m.a.g.i.c. guidelines
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The Michigan Appropriateness Guide for Intravenous Catheters(MAGIC): Results From a Multispecialty Panel Using the RAND/UCLAAppropriateness MethodVineet 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; and Steven J. Bernstein, MD, MPH
Use of peripherally inserted central catheters (PICCs) has grownsubstantially in recent years. Increasing use has led to the real-ization that PICCs are associated with important complications,including thrombosis and infection. Moreover, some PICCs maynot be placed for clinically valid reasons. Defining appropriateindications for insertion, maintenance, and care of PICCs is thusimportant for patient safety.
An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use ofPICCs. After systematic reviews of the literature, scenarios re-lated to PICC use, care, and maintenance were developed ac-cording to patient population (for example, general hospitalized,critically ill, cancer, kidney disease), indication for insertion (infu-sion of peripherally compatible infusates vs. vesicants), and du-ration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days).Within each scenario, appropriateness of PICC use was com-pared with that of other venous access devices.
After review of 665 scenarios, 253 (38%) were rated as appro-priate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappro-priate. For peripherally compatible infusions, PICC use was ratedas inappropriate when the proposed duration of use was 5 orfewer days. Midline catheters and ultrasonography-guided pe-ripheral intravenous catheters were preferred to PICCs for usebetween 6 and 14 days. In critically ill patients, nontunneled cen-tral venous catheters were preferred over PICCs when 14 orfewer days of use were likely. In patients with cancer, PICCs wererated as appropriate for irritant or vesicant infusion, regardless ofduration.
The panel of experts used a validated method to develop ap-propriate indications for PICC use across patient populations.These criteria can be used to improve care, inform quality im-provement efforts, and advance the safety of medical patients.
Ann Intern Med. 2015;163:S1-S39. doi:10.7326/M15-0744 www.annals.orgFor author affiliations, see end of text.
Reliable venous access is a cornerstone of safe andeffective care of hospitalized patients. Spurred by
technological advances, several venous access devices(VADs) for use during and beyond hospitalization areavailable to meet this need. In recent years, peripher-ally inserted central catheters (PICCs) have becomepopular for venous access in hospital settings (1, 2).Compared with traditional central venous catheters(CVCs), PICCs offer several advantages, including saferinsertion in the arm, cost-effective and convenientplacement via vascular access nursing teams, and self-care compatibility that facilitates use beyond hospital-ization (3–5). It is therefore not surprising that use ofPICCs has grown considerably worldwide (6–8).
Despite these advantages, PICCs are central ve-nous catheters that may lead to important complica-tions (9). For instance, problems such as luminalocclusion, malpositioning, and dislodgement occur fre-quently with these devices (10–12). Similarly, superficialthrombophlebitis or infection at the site of PICC inser-tion may occur despite uneventful and optimal place-ment (13, 14). In addition, PICCs are associated withmorbid complications, including venous thromboem-bolism and central line–associated bloodstream infec-tion (15–17). Ensuring appropriate use of PICCs is thusvital to preventing these costly and potentially fatal ad-verse events.
A growing number of studies suggest substantialvariation and potentially inappropriate use of PICCs inhospitalized patients. For example, in a study from a
large academic medical center, many PICCs were notactively used or were inserted in patients who also hadperipheral intravenous catheters (18). In a decade-longstudy conducted in a tertiary hospital, changes in pat-terns of PICC use, including shorter dwell times andambiguous indications for insertion, were reported(19). Additional cause for concern comes from a recentstudy, which found that 1 in 5 inpatient providers didnot know that their patients had CVCs, with lack ofawareness being greatest for PICCs (20). Surveys of in-patient providers have also demonstrated knowledgegaps related to appropriate indications and care prac-tices for PICCs (21, 22). Collectively, these data havenot only led to reviews of PICC use in hospitals (23) butalso to calls by the Choosing Wisely initiative to im-prove PICC practices across the United States (24, 25).
The concepts of inappropriate overuse and under-use of medical devices are by no means unique toPICCs. Rather, such issues accompany the diffusion ofmany novel health technologies. In many such in-stances, a key barrier to achieving appropriate use is
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the fact that evidence at a level of detail needed toapply to the range of patients seen in everyday practiceis not available. Nevertheless, clinicians must makechoices regarding such innovations on a daily basis,potentially fueling inconsistent practice. In the absenceof high-quality evidence, an approach that combinesavailable data with the experience and insight of clini-cal experts is valuable as it would provide guidancewhere none is otherwise available.
Given this background, we organized and con-ducted a multidisciplinary meeting of national and in-ternational experts to develop appropriateness criteriafor use, care, and management of PICCs and relatedVADs in hospitalized patients. Our objectives were to 1)develop a list of appropriate indications for use ofPICCs in relation to other VADs, 2) define the appropri-ateness of practices associated with the insertion andcare of PICCs, 3) determine appropriate practices fortreatment and prevention of PICC complications, and4) rate the appropriateness of peripheral intravenouscatheter use in situations that prompt PICC placement.
METHODSOverview of the RAND/UCLA AppropriatenessMethod
We used the RAND Corporation/University of Cali-fornia Los Angeles (RAND/UCLA) AppropriatenessMethod to create criteria for appropriate use of PICCsand related VADs (10). Introduced in the 1980s, theRAND/UCLA method was developed to enable mea-surement of overuse of medical and surgical proce-dures. According to this methodology, a procedure isconsidered appropriate when the “expected healthbenefits (e.g., increased life expectancy, relief of pain,reduction of anxiety or pain) exceed the expected neg-ative consequences (e.g., mortality, morbidity, anxiety,pain) by a sufficiently wide margin such that the proce-dure is worth doing, exclusive of cost.” The approachhas thus been applied to an array of procedures, in-cluding coronary angiography (26), surgical proce-dures (27, 28), cataract removal (29), and transplant or-gan allocation (30). Recently, the method was also usedto develop criteria for appropriate use of urinary cath-eters in hospitalized patients (31).
The RAND/UCLA method was particularly valuablefor developing PICC appropriateness criteria for sev-eral reasons. First, the approach allowed the synthesisof the best available evidence with practice-based,domain-specific insights from experts. This uniquecombination ensured both clinical relevance and evi-dentiary support for the developed recommendations.Second, unlike other group-rating methods, the focusof the RAND/UCLA approach is not to ensure consen-sus, but minimize artifactual disagreement that mayarise from misunderstanding of scenarios being rated.This nuance is highly relevant in the case of PICCs, be-cause available evidence is derived from heteroge-neous study designs (for example, retrospective, case–control studies and randomized trials), populations (forexample, critically ill, cancer), and clinical specialties
(nursing, radiology, medical or surgical disciplines) andis thus prone to misinterpretation. Because the RAND/UCLA method pairs clear instructions and precise clin-ical definitions with a systematic, reliable, and repro-ducible rating system (27), the recommendationsgenerated will have high internal validity. Finally,should clinical scenarios lack sufficient detail to makean informed judgment regarding appropriateness, theRAND/UCLA method encourages clarification by pan-elists so as to make ratings more relevant and precise.In this fashion, generalizability and external validity ofthe developed appropriateness indications are alsoensured.
Proper conduct of the RAND/UCLA Appropriate-ness Method requires the sequential performance ofseveral steps, including information synthesis, panelistselection, creation of scenarios, rating process, andanalysis of results.
Information SynthesisThe first step of the RAND/UCLA Appropriateness
Method is to systematically review and synthesize theavailable literature. With the assistance of 2 researchlibrarians, we searched for English-language articles(between 12 November 2012 and 1 July 2013) by usingthe following databases: MEDLINE via Ovid (1950 topresent), EMBASE (1946 to present), BIOSIS (1926 topresent), and the Cochrane Central Register of Con-trolled Trials via Ovid (1960 to present). The searchstrategy incorporated Boolean logic, controlled vocab-ularies (for example, Medical Subject Heading terms)and free-text words. Because the panel was focused ondetermining the appropriateness of PICC use in hospi-talized adults, articles that included only pediatric pa-tients or devices not comparable with PICCs (for exam-ple, arterial or hemodialysis catheters) were excluded.
We also included relevant guidelines, such as theInfusion Nursing Society Standards of Practice (32),Centers for Disease Control and Prevention/HealthcareInfection Control Practices Advisory Committee centralline–associated bloodstream infection preventionguidelines (33), American Society of AnesthesiologyTask Force on Central Venous Access (34), AmericanCollege of Chest Physicians Antithrombotic Therapyand Prevention of Thrombosis Guidelines (35), and In-ternational Clinical Practice Guidelines for the Treat-ment and Prophylaxis of Thrombosis Associated WithCentral Venous Catheters in Patients With Cancer (36).
All retrieved articles were independently scannedfor eligibility by 2 of the authors. Disagreements on el-igibility were resolved by consensus, and a final list ofeligible studies and tables summarizing the evidencewere created. The search strategy is provided inAppendix Table 1 (available at www.annals.org), andTable 1 (on page S25) summarizes the included articles.
Participant and Panelist SelectionViewpoints related to PICC use are known to vary
across specialties; thus, what may be appropriate inone field may not be appropriate in another. To fosterdiscussions about these issues, specialists representingvascular access nursing, hospital-based medicine, inter-
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nal medicine, infectious disease, critical care, nephrol-ogy, hematology/oncology, pharmacy, surgery, and in-terventional radiology were considered necessary toensure representativeness of the panel. Leading na-tional and international experts from each of these pro-fessions who are eminent scholars or researchers, rep-resent relevant medical societies, or have substantialclinical experience in the field were invited to participate.
To ensure that deliberations took into accountpatient-centered viewpoints, we also invited a patientto participate on our panel. We recognized that theideal patient had to be able to speak about experi-ences with PICCs and related VADs. We recruited sucha patient from our university practice in Ann Arbor,Michigan. Owing to the scientific nature of the material,however, the patient panelist did not rate scenarios andinstead contributed to panelist discussions. Throughthis process, 15 multispecialty panelists were recruitedto develop the Michigan Appropriateness Guide for In-travenous Catheters (MAGIC) (Appendix Table 2, avail-able at www.annals.org).
Creation of ScenariosOn the basis of articles found through the system-
atic literature searches, we created clinical scenarios torate the appropriateness of insertion, maintenance, andcare of PICCs. To accurately reflect clinical decisionmaking, devices, including peripheral intravenous cath-eters, ultrasonography-guided peripheral intravenouscatheters, midline catheters, nontunneled CVCs, tun-neled CVCs, and ports, were compared with PICCs(Figure 1). Scenarios were crafted so as to allow judg-ment of real-world use of PICCs; thus, areas of consen-sus, controversy, and ambiguity were purposefully in-cluded. To further ensure validity, we asked eachexpert to provide a list of concerns related to PICC usethat were most relevant to their practice (Appendix Ta-ble 3, available at www.annals.org). If not already rep-resented, these issues were also incorporated into sce-narios of appropriateness.
We developed a conceptual framework to ensurethat scientific content, clinical indications, relevantVADs, and contextual factors were adequately repre-sented when drafting scenarios (Figure 2). Thus, indica-tions for PICC insertion were systematically categorizedinto 1) duration of venous access (≤5 days, 6 to 14 days,15 to 30 days, ≥31 days); 2) type of infusate (for exam-ple, irritants or vesicants, including parenteral nutritionand chemotherapy); and 3) use for specific reasons,such as frequent obtaining of blood samples, poor ordifficult venous access, and continuation of intravenoustherapies in the outpatient setting. For each of theseinstances, clinical scenarios incorporating 1) patient-specific factors (for example, critical illness, cancer di-agnosis, stage of chronic kidney disease [CKD]), 2)device-specific factors (number of lumens, gauge, typeof PICC, alternative VADs), and 3) provider-specific fac-tors (the operator inserting the PICC, technique forPICC insertion) were created. In addition, scenarios re-garding appropriate practices for care, management,and treatment of PICC complications were written. Fi-
nally, because lack of peripheral access often promptsPICC use for specific clinical needs (for example, needfor contrast-based studies or blood transfusion), sce-narios related to use of peripheral intravenous catheterin such settings were created.
