document “PICC line approved by Medicine leadership” in the “comments” sections of the Epic order. The vascular access nurses would only place PICC lines in patients with the appropriate notation in their order. If a PICC was not approved, there was an opportunity for Medicine leadership to further educate the provider on alternatives and appropriateness criteria.
The Vascular Access Stewardship initiative resulted in a 38% decrease in the number of PICCs placed on Medicine patients (224/quarter to 140/quarter) and a 46% decrease in the number of PICC days (1,611/quarter to 867/quarter) (Figure 1). The number of non-mucosal barrier injury related CLABSIs/1,000 line days decreased from 1.11 (FY17) to 0.46 (FY18 to date). The overall hospital-acquired VTE rate related to PICC insertion was unchanged. The percent of patients who received a PICC and died within 3 months of its insertion decreased from 13.4% to 3.7%. Number of midlines placed increased from 240/quarter to 435/quarter (Figure 2). The cost of placing a midline instead of a PICC (in which a chest X-ray is also required) is $90 less.
 Caparas et al, J Vasc Access 2014;15 (4): 251-256.
Our Vascular Access Stewardship initiative is an effective and portable strategy that enhances patient safety and is less costly.
Implications for the Patient
Providers must carefully consider the indications for and alternatives to PICC line placement to provide safe and cost-effective care. A vascular access stewardship program decreases PICC line days, CLABSIs, and cost. Additionally, it provides an opportunity for culture change around best practice for vascular access and patient safety.