We pilot-tested all scenarios with 2 hospital-medicine physicians and further edited them for con-tent and clarity on the basis of their feedback. In thismanner, 665 scenarios and 391 unique indications forPICCs and related VADs were developed.
Rating ProcessRating of scenarios and indications were con-
ducted over 2 rounds. In round 1, each panelist re-ceived the literature review, definitions of all termsused, a rating document, and instructions for rating.Panelists were asked to dedicate at least 4 hours tocomplete the rating document. In accordance with theRAND/UCLA method, panelists were instructed not toconsider cost when making judgments; rather, theywere asked to use the available scientific evidence andbest clinical judgment in rating appropriateness (Sup-plement, available at www.annals.org). To ensure thatappropriateness was rated exclusive of confoundingcircumstances (such as specialist availability), panelistswere also instructed to assume availability of all re-sources related to the scenarios.
For each indication, panel members rated appro-priateness by considering the benefit–harm ratio on ascale of 1 to 9, where 1 indicated that harms outweighbenefit and 9 signified that benefits outweigh harm;Appendix Table 4 (available at www.annals.org) pro-vides examples of this process. A middle rating of 5signified that harms or benefits were equal, or that therater could not make an informed judgment on the in-dication. For a series of indications where 2 deviceswere appropriate, we asked panelists to rate prefer-ence for use of one device compared with the other,regardless of cost. Median ratings on opposite ends ofthe scale (for example, 1 to 3 or 7 to 9) were used toindicate preference of one device over another; a rat-ing in the range of 4 to 6 suggested no preference.
Each panelist rated every scenario twice in a2-round, modified Delphi process. In the first round,ratings were made individually and no interaction be-tween panelists occurred. In the second round, panelmembers traveled to Ann Arbor, Michigan, for an in-person meeting where individualized documents show-ing their ratings along with the distribution of all first-round ratings of the panel were provided.
Over 2 days, a RAND/UCLA methodology expertand a scientific content expert moderated a panel dis-cussion of all indications and scenarios. The sessionswere structured to encourage debate and discussionspecifically about ratings where disagreement (oppo-site ratings) or neutrality/uncertainty (ratings of 4 to 6)occurred in round 1. For instance, it often became ap-parent in the second round that panelists had dis-agreed not on the indication, but on the patient or cir-cumstances being considered because of inherentassumptions, specialty-specific views, or ambiguity in
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the scenario itself. When this occurred, the scenariowas rewritten with input from the entire panel such thatclarifying language or necessary specification wasincluded.
For example, ratings for PICC insertion in patientswith CKD were found to be widely disparate in round 1.During round 2, our panel nephrologist clarified that
placement of PICCs in patients with stage 3b or greaterCKD was specifically contraindicated. Therefore, for in-dications that included CKD, 2 sets of scenarios werecreated (stage 3a or lower vs. stage 3b or higher), usingXs and Os on the rating form to distinguish these rat-ings. Panelists then rerated each of the scenarios, im-proving validity and agreement of their responses.
Figure 1. Vascular access devices reviewed to formulate appropriateness ratings.
A. Peripheral IV Catheter
B. US-Guided Peripheral IV Catheter
C. Midline Catheter
E. Tunneled Central Venous Catheter
F. Implanted Port
D. Nontunneled Central Venous Catheter
G. Peripherally InsertedCentral Catheter
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 usedto 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. Thesedevices 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 cephalicvein, terminating just short of the subclavian vein. These devices cannot accommodate irritant or vesicant infusions. D. Nontunneled central venouscatheter. Also referred to as “acute” or “short-term” central venous catheters, these are often inserted for durations of 7 to 14 d. They are typically15 to 25 cm and are placed via direct puncture and cannulation of the internal jugular, subclavian, or femoral veins. E. Tunneled central venouscatheter. 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 theexit site. Tunneled devices may be cuffed or noncuffed; the former devices have a polyethylene or silicone flange that anchors the catheter withinthe subcutaneous tissue and limits entry of bacteria along the extraluminal surface of the device. F. Implanted port. Ports are implanted in thesubcutaneous tissue of the chest and feature a reservoir for injection or aspiration (inset) and a catheter that communicates from the reservoir to adeep vein of the chest, thus providing central venous access. Ports are cosmetically more desirable than other types of central venous catheter andcan remain in place for months or years. G. Peripherally inserted central catheter. These long vascular access devices (>45 cm) are inserted intoperipheral 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 orupper portion of the right atrium. They are similar to central venous catheters in that they provide access to the central circulation, but they do sowithout the insertion risks associated with direct puncture of deep veins in the neck, chest, or groin.
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Data Processing and AnalysisFirst-round ratings were submitted either electron-
ically via an online survey system or through paperforms. Data obtained from paper ratings were manuallyentered into a study database (Qualtrics Research SuitePackage, Qualtrics USA) and checked in duplicate fortranscription errors. Descriptive statistics (mean, me-dian, mode) were calculated for all variables. A sum-mary result document was created that listed the fre-quency of responses, median responses, and eachindividual panelist's response for every scenario. In ac-cordance with the RAND/UCLA method, all indicationswere classified into 3 levels of appropriateness:
1. Appropriate: panel median score of 7 to 9, with-out disagreement;
2. Uncertain/neutral: panel median score of 4 to 6,or with disagreement regardless of median; and
3. Inappropriate: panel median score of 1 to 3,without disagreement.
Disagreement was said to have occurred when atleast 5 of the 15 panel members rated an indication asappropriate (median score, 7 to 9) and at least 5panelists rated the same indication as inappropriate(median score, 1 to 3). Only indications withoutdisagreement were classified as inappropriate orappropriate.
DefinitionsTo ensure consistency, standardized definitions of
devices (for example, PICC, midline), populations (ac-tive cancer, “special” populations), indications (for ex-ample, frequent obtaining of blood samples, hemody-namic monitoring), and infusates (irritant, vesicant)were provided to panelists. A complete glossary ofterms and definitions used is provided in the ratingsdocument in the Supplement (available at www.annals.org).
Figure 2. Conceptual framework used for the development of scenarios and indications of appropriateness.
AppropriatenessIndications
Proposed durationof venous access
Indication forvenous access Nature of infusate
Patientcharacteristics
Devicecharacteristics
Providercharacteristics
Systematic Review of the Literature
Clin
ical
Par
adig
ms
and
Pane
list
List
s A
reas of Controversy, A
mbiguity, or U
ncertainty
Maintenance andcare practices
Treatment ofcomplications
Developmentof
ClinicalScenarios
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 withperipherally inserted central catheters. By methodologically pairing selection of venous access device with indication, duration, and nature ofvenous access and specific patient, device, and provider variables (center boxes), scenarios for panelists were created. These scenarios formed thebasis for the appropriateness indications.
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Role of the Funding SourceThis project was supported by a Young Researcher
Award from the Society of Hospital Medicine to Dr.Chopra. Funds were used to support panelist lodging,meals, transportation, and venue. Blue Cross BlueShield of Michigan provided salary support for 3 of theauthors through a grant to the University of Michigan.Neither funder had a role in the design, conduct, oranalysis of the project or the decision to submit themanuscript for publication.
RESULTSWithin the 665 scenarios reviewed, panel members
rated 391 unique indications for PICCs and relatedVADs. During the first round, the panel rated 237 sce-narios as appropriate (36%), 267 as inappropriate(40%), and 161 as neutral/uncertain (24%). After thesecond round of in-person interactions, 253 scenarioswere rated as appropriate (38%), 288 as inappropriate(43%), and 124 as neutral/uncertain (19%). Thus, duringthe second round of discussions, better distinction ofneutral/uncertain indications as being appropriate orinappropriate indications occurred. A substantial pro-portion of this convergence in ratings reflected resolu-tion of disagreement (30 of 37 scenarios) from round 1to round 2.
1. Appropriateness of PICC Insertion in SpecificPopulationsA. Appropriateness of PICC Insertion in HospitalizedMedical Patients
In hospitalized medical patients, panelists rated in-sertion of PICCs for infusion of peripherally compatibleinfusates as inappropriate if the expected duration ofuse was 5 or fewer days. In such scenarios, use of pe-ripheral intravenous catheters or ultrasonography-guided peripheral intravenous catheters was rated asappropriate.
If the proposed duration of infusion was 6 to 14days, panelists rated PICC use as appropriate butindicated a preference for midline catheters andultrasonography-guided peripheral intravenous cathe-ters over PICCs for this period. This rating reflected ev-idence from observational studies that suggested bothefficacy and lower risk for complications associatedwith these devices compared with PICCs for this inter-val (37–41).
When the proposed duration of infusion was 15 ormore days, PICCs were preferred to midline catheters,given the possibility of failure of the latter beyond thisperiod (42, 43). However, panelists recognized thatmidline catheters may be used for up to 4 weeks andare approved for such duration of use (32).
Use of tunneled catheters and implanted portswere rated appropriate only if the proposed duration ofinfusion was 31 or more days. Panelists noted thatthese more invasive devices should be reserved for in-stances when use of PICCs is not feasible (for example,no suitable vein or site of insertion for PICC is identi-fied), is relatively contraindicated (for example, recent
history of thrombosis), or when episodic infusions overseveral months are necessary (Figure 3).
For infusion of irritants or vesicants, such as paren-teral nutrition or chemotherapy, PICC use was rated asappropriate at any proposed duration of use. Becauseperipheral intravenous catheters, ultrasonography-guided peripheral intravenous catheters, and midlinecatheters would not provide central venous access,these VADs were rated as inappropriate for this indica-tion for all durations of use.
If skilled operators are available, panelists rateduse of nontunneled CVCs as appropriate when the ex-pected duration of use was 14 or fewer days. Panelistsalso rated use of tunneled, cuffed catheters and im-planted ports as appropriate for infusion of irritants orvesicants, but only when the proposed duration of ther-apy was 15 or more days or 31 or more days, respec-tively (Figure 4).
Panelists disagreed on the appropriateness ofPICC placement when the indication was frequent ob-taining of blood samples (≥3 phlebotomies per day) ordifficult or poor peripheral venous access for proposeddurations of 5 or fewer days. Our patient panel mem-ber actively participated in this discussion, suggestingthat such decisions should be individualized betweenthe patient and provider after discussing risks and ben-efits related to PICC use and alternative options. Inser-tion of PICCs was rated as appropriate when the pro-posed duration of use for frequent phlebotomy ordifficult venous access was 6 or more days. In patientswith difficult venous access, ultrasonography-guidedperipheral intravenous catheters and midline catheterswere preferred over PICCs when the expected durationof use was 14 or fewer days. Panelists rated use ofCVCs for both difficult venous access and frequentphlebotomy as appropriate, provided the proposedduration of use was 14 or fewer days. Placement oftunneled catheters for patients with difficult venous ac-cess was rated as appropriate only if the proposed du-ration of use was 31 or more days. Ports were rated asinappropriate for frequent obtaining of blood samplesat all durations and appropriate for difficult venous ac-cess if use for 31 or more days was expected (Figures 5and 6).
B. Appropriateness of PICCs in Patients With CKD,Cancer, or Critical Illness
Panelists rated the appropriateness of PICC place-ment in patients with CKD according to disease stageas defined by the Kidney Disease: Improving GlobalOutcomes CKD Work Group (44). Among patients withstage 1 to 3a CKD (estimated glomerular filtration rate≥45 mL/min), rating of indications for PICC use fol-lowed those of general medical patients. However, thepanel noted that managing such patients on the basisof CKD stage alone might be imperfect because myriadfactors, including age, magnitude of albuminuria, race,and blood pressure, influence progression of renal dis-ease (45–49). The panel therefore recommended con-sultation with a nephrologist before PICC insertion if
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ambiguity regarding the severity of underlying kidneydisease exists. However, for patients with stage 3b CKDor greater (estimated glomerular filtration rate <45 mL/min), panelists acknowledged the imperative to pre-serve peripheral and central veins for possible hemodi-alysis or creation of arteriovenous fistulae and grafts(49). Thus, regardless of indication, insertion of devices(PICCs, midline catheters) into arm veins was rated asinappropriate in such patients. When venous access for5 or fewer days was necessary, panelists recommendplacement of peripheral IVs in the dorsum of the hand(avoiding the forearm veins) for infusion of peripherallycompatible infusates. If venous access for longer dura-tions or infusion of a non–peripherally compatible drugis needed, use of tunneled small-bore central catheters(for example, 4-French single-lumen or 5-Frenchdouble-lumen catheters inserted in the jugular vein andtunneled toward the chest) was rated as appropriate(50). For patients receiving any form of renal replace-ment therapy, panelists also recommended consulta-tion with a nephrologist to discuss the possibility ofdrug administration during or toward the end of thedialysis procedure.
These recommendations notwithstanding, panel-ists acknowledged that recommendations for patients
with stage 3b CKD or greater would need to be indi-vidualized, taking into account such factors as the ur-gency of the situation; rationale for venous preserva-tion; likelihood of eventual renal replacement therapy;and availability of resources, such as tunneled small-bore central catheters.
Given the risks for and consequences of infectious(51, 52) and thrombotic (53–55) complications, as wellas the unique indication of chemotherapy, ratings forPICC placement in patients with cancer differed fromthose for general medical patients. Recognizing theheterogeneity of thrombosis risk in patients with can-cer, the panel discussion focused largely on patientswith solid tumors. Panelists debated on whether ratingsfor chemotherapy should be structured by cycles oftreatment versus time; given the desire for generaliz-ability, the panel agreed on time as a more practicalscale. Therefore, for infusion of nonirritant or nonvesi-cant chemotherapy, PICCs were rated as appropriateonly if the proposed duration of such treatment was 3or fewer months.
When peripherally administrable chemotherapy forless than 3 months was necessary, panelists disagreedon PICC appropriateness, given the availability of high-
Figure 3. Venous access device recommendations for infusion of peripherally compatible infusate.
Proposed Duration of Infusion
6–14 d 15–30 dDevice Type
Peripheral IVcatheter
No preference betweenperipheral IV and US-guided
peripheral IV cathetersfor use ≤5 d
US-guided peripheral IV catheter preferred to peripheral IVcatheter if proposed duration is 6–14 d
Central venous catheter preferred in critically ill patientsor if hemodynamic monitoring is needed for 6–14 d
Midline catheter preferred to PICC if proposed duration is ≤14 d
PICC preferred to midline catheter if proposed duration of infusion is ≥15 d
PICC preferred to tunneledcatheter and ports for
infusion 15–30 d
Midline catheter
PICC
Tunneled catheter
Port
US-guidedperipheral IV catheter
Nontunneled/acutecentral venouscatheter
≤5 d ≥31 d
Appropriate Inappropriate DIsagreementNeutral
IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.
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quality evidence regarding risk for thrombosis withthese devices in patients with cancer (16). However,members of the panel cited conflicting evidence re-garding nonthrombotic complications associated withPICC use (15, 56–58). Of note, a study published sincethe panel meeting (coauthored by one of our panelists)reported a low rate of PICC complications when propercare was ensured (59). Nevertheless, given the diver-gent data, panelists rated interval placement of periph-eral intravenous catheters with each chemotherapytreatment as the most appropriate strategy.
Like PICCs, tunneled, cuffed catheters were ratedas appropriate when at least 3 months of treatmentwere proposed or when PICCs were not feasible (forexample, peripheral veins were not available). Portswere rated as appropriate if the duration of treatmentwas projected to be 6 or more months, but neutral fordurations of 3 to 6 months. Panelists noted that earlieruse of ports may be appropriate but may be challeng-ing owing to coagulation abnormalities or availability ofinterventional radiology.
For infusion of irritant or vesicant chemotherapy,panelists rated PICC or tunneled, cuffed catheter use asappropriate at all time intervals; ports were rated asneutral at 3 to 6 months and appropriate at 6 or more
months. Panelists recommended tunneled, cuffed cath-eters over multilumen PICCs in settings where multipleor frequent infusions are required, citing lower risk forcomplications (60). However, panelists preferred PICCsto tunneled, cuffed catheters when managing patientswith coagulopathy and those with severe or prolongedthrombocytopenia (61). When the indication for PICCplacement was frequent phlebotomy or difficult periph-eral venous access in a hospitalized patient with cancer,panelists raised the threshold for PICC use comparedwith general medical patients. Thus, PICCs were con-sidered appropriate only if the proposed duration ofuse was 15 or more days; midline catheters were ratedas appropriate for 14 or fewer days of use.
Appropriateness of indications for PICC insertion incritically ill patients also differed from those for generalmedical patients, given the likely availability of intensiv-ists who could insert CVCs and concerns about hemo-dynamic stability, infection, and thrombosis. Panelistsconsequently rated PICC use as inappropriate for infu-sion of peripherally compatible infusates unless theproposed duration of treatment was 15 or more days.For the same indication, peripheral intravenous cathe-ters and midline catheters were rated as appropriatefor proposed durations of 5 or fewer days and 6 to 14
Figure 4. Venous access device recommendations for infusion of non–peripherally compatible infusates.
Proposed Duration of Infusion
6–14 d 15–30 dDevice Type
Peripheral IVcatheter
No preference between tunneled catheter and PICC for proposed durations ≥15 d
Central venous catheter preferred in critically ill patientsor if hemodynamic monitoring is needed for 6–14 d
PICCs rated as appropriate at all proposed durations of infusion
No preference amongport, tunneled catheter, or
PICC for ≥31 d
Midline catheter
PICC
Tunneled catheter
Port
US-guidedperipheral IV catheter
Nontunneled/acutecentral venouscatheter
≤5 d ≥31 d
Appropriate Inappropriate DIsagreementNeutral
Tunneled catheter neutral for for use ≥15 d
IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.
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days, respectively. Although limited data supportingthe recommendation for midline catheter use in criticalcare patients were available at the time of the meeting,a recent study reported favorable outcomes and costsavings with this device (62). Central venous catheterswere rated as appropriate when the proposed durationof treatment was 6 to 14 days in hemodynamically sta-ble patients; use of CVCs for proposed durations be-yond 15 days was rated as uncertain, with panelists ex-pressing concerns about infection and thrombosis.
In hemodynamically unstable patients or scenarioswhere invasive hemodynamic monitoring or central ac-cess was necessary, insertion of CVCs and PICCs wasrated as appropriate for durations of 14 or fewer daysand 15 or more days, respectively. Panelists preferredCVCs to PICCs in patients who were hemodynamicallyunstable or were actively receiving vasopressors. In thissetting, urgent requests for PICC placement were ratedas inappropriate. Given the risk for insertion complica-tions, panelists preferred use of PICCs to CVCs in criti-cally ill patients with coagulopathies (such as dissemi-nated intravascular coagulation or sepsis), especially ifuse for more than 15 days was proposed.
C. Appropriateness of PICC Insertion in SpecialPopulations
Panelists rated the appropriateness of PICCs inpopulations that need lifelong intravenous access (forexample, sickle cell anemia, short-gut syndrome, orcystic fibrosis) and populations residing in skilled nurs-ing facilities.
For populations that may require lifelong access,ratings were structured on the basis of how often pa-tients may be hospitalized within 1 year. For patientswho are infrequently hospitalized (≤5 hospitalizationsper year), PICC insertion was rated as inappropriatewhen the expected duration of use was 5 or fewer days.Insertion of a PICC was rated as uncertain when theexpected duration of use was between 6 and 14 days.The panel preferred midline catheters to PICCs for thisduration, assuming that peripherally compatible infus-ates were proposed (63). However, PICCs were rated asappropriate when the duration of use was expected tolast 15 or more days.
More permanent devices, such as tunneled, cuffedcatheters or ports, were not considered appropriate forpatients with infrequent hospitalizations, but our pa-tient panelist (reflecting on her experiences) com-
Figure 5. Venous access device recommendations for patients with difficult venous access.
Proposed Duration of Infusion
6–14 d 15–30 dDevice Type
Peripheral IVcatheter
No preference betweenperipheral IV and US-guided
peripheral IV cathetersfor use ≤5 d
US-guided peripheral IV catheters preferred to peripheral IVcatheters if proposed duration is 6–14 d
Central venous catheter preferred to PICC for use≤14 d in critically ill patients
Midline catheters preferred to PICC if proposed duration is ≤14 d
Midline catheter
PICC
Tunneled catheter
Port
US-guidedperipheral IV catheter
Nontunneled/acutecentral venouscatheter
≤5 d ≥31 d
Appropriate Inappropriate DIsagreementNeutral
Disagreement onappropriateness of PICC
for durations <5 d
PICC use appropriate if proposed duration is ≥6 d; PICCs preferred to tunneled catheters fordurations of 15–30 d
No preference betweentunneled catheter or port for
use ≥31 d
Tunneled catheter neutral fordifficult IV access for
use ≥15 d
IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.
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mented that an individualized approach would be nec-essary in such situations. In contrast, when patients inthis category are frequently hospitalized (≥6 hospital-izations per year), panelists rated use of tunneled,cuffed catheters as appropriate when the expected du-ration of venous access was 15 or more days. Portswere rated as appropriate when the proposed durationof use in frequently hospitalized patients was expectedto be 31 or more days. Panelists preferred placementof tunneled, cuffed catheters to PICCs when use for 15or more days was expected, citing the need to preserveveins to meet future, likely recurrent needs.
For patients residing in skilled nursing facilities,PICCs were rated as appropriate for infusion of nonirri-tant, nonvesicant treatments or frequent phlebotomy ifthe proposed duration of use was expected to be morethan 15 days. Appropriateness of PICC was rated asuncertain for durations of 6 to 14 days, where panelistsrated midline catheters as appropriate. For venous ac-cess of 5 or fewer days, peripheral intravenous cathe-ters were rated as being the most appropriate VAD.Given the variable resources in such facilities and chal-lenges in obtaining venous access, the appropriatenessof midline catheters was rated neutral for this period.For infusion of irritants or vesicants in this setting, pan-
elists rated PICCs as appropriate regardless of durationof use.
A summary of these ratings is provided in Table 2.
2. Appropriateness of PICC PracticesA. Appropriateness of PICC Insertion Practices
Before PICC insertion for specialty-specific indica-tions, panelists rated consultations with specialists asappropriate (for example, infectious diseases beforeplacement of a PICC for intravenous antibiotic therapy,or hematology–oncology before PICC insertion for che-motherapy). For patients who require prolonged anti-biotic infusions (for example, infections, such as osteo-myelitis), panelists rated PICC placement within 2 to 3days of hospital admission as appropriate in the ab-sence of bacteremia. In the presence of bacteremia,PICC placement was rated as uncertain owing to ambi-guities regarding pathogen, intensity of bacteremia,and clearance of infection, among other factors. Con-sultation with infectious diseases specialists was sug-gested in this setting.
Preferential placement of PICCs by interventionalradiology professionals was rated as appropriate when1) a suitable target vein for insertion cannot be identi-
Figure 6. Venous access device recommendations for patients who require frequent phlebotomy.
Proposed Duration of Infusion
6–14 d 15–30 dDevice Type
Peripheral IVcatheter
Midline catheter
PICC
Tunneled catheter
Port
US-guidedperipheral IV catheter
Nontunneled/acutecentral venouscatheter
≤5 d ≥31 d
Appropriate Inappropriate DIsagreementNeutral
Disagreement onappropriateness of PICC
for durations <5 d
PICC use appropriate if proposed duration ≥6 d; PICC preferred to tunneled catheter fordurations of 15–30 d
No preference betweenperipheral IV and US-guided
peripheral IV catheterfor use ≤5 d
US-guided peripheral IVcatheter preferred if venous
access difficult
Midline catheter preferred to PICCs if proposed duration is ≤14 d
Central venous catheter preferred to PICC for use≤14 d in critically ill patients
Tunneled catheter neutral fordifficult intravenous access for
use ≥15 d
Ports inappropriate for frequent phlebotomy, regardless of proposed duration of use
Midline catheter neutral for frequent phlebotomy at
this duration
IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.
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fied on bedside ultrasonography, 2) the guidewire orcatheter fails to advance during bedside placement, or3) the patient requests sedation that cannot be safelydelivered at the bedside. In addition, placement by aninterventional radiologist was rated as appropriate forpatients with bilateral mastectomy, altered chest anat-omy, or superior vena cava filters. For patients withpermanent pacemakers or defibrillators, preferentialplacement by an interventional radiologist rather than avascular nursing professional was rated as appropriateif the contralateral arm was not amenable to insertion.These ratings were largely driven by expert opinion.
Panelists rated the appropriateness of specificPICC insertion practices on the basis of availability ofthe contralateral arm for placement. In accordance withInfusion Nursing Society Standards of Practice (32),avoiding insertion over a bruised or corded venoussegment, near or over an open wound or burn, andinto veins below the elbow was rated as appropriate.Owing to heightened risk for thrombosis, panelistsrated avoiding PICC placement in a hemiparetic or im-mobile arm as appropriate when the opposite limb wasavailable (64). Avoiding PICC insertion in the dominantarm as a strategy to prevent complications was rated asinappropriate, given the lack of convincing data to sup-port this practice. However, our vascular nursing andpatient panelists recommended that technical aspectsand patient preferences be considered when selectingarm of insertion.
Prior to PICC use, radiographic verification of PICCtip position was rated as appropriate after blind bed-side PICC placement or admission to a hospital with anexisting PICC. Conversely, panelists rated routine ra-diographic verification of PICC tip position as inappro-priate when PICCs were placed with electrocardio-graphic guidance, provided that proficiency with thistechnology had been demonstrated and adequatetracings (such as P-wave deflections) were observed.
To limit the risk for thrombosis, the U.S. Food andDrug Administration and specialty societies recom-mend that CVCs terminate in the lower one third of thesuperior vena cava or cavoatrial junction; “higher” (suchas the upper one third of the superior vena cava) or“lower” positions (such as the right atrium) were notrecommended (32, 65, 66). Acknowledging these con-cerns, panelists rated adjustment of the PICC when thetip was in the upper or middle one third of the superiorvena cava or right ventricle as appropriate.
However, panelists deviated from existing recom-mendations in rating the right atrium as an appropriateposition for the PICC tip and one that does not warrantadjustment. This rating was made after extensive dis-cussions of clinical practice and review of contempo-rary evidence, which did not suggest that terminationof PICCs or CVCs in the right atrium was associatedwith adverse outcomes in adults (66–71). Panelists rec-ognized that supporting data were observational, and awell-conducted randomized, controlled trial would behelpful in supporting this recommendation.
The possibility of atrial tachyarrhythmia during orafter PICC insertion in this position was also debated(72). As with any CVC, placement of the PICC tip in theright atrium in the setting of an atrial arrhythmia wasnot recommended. However, in the absence ofcontraindications, repositioning the PICC tip simply be-cause it resides in the right atrium was rated asinappropriate.
Table 2. Guide for PICC Use
Appropriate indications for PICC useDelivery of peripherally compatible infusates when the proposed
duration of such use is ≥6 d*Delivery of non–peripherally compatible infusates (e.g., irritants or
vesicants), regardless of proposed duration of useDelivery of cyclical or episodic chemotherapy that can be administered
through a peripheral vein in patients with active cancer, provided thatthe proposed duration of such treatment is ≥3 mo†
Invasive hemodynamic monitoring or requirement to obtain centralvenous access in a critically ill patient, provided the proposed durationof such use is ≥15 d‡
Frequent phlebotomy (every 8 h) in a hospitalized patient, provided thatthe proposed duration of such use is ≥6 d
Intermittent infusions or infrequent phlebotomy in patients with poor/difficult peripheral venous access, provided that the proposedduration of such use is ≥6 d§
For infusions or palliative treatment during end-of-life care��Delivery of peripherally compatible infusates for patients residing in
skilled nursing facilities or transitioning from hospital to home,provided that the proposed duration of such use is ≥15 d¶
Inappropriate indications for PICC usePlacement for any indication other than infusion of non–peripherally
compatible infusates (e.g., irritants or vesicants) when the proposedduration of use is ≤5 d
Placement in a patient with active cancer for cyclical chemotherapy thatcan be administered through a peripheral vein, when the proposedduration of such treatment is ≤3 mo and peripheral veins are available
Placement in a patient with stage 3b or greater chronic kidney disease(estimated glomerular filtration rate ≤44 mL/min) or in patientscurrently receiving renal replacement therapy via any modality
Insertion for nonfrequent phlebotomy if the proposed duration of suchuse is ≤5 d
Patient or family request in a patient who is not actively dying or inhospice, for comfort in obtaining daily blood samples for laboratoryanalysis
Medical or nursing provider request in the absence of other appropriatecriteria for PICC use
PICC = peripherally inserted central catheter.* Use of ultrasonography-guided peripheral intravenous catheters ormidlines is preferred over use of PICCs for infusion of peripherallycompatible infusates up to 14 d. In patients with poor peripheral ve-nous access, use of ultrasonography-guided peripheral intravenouscatheters and midlines is also preferred over use of PICCs.† In patients with cancer, the risk for thrombosis associated with PICCsmay outweigh benefits. Patients who are scheduled to receive multi-ple cycles of peripherally compatible chemotherapy for durations <3mo should do so via peripheral intravenous catheters with eachinfusion.‡ Use of nontunneled central venous catheters is preferred over use ofPICCs for central venous access or invasive hemodynamic monitoring<14 d and in patients with documented hemodynamic instabilitywhere urgent venous access is necessary.§ Use of ultrasonography-guided peripheral intravenous catheters ormidlines is preferred over use of PICCs for patients with poor/difficultperipheral venous access.�� Placement of a PICC in a terminally ill patient is appropriate if itfacilitates comfort goals of care. PICCs may be left in place in suchpatients to attain similar goals.¶ Use of PICCs for home-based infusions or in skilled nursing facilities(where resources are limited) is inappropriate for short-term durations(<14 d). In such settings, use of peripheral intravenous catheters ormidlines was rated as appropriate.
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B. Appropriateness of PICC Selection, Care, andMaintenance Practices
Without a documented rationale for a multilumenPICC (for example, multiple incompatible fluids), panel-ists rated default use of single-lumen devices as an ap-propriate and potentially important way to reduce PICCcomplications (73–75). Insertion of multilumen PICCs toseparate obtaining blood samples from giving infu-sions or to ensure a “backup” lumen was available wasalso rated as inappropriate. To clarify device needs,collaboration with pharmacists or vascular access oper-ators before ordering a PICC was rated as appropriate.
Regarding dressings, panelists rated placement ofsterile gauze between the PICC entry site and adhesivedressing for the first 1 to 2 days of insertion as appro-priate; thereafter use of clear, transparent dressingsthat permit site examination and weekly or more fre-quent changes of wet, loose, or soiled dressings wasrated appropriate. Use of cyanoacrylate products (“su-per glue”) to prevent oozing or discharge from the exitsite or to secure catheters was rated as neutral by pan-elists, who noted lack of substantial evidence or expe-rience to support this recommendation (76). In accor-dance with available guidelines (33), routine use ofchlorhexidine dressings without documented adher-ence to basic infection-prevention efforts or in the ab-sence of high rates of central line–associated blood-stream infection was rated as inappropriate.
Panelists rated use of normal saline rather thanheparin to maintain catheter patency and prevent lu-men occlusion as appropriate, as reflected in recentrecommendations (77, 78). Regardless of how far outthe PICC was dislodged, panelists rated advancementof migrated PICCs as inappropriate; in this setting,guidewire exchange of the PICC was rated as appropri-ate, provided that there are no signs of local or sys-temic infection. Guidewire exchange was also rated asappropriate when changes to existing PICC character-istics (such as number of lumen or power-injectioncompatibility) were desired. Should a PICC no longerbe functional, exchange over a guidewire was rated asappropriate, provided that an indication warrantingcontinued PICC use was present. Ratings regardingguidewire exchanges were driven largely by expertrecommendation.
C. Appropriateness of Management of PICCComplications
In patients with a centrally positioned, otherwisefunctional PICC that is complicated by image-confirmed PICC-related deep venous thrombosis(DVT), panelists rated PICC removal as appropriate onlywhen 1) the PICC is clinically no longer necessary; 2)the PICC is only being used for phlebotomy, but pe-ripheral veins are available; 3) symptoms of venous oc-clusion (arm pain, swelling) persist despite therapeuticanticoagulation for 72 or more hours; and 4) bactere-mia with objective evidence of line-related infection ex-ists. Panelists rated removal of a functional PICC in thepresence of DVT as inappropriate when 1) irritants or
vesicant infusions remain necessary; 2) the patient haspoor peripheral venous access and requires frequentphlebotomy (and may thus require another PICC); and3) the patient has minimal improvement in symptoms ofvenous occlusion, but therapeutic anticoagulation hasbeen provided for 72 or fewer hours. Panelists wereneutral regarding PICC removal when 1) a patientcould not receive systemic anticoagulation, but thePICC remained clinically necessary and 2) a line-relatedinfection was suspected, but not confirmed. In general,these ratings mirrored existing evidence-based recom-mendations (35, 53, 79).
When treating PICC-related DVT, panelists ratedprovision of at least 3 months of anticoagulation at atreatment dose as appropriate. Shorter durations of an-ticoagulation or removal of the PICC as definitive ther-apy (in the absence of contraindications to anticoagu-lation) was rated as inappropriate. When treating withwarfarin, panelists recommended targeting anticoagu-lation to an international normalized ratio of 2 to 3;lower or higher international normalized ratio targetswere rated as inappropriate. Use of low-molecular-weight heparin over warfarin was preferred in patientswith cancer. Owing to insufficient evidence, preferen-tial use of target-specific oral anticoagulants over tradi-tional agents among patients with cancer was rated asinappropriate. Panelists rated urgent referral to inter-ventional radiology for catheter-directed treatment ofPICC-related DVT as appropriate when symptoms ofvenous occlusion were associated with phlegmasiacerulea dolens (swollen, enlarged, painful, and purplishdiscoloration of the affected limb).
Panelists rated the appropriateness of placementof a new PICC in patients who experienced PICC-related DVT within the past 30 days. In this scenario,panelists strongly urged against placement of a PICC,given the high risk for recurrent thrombosis. Placementof a PICC was specifically rated as inappropriate if theindication for insertion was 1) frequent phlebotomywhen peripheral access was available, or 2) patient re-quest for comfort in non–end-of-life settings. Insertionof a PICC was also considered inappropriate if the pa-tient were to require surgery lasting 1 hour or longer,owing to heightened risk for DVT in this situation (67).
In the setting of PICC-related DVT, appropriatenessof PICC insertion for parenteral antibiotics for 10 ormore days was rated as uncertain; panelists recom-mended a midline catheter in this scenario. If a PICCwas absolutely necessary in a patient with recent PICC-related DVT, panelists rated use of the smallest cathetergauge and least number of lumens as appropriate (74,75, 80). Placement in a vein in the contralateral armfollowing at least 3 months of anticoagulation for thePICC-related DVT was also rated as appropriate in thissetting.
Panelists rated the appropriateness of practices re-lated to management of PICC-related bloodstream in-fections. Regardless of clinical context and in accor-dance with recommendations (33, 81), panelists rateduse of PICCs as a strategy to reduce bloodstream infec-tion as inappropriate. In the setting of bacteremia or
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fever, PICC removal in the absence of confirmatory ev-idence of line-related infection was rated as uncertain.Panelists stated that these approaches would be dic-tated by such factors as pathogen, intensity of bacter-emia, and clinical stability, among others, and consulta-tion with infectious disease would be appropriate.
In patients with confirmed PICC-related blood-stream infection, continued treatment using the af-fected PICC, guidewire exchange, or placement of anew device in the contralateral arm without docu-mented clearance of infection was rated as inappropri-ate. After a line-free interval (typically 48 to 72 hours)and negative blood cultures, panelists rated placementof a PICC or other acute CVC as appropriate only if anindication warranting central catheter use was present.Panelists preferred use of peripheral IVs in such pa-tients wherever possible.
D. Appropriateness of PICC RemovalIn contradistinction to indwelling urinary catheters
(82), panelists rated PICC removal without physiciannotification as inappropriate. After physician notifica-tion, panelists rated PICC removal as appropriate when1) the PICC has not been used for any clinical purposefor 48 hours or longer; 2) the patient no longer has aclinical indication for a PICC, or the original indicationfor use has been met (for example, an antibiotic coursehas been completed); or 3) the PICC is only used forroutine obtaining of blood samples in a hemodynami-cally stable patient and peripheral veins are available.Panelists rated routine removal of a PICC in a hemody-namically stable patient with poor venous access or he-modynamically unstable patients as uncertain. Removalof a PICC by clinicians who have received training toremove CVCs, but not PICCs, was rated as inappropri-ate (32).
A summary of these ratings is provided in Table 3.
3. Appropriateness of Peripheral IntravenousCatheter Use in Specific Scenarios
Because PICC use is often driven by difficult pe-ripheral venous access, we asked panelists to rate ap-propriateness of peripheral intravenous catheter use invarious clinical scenarios that often prompt PICC use. Inthe absence of other indications for central venous ac-cess, panelists rated use of ultrasonography-guidedperipheral intravenous catheters as appropriate beforeinsertion of a PICC in general medical, critically ill, andcancer populations with difficult venous access (39, 68).However, use of ultrasonography-guided peripheral in-travenous catheters in patients with stage 3b or greaterCKD was rated as inappropriate. If a suitable arm veincould not be found, panelists rated placement of a pe-ripheral intravenous catheter catheter in the externaljugular vein of the neck as appropriate only if the pro-posed duration of use was 96 hours or less or in anemergency situation. Panelists rated placement of a pe-ripheral intravenous catheter in the lower extremity asappropriate only in emergencies.
Citing the results of a Cochrane systematic review(83) and a randomized trial (84), panelists rated re-
placement of peripheral intravenous catheters as ap-propriate when prompted by clinical signs and symp-toms rather than prespecified durations. Panelistsnoted that such practice might extend availability of pe-ripheral venous access (83), reduce cost (85), and limituse of PICCs, but recognized that these data were lim-ited to 1 randomized trial and low event rates in theliterature. When PICC placement was requested forblood transfusions, panelists rated 16-, 18-, and 20-
Table 3. Guide for PICC Insertion, Care, and MaintenancePractices
Appropriate PICC practicesBefore ordering a PICC, consult relevant specialists (e.g., infectious
diseases, oncology), operators (vascular access professional), and/orhospital pharmacists to determine optimal device choice andcharacteristics*
After non-EKG or non–fluoroscopically guided PICC insertion, verify PICCtip position via chest radiography
Only adjust PICCs that terminate in the upper or middle one third of thesuperior vena cava or right ventricle
In the absence of indications for a multilumen PICC, use a single-lumenPICC of the smallest gauge
Use normal saline rather than heparin to flush PICCs after infusion orphlebotomy
Exchange PICCs to change device features (e.g., number of lumens) ortreat dislodgement over a guidewire
Provide ≥3 mo of uninterrupted systemic anticoagulation for treatmentof PICC-related DVT in the absence of contraindications to suchtherapy†
Use the smallest sized catheter and vein on the contralateral arm after≥3 mo of therapeutic anticoagulation when placing a PICC in a patientwith history of PICC-related DVT‡
Provide a "line-free" interval to ensure clearance of bacteremia whenmanaging PICC-related bloodstream infections
Inappropriate PICC practicesUrgent requests for PICC placement in a hemodynamically unstable
patient in the wards or ICUPreferential placement of a PICC on the basis of arm dominanceChest radiography verification of the PICC tip after placement via verified
EKG guidance or fluoroscopy§Adjustment of PICC tips that reside in the lower one third of the superior
vena cava, cavoatrial junction, or right atriumAdvancement of a partially dislodged PICC in the setting of external
migration of the catheter of any lengthRemoval of PICCs that are clinically necessary, centrally positioned, and
otherwise functional in the setting of PICC-related DVTRoutine removal or replacement of PICCs that are clinically necessary
without objective evidence of catheter-associated bloodstreaminfection in febrile patients
Removal of a PICC by a health care team member not trained to removethis device
DVT = deep venous thrombosis; EKG = electrocardiography; ICU =intensive care unit; PICC = peripherally inserted central catheter.* Consultations with nephrologists for patients with stage 1 to 3achronic kidney disease was rated as neutral owing to challenges re-lated to determining stage of kidney disease in hospitalized patients.In such patients, consultation is recommended especially if hospital-ized with acute kidney injury or fluctuating renal function.† In patients with cancer, use of low-molecular-weight heparin overwarfarin for systemic anticoagulation was rated as preferred. Extend-ing the duration of anticoagulation beyond such periods if the PICCremained in place was rated as appropriate.‡ If the contralateral arm is not available, selection of a vein not in-volved with the original PICC-DVT in the ipsilateral arm was rated asappropriate.§ When forgoing chest radiographs for PICC tip position, technicalproficiency in the placement of PICCs via EKG guidance is assumed.Additionally, verification of tip-positioning via EKG (adequate P-wavedeflection/mapping) is assumed. If concerns regarding positioning ex-ist, obtaining a chest radiograph is appropriate.
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gauge peripheral intravenous catheters as appropriateand preferable to PICC use. For administering intrave-nous contrast through radiographic injectors, panelistsrated use of 16- to 20-gauge peripheral intravenouscatheters as appropriate and preferred over PICCs;use of 22-gauge devices or larger was rated asinappropriate.
A summary of these ratings is provided in Table 4.
DISCUSSIONOur 15-member multidisciplinary panel success-
fully applied the RAND/UCLA Appropriateness Methodto generate novel criteria for use, care, and manage-ment of PICCs in hospitalized patients. In addition, pan-elists rated the comparative utility of other VADs in re-lation to PICCs, providing new insights for decisionmaking in venous access. The implication of this work issubstantial, because it provides a potential means to
quantify appropriateness, qualify existing use, and im-prove care of PICCs and related devices in hospitalizedpatients. Given an international team of experts thatrepresented multiple subspecialties and the inclusionof a patient to formulate panelist ratings, these criteriaare well-positioned to broadly improve the quality andsafety of venous access in hospitalized adults.
As with many health care innovations, PICCs wereintroduced to solve an important clinical problem in adefined population (86). However, over time, the use ofPICCs has evolved to span diverse indications and pa-tient populations. In hospital settings, accumulating ev-idence suggests that placement of PICCs may occur forpotentially inappropriate reasons (18, 87). Notwith-standing such benefits as convenience, comfort, andeconomic efficiency (4, 88), PICC insertion may intro-duce unnecessary risk and potential for preventableharm (15, 16, 73). Despite this fact, no framework toinform use of these devices has been developed todate.
These observations were the motivation underlyingthis project, which sought to incorporate existing evi-dence with the knowledge of clinicians and content ex-perts to define criteria for appropriate PICC use. Unlikeexisting recommendations, our appropriateness criteriarepresent a departure from the status quo in severalways.
First, they offer clinical granularity for clinicians. Forexample, existing guidelines recommend “use of mid-line catheters or PICCs instead of a short peripheralintravenous catheter when the duration of IV [inter-venous] therapy will likely exceed six days” (33). Ourcriteria build on this advice by adding such details aswhat patient-specific considerations should be incorpo-rated in this decision, which other devices may be ap-propriate, and when PICC use for shorter durationsmight be reasonable.
Second, whereas existing recommendations targetproceduralists or specialties that most often insert de-vices, our criteria are the first to provide direction toclinicians, such as internists or hospitalists, who orderPICCs. Thus, these criteria fill a critical gap, bringingrecommendations to those that drive the decision toplace such devices.
Finally, by tackling some of the most controversialtopics of venous access—including when to adjust thePICC position, appropriate indications for removal, andindications for reinsertion of PICCs after complications—our criteria advance the science of vascular access inimportant and innovative ways.
Some aspects of panelist deliberations and ratingsmerit further discussion. First, patterns of recommenda-tions for PICC appropriateness often hinged on 2 vari-ables: the nature of the infusate and duration ofvenous access. Thus, non–peripherally compatible infu-sions or scenarios where venous access was necessaryfor 6 days or longer often led panelists to rate PICC useas appropriate; conversely, shorter duration of use withperipherally compatible infusions led to a recommen-dation for use of a peripheral intravenous catheter,ultrasonography-guided catheter, or midline catheter.
Table 4. Guide for Peripheral Intravenous CatheterPractices
Appropriate peripheral intravenous catheter practicesInsert a peripheral intravenous catheter in the external jugular vein if the
proposed duration of use is ≤4 d or an emergent/life-threateningsituation exists
Place a peripheral intravenous catheter in the foot only in the setting ofan emergent, life-threatening situation
Use ultrasonographic guidance to place short or long peripheralintravenous catheters in patients with difficult venous access whorequire treatment for ≤5 d*
Remove peripheral intravenous catheters in the setting of redness,swelling, or phlebitis over the vein of insertion
In hospitalized patients who are likely to require ≥15 d of intravenousantibiotics, transition from a peripheral intravenous catheter to a PICCor midline catheter as soon as possible†
Use a 16-, 18-, or 20-gauge peripheral intravenous catheters in anupper-extremity vein rather than a PICC when venous access isneeded for blood transfusion or performance of a contrast-basedradiographic study
Inappropriate peripheral intravenous catheter practicesRemoval of peripheral intravenous catheters on the basis of a routine
schedule or in the absence of redness, swelling, or other signs ofinflammation is inappropriate; site rotation should be driven byclinically warranted change‡
Removal of a functioning peripheral intravenous catheter that has beeninserted in the field (e.g., ambulance or nonhospital site) in theabsence of redness, tenderness, or swelling over the insertion site isinappropriate
Placement of peripheral intravenous catheters on the same side as priorbreast surgery, axillary node dissection, or arteriovenous fistulae(regardless of whether the fistula is functional or not) is inappropriate
In the absence of a clinical indication warranting insertion, routineplacement of a peripheral intravenous catheter at the time ofadmission to the hospital is inappropriate
In the absence of a clinical indication warranting continued use, routinereplacement of a peripheral intravenous catheter is inappropriate
PICC = peripherally inserted central catheter.* Use of ultrasonography-guided peripheral intravenous catheters isinappropriate in patients with advanced (stage 3b or greater) chronickidney disease. In such patients, consultation with a nephrologist anduse of a small-bore tunneled central catheter are appropriate.† Delaying transition from a peripheral intravenous catheter to a PICCbefore discharge may deplete available venous access sites and is notappropriate when intravenous antibiotic treatment beyond 15 d isclinically necessary.‡ Routine changes of peripheral intravenous catheters may result inloss of potentially available peripheral veins for infusion or therapy,inadvertently leading to greater use of PICCs in hospitalized patients.
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Unlike existing standards, however, variation in risk forcomplications according to patient population influ-enced this pattern. This is well-illustrated in ratings forcritically ill patients and those with cancer, where atheme of limiting PICCs to durations of use of 15 daysor longer is evident.
Second, throughout deliberations, panelists notedthat it is often challenging for clinicians to estimate anexpected duration of venous access. Relatedly, a “max-imal” window within which PICCs may be safely used isnot known and depends on myriad factors, includingadequacy of care and differential risk for complications.Finally, panelists acknowledged that separation of indi-cations for PICC placement into individual categoriesand defining VADs by finite duration was artificial, be-cause venous access is rarely driven by a single clinicalpurpose or limited by duration.
On balance, panelists rationalized that clinicians of-ten do not reflect carefully enough on the nature ofvenous access or weigh its inherent risks and benefits.Panel members added that in many hospitals, the deci-sion to place a PICC is often dichotomous, with consid-eration of other devices lacking. Thus, an unforeseenadvantage of these criteria is the introduction of aphysician-directed “time-out” in vascular access deci-sion making. During this pause, reflection on the ap-propriate device, patient risk factors, and discussionswith specialists could conceivably improve outcomes inhospital settings.
Our approach has several limitations. First, we ex-cluded neonatal and pediatric studies when formulat-ing these recommendations, because considerable dif-ferences in PICC use exist between these patients andadults. However, because these populations often re-ceive PICCs, future panels should choose to focus onthese subsets.
Second, although our panel was multidisciplinary,we did not include bedside nurses, who often requestPICCs in hospitalized settings. However, vascularnurses and hospitalists are attuned to considerationsregarding PICC use from this group of providers andwere well-represented on our panel.
Third, the applicability of these recommendationswill vary on the basis of provider scope of practice, ed-ucation, and training. As echoed in other standards(89), provider availability, competence, and technicalexpertise should guide insertion and selection of ap-propriate VADs.
Finally, our panel was focused on appropriatenessof PICCs in relation to other devices. We acknowledgethat certain devices may be used for longer durations(for example, midline catheters for up to 28 days) orindications of different durations (for example, intrave-nous antibiotics for 6 weeks). These limitations werenecessary to ensure comparability among various de-vices and generalizability of these recommendations.
Despite these limitations, our appropriateness cri-teria represent a major multidisciplinary effort towardimproving decision making related to PICCs and re-lated VADs. Avoiding PICC use for inappropriate indi-cations, considering alternative devices, ensuring ap-
propriate consultations, and outlining instances wherePICC removal is appropriate are but a few examples ofhow these recommendations may be implemented toimprove practice. In addition, by including a patientwhose opinion influenced panel deliberations, we tookinto account the implications of provider decisionsfrom “the other side of the needle.” Finally, the criteriawe propose span not just indications for PICC insertionbut also best practices for use, care, and maintenance.Thus, we hope that our recommendations will provideclarity for management of complex situations not onlybefore, but also during and after, PICC placement.
Although optimal strategies to implement our cri-teria remain to be defined, an expansive range of op-tions is possible. For example, routine benchmarkingand feedback of metrics, such as PICC dwell time, indi-cations for insertion, and practices related to manage-ment of complications, may serve to inform hospital-specific “PICC dashboards” and quality-improvementefforts. Alternatively, more sophisticated paradigms,such as decision aids and computerized physicianorder-entry taking into account proposed duration ofuse, indication, and patient characteristics, are alsoplausible.
Because many of our recommendations are algo-rithmic, Web sites or smartphone applications to deter-mine the appropriateness of PICCs before insertionseem to be feasible. We are beginning to explore theseoptions through 2 strategic partners. First, through theongoing Blue Cross Blue Shield/Blue Care Network–funded Hospital Medicine Safety collaborative qualityimprovement project, we will use our appropriatenesscriteria to evaluate and improve PICC utilization in 47Michigan hospitals (90). Because the Hospital MedicineSafety project is composed of diverse hospitals and isbuilt on a robust data platform, we will also seek tounderstand contextual barriers, facilitators, and unin-tended consequences related to use of our criteria.
Second, through work recently funded by the Vet-erans Affairs National Center for Patient Safety and theNo Preventable Harms Campaign, we will test ways inwhich to operationalize our criteria within the highly in-tegrated Veterans Affairs health system. Given the ad-vanced electronic medical record systems in thissetting, our experiences will shed new light on imple-mentation strategies that could inform our work withinand beyond this setting. Such research may take sev-eral forms. For instance, quasi-experimental designs,such as pre–post or interrupted time series that exam-ine the influence of specific appropriateness recom-mendations (for example, avoid use of PICCs for pe-ripherally compatible infusions lasting 5 days or less)within and between hospitals, could be tested in par-ticipating Michigan and Veterans Affairs sites. Alterna-tively, a “bundle” of best practices related to PICCs,including appropriateness criteria for insertion, care,and management, may be deployed, leveraging a step-wedge or cluster randomized approach to account forsecular trends.
More robust research designs, such as randomizedclinical trials, that utilize our criteria are also feasible.
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For example, randomly assigning patients who requireless than 2 weeks of peripherally compatible infusionsto receive a midline catheter or PICC is not only feasi-ble but also relevant, because many PICCs are placedto deliver antibiotics for such intervals after hospital dis-charge. Such a study may be powered to ascertain thenoninferiority of midline catheters, rates of therapycompletion, or complications with either device. There-fore, several research designs that span one or morehospitals, and one or more of our recommendations,may be used as interventions to target clinical out-comes, overall utilization, adverse events, and costs.
In conclusion, we used the RAND/UCLA Appropri-ateness Method to define best practices for PICC inser-tion, care, and management. Although a key first step,these criteria offer but a blueprint of best practices. Tomake MAGIC truly happen, diffusion, uptake, and re-finement from the providers and stakeholders engagedin vascular access is necessary. Through use of a sys-tematic rating process, a multidisciplinary internationalpanel, and patient representation, we hope to achievethis goal. Our patients deserve nothing less.
From University of Michigan Medical School, Patient SafetyEnhancement Program of the Veterans Affairs Ann ArborHealthcare System, and the Institute for Healthcare Policy andInnovation, University of Michigan Ann Arbor, and OakwoodHospital, Dearborn, Michigan; Intermountain Medical Center,Murray, and the University of Utah School of Medicine, SaltLake City, Utah; Clinical Center, National Institutes of Health,Bethesda, and Greater Baltimore Medical Center, Baltimore,Maryland; William S. Middleton Memorial Veterans AffairsHospital and Division of Infectious Diseases, University of Wis-consin Medical School, Madison, Wisconsin; Perelman Schoolof Medicine, University of Pennsylvania, Philadelphia, Pennsyl-vania; PICC Excellence, Hartwell, Georgia; Catholic University,Rome, Italy; American University of Beirut, Lebanon; and Uni-versity of British Columbia, Vancouver, British Columbia,Canada.
Portions of this work were presented at the 2015 Annual So-ciety of Hospital Medicine Meeting, Washington, DC, and the2015 Society for Healthcare Epidemiology of America Meet-ing, Orlando, Florida.
Acknowledgment: The authors thank Tanya Boldenow, MD,and Aaron Berg, MD, for reviewing early drafts of the appro-priateness document; Andy Hickner, MSI, and Marisa Conte,MSI, for assistance with literature searches; and GeorgiannZiegler, their patient panelist, whose views greatly influencedpanel discussions.
Disclosures: Dr. Chopra reports grants from the Society ofHospital Medicine and Agency for Healthcare Research andQuality during the conduct of the study. Dr. Flanders reportsgrants from Blue Cross Blue Shield of Michigan during theconduct of the study and consultancy for the Institute forHealthcare Improvement and the Society of Hospital Medi-cine; employment by the University of Michigan; one expertreview per year as expert testimony; grants or grants pendingfrom the CDC Foundation, Blue Cross Blue Shield of Michi-
gan, Michigan Hospital Association, and Agency for Health-care Research and Quality; honoraria for various talks at hos-pitals as a visiting professor; and royalties from WileyPublishing outside the submitted work. Dr. Saint reports serv-ing on the medical advisory board of Doximity (a social net-working site for physicians) and receiving an honorarium forbeing a member of this medical advisory board, and servingon the scientific advisory board of Jvion (a health care tech-nology company) outside the submitted work. Dr. Woller re-ports a grant paid by Bristol Myers-Squibb to IntermountainHealthcare, with no financial support to Dr. Woller, outsidethe submitted work. Dr. Trerotola reports personal fees fromUniversity of Michigan during the conduct of the study andgrants from Vascular Pathways; personal fees from Bard Pe-ripheral Vascular, B. Braun, Orbimed, Teleflex, Cook, W.L.Gore, and Lutonix outside the submitted work. Dr. Moureaureports PICC Appropriateness Panel reimbursement duringthe conduct of the study and serving as chief executive officerof PICC Excellence, Inc.; vascular access specialist and teammember at Greenville Hospital System, Greenville, South Car-olina; and associate adjunct professor and member of Alli-ance for Vascular Access Device Training and Research (AVA-TAR), Griffith University, Brisbane, Australia, outside thesubmitted work. Dr. LeDonne reports personal fees from Tele-flex, Ethicon, Bard International, SonoSite, and 3M outside thesubmitted work. Ms. Becker reports grants from the Society ofHospital Medicine and Blue Cross Blue Shield of Michiganduring the conduct of the study. Dr. Bernstein reports grantsfrom Department of Veterans Affairs National Center for Pa-tient Safety and Blue Cross Blue Shield of Michigan during theconduct of the study; in addition, he is a member of the BlueCare Network Clinical Quality Committee, which reviews is-sues related to quality of care, and although peripherally in-serted central venous catheters have not been considered inthe past, their use may be reviewed in the future. Dr. Bern-stein is also director of quality for the University of MichiganMedical Group; if the appropriateness of peripherally insertedcentral venous catheter criteria developed as part of this pro-cess are widely adopted, they could be applied to the Univer-sity of Michigan by outside agencies. Authors not named herehave disclosed no conflicts of interest. Disclosures can alsobe viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0744.
Grant Support: By a Young Researcher Award from the Soci-ety of Hospital Medicine and a career development award(1-K08-HS022835-01) from the Agency for Healthcare Re-search and Quality to Dr. Chopra and by Blue Cross BlueShield and Blue Care Network of Michigan, which providedsalary support for Drs. Flanders and Bernstein and Ms. Beckerthrough the Michigan Hospital Medicine Safety Consortium.
Requests for Single Reprints: Vineet Chopra, MD, MSc, Insti-tute for Healthcare Policy and Innovation, University of Michi-gan, North Campus Research Complex, 2800 Plymouth Road,Building 16, Room 432W, Ann Arbor, MI 48109; [email protected].
Current Author Addresses: Dr. Chopra: Institute for Health-care Policy and Innovation, University of Michigan, NorthCampus Research Complex, 2800 Plymouth Road, Building16, Room 432W, Ann Arbor, MI 48109.
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Dr. Flanders: Taubman Medical Center, University of Michi-gan, 1500 East Medical Center Drive, SPC 5376, Ann Arbor,MI 48109.Dr. Saint: Institute for Healthcare Policy and Innovation, Uni-versity of Michigan, North Campus Research Complex, 2800Plymouth Road, Building 16, Room 432W, Ann Arbor, MI48109.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 Cen-ter, National Institutes of Health, 10 Center Drive, Building 10,Room 2C145, Bethesda, MD 20892.Dr. Safdar: University of Wisconsin Medical School, MFCB5221, 1685 Highland Avenue, Madison WI 53705.Dr. Trerotola: Department of Radiology, University of Pennsyl-vania Medical Center, 1 Silverstein, 3400 Spruce Street, Phil-adelphia, PA 19104.Dr. Saran: Division of Nephrology, Department of InternalMedicine, University of Michigan Medical School, 1415 Wash-ington 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, 00135Rome, Italy.Dr. Akl: American University of Beirut Medical Center, PO Box11-0236 Riad-El-Solh 1107 2020, Beirut, Lebanon.Dr. Lee: Division of Hematology, University of British Colum-bia, 2775 Laurel Street, 10th Floor, Vancouver, British Colum-bia V5Z 1M9, Canada.Dr. Courey: Taubman Medical Center, University of Michigan,1500 East Medical Center Drive, SPC 3918, Ann Arbor, MI48109-3918.Dr. Swaminathan: Division of Hospital Medicine, OakwoodHospital, 18101 Oakwood Boulevard, Dearborn, MI 48124.Dr. LeDonne: Department of Surgery, Greater Baltimore Med-ical Center, 10210 Breconshire Road, Ellicott City, MD 21041.Ms. Becker: Institute for Healthcare Policy and Innovation, Uni-versity of Michigan, North Campus Research Complex, 2800Plymouth Road, Building 16, Room 476C, Ann Arbor, MI48109.Dr. Krein: Department of Veterans Affairs, 2800 PlymouthRoad, 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, MI48109.
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. WollerAnalysis and interpretation of the data: C. Becker, S.J. Bern-stein, V. Chopra, J. LeDonne, A.Y. Lee, M. Pittiruti, S. TrerotolaDrafting 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. Trero-tola, 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. Flan-ders, 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. Cho-pra, S.A. Flanders, N.L. Moureau, N. O'Grady, L. Swaminathan,S. Trerotola, S. Wiseman, S. Woller.
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peripheral venous catheters in gynecology oncology patients. Gyne-col Oncol. 2003;89:301-5. [PMID: 12713995]213. Seeley MA, Santiago M, Shott S. Prediction tool for thrombiassociated with peripherally inserted central catheters. J Infus Nurs.2007;30:280-6. [PMID: 17895807]214. Shea CD, Chang GL, Rahimi R, Mahdavian M. The incidence ofsymptomatic, PICC-related venous thrombosis in hospitalized pa-tients with inflammatory bowel disease [Abstract]. Am J Gastroen-terol. 2006;101:S460.215. Simcock L. No going back: advantages of ultrasound-guidedupper arm PICC placement. Journal of the Association for VascularAccess. 2008;13:191-7.216. Skaff ER, Doucette S, McDiarmid S, Huebsch L, Sabloff M. Vas-cular access devices in leukemia: a retrospective review amongstpatients treated at the Ottawa Hospital with induction chemotherapyfor acute leukemia. Leuk Lymphoma. 2012;53:1090-5. [PMID:22080756] doi:10.3109/10428194.2011.639879217. Skiest DJ, Abbott M, Keiser P. Peripherally inserted central cath-eters in patients with AIDS are associated with a low infection rate.Clin Infect Dis. 2000;30:949-52. [PMID: 10880311]218. Smith JR, Friedell ML, Cheatham ML, Martin SP, Cohen MJ,Horowitz JD. Peripherally inserted central catheters revisited. Am JSurg. 1998;176:208-11. [PMID: 9737634]219. Smith RN, Nolan JP. Central venous catheters. BMJ. 2013;347:f6570. [PMID: 24217269] doi:10.1136/bmj.f6570220. Snelling R, Jones G, Figueredo A, Major P. Central venous cath-eters for infusion therapy in gastrointestinal cancer. A comparativestudy of tunnelled centrally placed catheters and peripherally in-serted central catheters. J Intraven Nurs. 2001;24:38-47. [PMID:11836843]221. Sperry BW, Roskos M, Oskoui R. The effect of laterality on ve-nous thromboembolism formation after peripherally inserted centralcatheter placement. J Vasc Access. 2012;13:91-5. [PMID: 21948128]doi:10.5301/jva.5000014222. Stokowski G, Steele D, Wilson D. The use of ultrasound to im-prove practice and reduce complication rates in peripherally in-serted central catheter insertions: final report of investigation.J Infus Nurs. 2009;32:145-55. [PMID: 19444022] doi:10.1097/NAN.0b013e3181a1a98f223. Strahilevitz J, Lossos IS, Verstandig A, Sasson T, Kori Y, Gillis S.Vascular access via peripherally inserted central venous catheters(PICCs): experience in 40 patients with acute myeloid leukemia at asingle institute. Leuk Lymphoma. 2001;40:365-71. [PMID: 11426559]224. Thakarar K, Collins M, Kwong L, Sulis C, Korn C, Bhadelia N.The role of tissue plasminogen activator use and systemic hyperco-agulability in central line-associated bloodstream infections. Am JInfect Control. 2014;42:417-20. [PMID: 24559598] doi:10.1016/j.ajic.2013.11.016225. Timsit JF, Farkas JC, Boyer JM, Martin JB, Misset B, Renaud B,et al. Central vein catheter-related thrombosis in intensive care pa-tients: incidence, risks factors, and relationship with catheter-relatedsepsis. Chest. 1998;114:207-13. [PMID: 9674471]226. Tiwari MM, Hermsen ED, Charlton ME, Anderson JR, Rupp ME.Inappropriate intravascular device use: a prospective study. J HospInfect. 2011;78:128-32. [PMID: 21507524] doi:10.1016/j.jhin.2011.03.004227. Toure A, Duchamp A, Peraldi C, Barnoud D, Lauverjat M, GelasP, et al. A comparative study of peripherally-inserted and Broviaccatheter complications in home parenteral nutrition patients. ClinNutr. 2015;34:49-52. [PMID: 24439240] doi:10.1016/j.clnu.2013.12.017228. Trerotola SO, Thompson S, Chittams J, Vierregger KS. Analysisof tip malposition and correction in peripherally inserted centralcatheters placed at bedside by a dedicated nursing team. J VascInterv Radiol. 2007;18:513-8. [PMID: 17446542]229. Trerotola SO, Stavropoulos SW, Mondschein JI, Patel AA, Fish-man N, Fuchs B, et al. Triple-lumen peripherally inserted centralcatheter in patients in the critical care unit: prospective evaluation.
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SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S24 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
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Tabl
e1.
Sum
mar
yo
fStu
die
sIn
clud
edin
the
Lite
ratu
reR
evie
w
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Ab
dul
lah
etal
,200
5(9
1)26
Pro
spec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
ceo
fDV
Tin
pat
ient
sw
ithPI
CC
sas
dia
gno
sed
with
anup
per
-lim
bve
nog
ram
atth
etim
eo
fPIC
Cre
mo
val
Patie
nts
aged
15–7
0y
with
PIC
Cs
atth
eU
nive
rsity
ofM
alay
aM
edic
alC
entr
ePI
CC
PIC
Cs
wer
eas
soci
ated
with
asi
gni
fican
trat
eo
fD
VT
by
veno
gra
phy
;no
corr
elat
ion
bet
wee
nsi
zean
din
sert
ion
site
ofc
athe
ter
and
UEV
TEw
ere
note
d.
Ahn
etal
,201
3(5
7)23
7R
etro
spec
tive
coho
rtst
udy
Asc
erta
inri
skfa
cto
rsas
soci
ated
with
PIC
C-r
elat
edD
VT
inca
ncer
pat
ient
sPa
tient
sw
ithca
ncer
and
PIC
Cs
atth
eD
alla
sV
Am
edic
alce
nter
fro
m20
06to
2009
PIC
CA
ntip
late
leta
gen
tsw
ere
pro
tect
ive
agai
nst
DV
Tw
here
asus
eo
fESA
s,ho
spita
lizat
ion,
and
trea
tmen
tdo
sean
tico
agul
atio
nw
ere
asso
ciat
edw
ithD
VT
Ake
rsan
dC
hellu
ri,2
009
(92)
5R
etro
spec
tive
coho
rtst
udy
Ana
lysi
so
fCV
Cus
e18
mo
bef
ore
and
afte
ra
hosp
italis
ttra
inin
gp
rog
ram
top
lace
PIC
Cs
3ho
spita
lists
wer
etr
aine
dto
pla
cePI
CC
sin
pat
ient
sat
1un
iver
sity
-affi
liate
dco
mm
unity
hosp
ital
PIC
CA
fter
trai
ning
,use
ofC
VC
sd
oub
led
,with
PIC
Cs
rep
rese
ntin
go
ver
80%
ofa
lld
evic
es
Akl
etal
,201
1(9
3)36
11C
och
rane
syst
emat
icre
view
Eval
uate
the
effic
acy
and
safe
tyo
fan
tico
agul
atio
nin
pat
ient
sw
ithca
ncer
Patie
nts
with
canc
eran
dC
VC
sfr
om
12R
CTs
CV
CA
clea
rra
tiona
lesu
pp
ort
ing
use
of
antic
oag
ulan
tsto
pre
vent
CR
Tco
uld
notb
ed
efine
dA
lexa
ndro
uet
al,2
014
(94)
3447
Pro
spec
tive
coho
rtst
udy
Rep
ort
char
acte
rist
ics
and
out
com
esfr
om
aC
VC
inse
rtio
nse
rvic
eo
ffere
db
ytr
aine
dnu
rses
Ad
ultp
atie
nts
with
aC
VC
,PIC
C,h
igh-
flow
dia
lysi
sca
thet
er,o
rm
idlin
esin
one
tert
iary
care
univ
ersi
tyho
spita
lin
Syd
ney,
Aus
tral
ia,b
etw
een
No
vem
ber
1996
and
Dec
emb
er20
09
CV
AD
sTr
aine
dva
scul
arac
cess
nurs
esus
ing
US
and
bes
tpra
ctic
eca
nlo
wer
com
plic
atio
nra
tes
dur
ing
inse
rtio
nan
dm
ayim
pro
vep
atie
ntsa
fety
Alh
imya
ryet
al,1
996
(95)
231
Pro
spec
tive
coho
rtst
udy
Rep
ort
com
plic
atio
nsus
ing
PIC
Cs
for
TPN
inno
n-IC
Up
atie
nts
com
par
edto
pla
cem
ent
ofC
VC
sin
the
sub
clav
ian
vein
No
n-IC
Up
atie
nts
who
need
edTP
Nre
ceiv
edPI
CC
sin
sert
edin
the
ante
cub
italv
ein
or
CV
Cs
at1
inst
itutio
nfr
om
July
1991
toM
arch
1994
CV
C,P
ICC
Co
mp
licat
ion
rate
sd
idno
tdiff
ersi
gni
fican
tlyb
etw
een
the
2g
roup
s;PI
CC
sca
nb
eus
edsa
fely
for
excl
usiv
eTP
Nad
min
istr
atio
nA
lkin
die
tal,
2012
(96)
16R
etro
spec
tive
coho
rtst
udy
Rev
iew
out
com
esre
late
dto
imp
lant
edp
ort
pla
cem
enti
np
atie
nts
with
sick
lece
lld
isea
sew
hore
qui
red
red
cell
exch
ang
e/tr
ansf
usio
n
Patie
nts
with
sick
lece
lld
isea
sew
how
ere
freq
uent
lyho
spita
lized
ata
sing
leac
adem
icm
edic
alce
nter
Port
Of2
4d
evic
esp
lace
d,1
7re
qui
red
rem
ova
lo
win
gto
infe
ctio
no
rth
rom
bo
sis.
The
med
ian
wo
rkin
glif
eo
fthe
po
rts
was
688.
5d
(ran
ge,
39–3
925
d).
The
num
ber
of
infe
ctio
nsw
assi
gni
fican
tlyco
rrel
ated
with
the
num
ber
ofp
ort
s(P
ears
on
r=
0.66
;P
<0.
01)
Alla
net
al,2
012
(97)
10In
vivo
com
par
iso
nst
udy
Rab
bit
mo
del
used
toev
alua
teth
ep
erfo
rman
ceo
fant
imic
rob
ial
(chl
orh
exid
ine)
–co
ated
PIC
Cs
ina
clin
ical
sett
ing
,co
mp
ared
with
unco
ated
cath
eter
s
Hea
lthy,
15-w
eek-
old
New
Zeal
and
whi
tefe
mal
era
bb
itsPI
CC
Chl
orh
exid
ine-
coat
edca
thet
ers
sig
nific
antly
red
uced
mic
rob
ialc
olo
niza
tion
and
pre
vent
edm
icro
bia
lmig
ratio
nco
mp
ared
with
unco
ated
dev
ices
Alle
net
al,2
000
(98)
119
Ret
rosp
ectiv
eco
hort
stud
yEv
alua
teth
era
teo
fDV
Tin
pat
ient
sw
hoha
dve
nog
rap
hyb
efo
rean
daf
ter
PIC
Cp
lace
men
t
354
PIC
Cs
wer
ep
lace
din
119
pat
ient
sb
etw
een
Ap
ril1
992
and
Aug
ust1
998
ata
sing
lece
nter
;al
lpat
ient
sun
der
wen
tven
og
rap
hyb
efo
rean
daf
ter
PIC
Cp
lace
men
t
PIC
CO
vera
llra
teo
fDV
Tas
soci
ated
with
PIC
Cs
was
38%
;inc
iden
cew
ashi
ghe
stfo
rPI
CC
sp
lace
din
the
cep
halic
vein
(57%
)
AlR
aiy
etal
,201
0(1
)12
60Pr
osp
ectiv
eco
hort
stud
yC
om
par
ePI
CC
-rel
ated
CLA
BSI
rate
sw
ithth
ose
asso
ciat
edw
ithC
VC
sin
hosp
italiz
edp
atie
nts
Patie
nts
with
CV
Cs
inno
n-IC
Us
and
pat
ient
sw
ithPI
CC
sho
spita
l-wid
eat
1in
stitu
tion
CV
C,P
ICC
CV
Cs
and
PIC
Cs
had
sim
ilar
rate
so
fCLA
BSI
;w
ithsu
rvei
llanc
ean
din
terv
entio
n,hi
gh-
risk
CV
Cs
wer
ere
mo
ved
;PIC
Cs
may
be
safe
rfo
rlo
nger
IVac
cess
Al-T
awfiq
etal
,201
2(9
9)92
PIC
Cs
Pro
spec
tive
coho
rtst
udy
Des
crib
ePI
CC
-rel
ated
BSI
inci
den
cein
1ho
spita
lset
ting
Ho
spita
lized
pat
ient
sw
ithPI
CC
sat
Dha
hran
Hea
lthC
are
Cen
ter,
Saud
iAra
bia
,fro
mJa
nuar
yto
Dec
emb
er20
09
PIC
CR
ates
ofP
ICC
-rel
ated
CLA
BSI
vari
edac
cord
ing
top
atie
ntfa
cto
rs,s
uch
asca
ncer
and
criti
cal
illne
ssA
mer
asek
era
etal
,20
09(1
00)
NA
Rev
iew
Ove
rvie
wo
fven
ous
anat
om
yan
dco
mp
licat
ions
rela
ted
toPI
CC
use
with
rad
iog
rap
hic
imag
es
NA
PIC
CTo
help
dia
gno
sePI
CC
com
plic
atio
ns,
rad
iolo
gis
tssh
oul
dha
veg
oo
dkn
ow
led
ge
ofv
eno
usan
ato
my
and
imag
ing
tech
niq
ues
rela
ted
toPI
CC
inse
rtio
nA
nder
son,
2004
(42)
6004
mid
line
cath
eter
s;33
7PI
CC
s
Rev
iew
artic
lean
dre
tro
spec
tive
coho
rtst
udy
Exam
ine
mid
line
cath
eter
use
asa
bri
dg
eb
etw
een
per
iphe
rala
ndce
ntra
lcat
hete
rso
ver
a6-
year
per
iod
Patie
nts
atEv
ang
elic
alC
om
mun
ityH
osp
itali
nLe
wis
bur
g,P
API
VC
,m
idlin
eca
thet
er,
PIC
CIV
Sub
stitu
ting
am
idlin
efo
ra
sho
rtp
erip
hera
lca
thet
erle
dto
imp
rove
do
utco
mes
,in
clud
ing
red
uced
rate
so
fven
ipun
ctur
e,d
ecre
ased
leng
tho
fsta
y,an
dim
pro
ved
staf
fan
dp
atie
ntsa
tisfa
ctio
nA
rmst
rong
etal
,201
3(1
01)
49C
ase–
cont
rols
tud
yC
om
par
eb
acte
rem
iara
tes
inp
atie
nts
with
antib
iotic
(min
ocy
clin
e–ri
fam
pin
)im
pre
gna
ted
PIC
Cs
vs.t
hose
who
rece
ived
conv
entio
nalP
ICC
s
Patie
nts
adm
itted
toa
reg
iona
lbur
nce
nter
who
req
uire
da
PIC
Cas
par
tofc
linic
alca
rePI
CC
Ant
ibio
tic-im
pre
gna
ted
PIC
Cs
sub
stan
tially
dec
reas
edth
era
teo
fbac
tere
mia
inb
urn
pat
ient
s(0
%vs
.50%
)
Ass
oci
atio
nfo
rV
ascu
lar
Acc
ess,
2011
(102
)N
AG
uid
elin
ePo
sitio
nst
atem
enta
ndre
com
men
dat
ions
for
the
inse
rtio
no
fCV
AD
sb
yre
gis
tere
dnu
rses
usin
gU
Sg
uid
ance
NA
CV
C,
mid
line
cath
eter
,PI
CC
US
gui
dan
cefo
rp
lace
men
tofC
VA
Ds
by
trai
ned
nurs
esis
safe
and
cost
-effe
ctiv
ean
dsh
oul
db
eco
me
par
tofr
out
ine
pra
ctic
e
Aw
etal
,201
2(1
03)
340
Ret
rosp
ectiv
eco
hort
stud
yD
eter
min
eth
ein
cid
ence
ofs
ymp
tom
atic
PIC
C-r
elat
edD
VT
inca
ncer
pat
ient
sPa
tient
sw
ithca
ncer
who
had
PIC
Cs
pla
ced
by
US
gui
dan
cefo
rd
eliv
ery
ofc
hem
oth
erap
yPI
CC
Sym
pto
mat
icPI
CC
-rel
ated
DV
Tis
freq
uent
inth
isp
op
ulat
ion;
dia
bet
esan
dch
roni
co
bst
ruct
ive
pul
mo
nary
dis
ease
are
risk
fact
ors
for
PIC
C-r
elat
edD
VT
Bai
and
Ho
u,20
10(1
04)
37Pr
osp
ectiv
eco
hort
stud
yEx
plo
refe
asib
ility
ofU
S-g
uid
edPI
CC
inse
rtio
nin
eld
erly
adul
tsus
ing
mo
difi
edSe
ldin
ger
tech
niq
ue
Eld
erly
adul
tsw
ithPI
CC
sin
sert
edb
yU
Sg
uid
ance
ina
Chi
nese
med
ical
cent
erPI
CC
US-
gui
ded
inse
rtio
no
fPIC
Cs
issa
fean
def
fect
ive
for
eld
erly
adul
tsw
ithno
npal
pab
leve
ins
Con
tinue
don
follo
win
gp
age
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S25
Downloaded From: http://annals.org/ by a Ebling Library Information Research User on 10/08/2015
Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Bai
etal
,201
3(1
05)
128
Pro
spec
tive
coho
rtst
udy
Det
erm
ine
clin
ical
out
com
esin
pat
ient
sw
hore
ceiv
edch
emo
ther
apy
via
anin
dw
ellin
gIV
sco
mp
ared
toPI
CC
s
Patie
nts
with
lung
canc
erin
1ra
dia
tion
onc
olo
gy
dep
artm
enti
nSh
enya
ng,C
hina
IV,P
ICC
Patie
nts
und
erg
oin
gco
mb
ined
rad
iatio
nth
erap
yan
dch
emo
ther
apy
pre
fer
aPI
VC
ove
ra
PIC
Cfo
rin
term
itten
tche
mo
ther
apy
Bar
ret
al,2
012
(106
)27
66R
etro
spec
tive
coho
rtst
udy
Exam
ine
rate
so
fco
mp
licat
ions
and
out
com
esin
pat
ient
sre
ceiv
ing
out
pat
ient
antib
iotic
ther
apy
by
dev
ice
typ
e
Patie
nts
inth
eam
bul
ato
ryca
rese
ttin
gus
ing
the
Gla
sgo
wo
utp
atie
ntan
tibio
ticth
erap
yse
rvic
eM
idlin
eca
thet
er,
PIC
C,
TCV
C
Line
infe
ctio
nsw
ere
asso
ciat
edw
ithd
urat
ion
ofl
ine
use,
fem
ale
sex,
and
TCV
Cs;
dw
ell
time
was
sig
nific
antly
asso
ciat
edw
ithri
skfo
rlin
ein
fect
ion
Bat
eset
al,2
012
(107
)N
AG
uid
elin
esfo
rd
iag
nosi
so
fDV
TId
entif
yan
dre
com
men
dst
rate
gie
sfo
rd
iag
nosi
so
fDV
Tin
amb
ulat
ory
adul
tsEl
igib
lest
udie
sin
clud
edth
ose
that
add
ress
edd
iag
nost
icac
cura
cyan
dcl
inic
alo
utco
mes
PIC
C,C
VC
For
dia
gno
sis
ofU
EDV
T,in
itial
eval
uatio
nw
ithco
mb
ined
mo
dal
ityU
So
ver
oth
erte
sts,
incl
udin
gve
nog
rap
hyan
dD
-dim
er,i
sre
com
men
ded
Bau
mg
arte
net
al,2
013
(108
)N
RPr
osp
ectiv
eco
hort
stud
yEv
alua
tea
trai
ning
and
imp
lem
enta
tion
pro
gra
mto
red
uce
CLA
BSI
inth
eho
me
heal
thca
reen
viro
nmen
t
Och
sner
hom
ein
fusi
on
out
pat
ient
sw
hore
ceiv
edPI
CC
lines
wer
ein
clud
ed;a
chec
klis
tfo
rb
est
dre
ssin
gp
ract
ices
and
ord
erse
tsw
ere
eval
uate
d
PIC
CA
fter
inst
itutio
no
fach
eckl
ista
ndan
ord
erse
tto
stan
dar
diz
eca
rein
hom
ein
fusi
on
pat
ient
s,PI
CC
infe
ctio
nra
tes
dec
reas
edb
y46
%co
mp
ared
with
pri
or
year
sB
axie
tal,
2008
(109
)13
50PI
CC
sR
etro
spec
tive
coho
rtst
udy
Eval
uate
the
asso
ciat
ion
bet
wee
np
ost
-pla
cem
enta
ndri
skfo
rPI
CC
-rel
ated
BSI
and
DV
T
Ho
spita
lized
pat
ient
sfr
om
Feb
ruar
yto
Aug
ust
2007
ata
qua
tern
ary
med
ical
cent
erin
Mic
hig
anPI
CC
Post
-pla
cem
enta
dju
stm
ento
fPIC
Cs
was
not
asso
ciat
edw
ithC
LAB
SIo
rD
VT.
Fact
ors
asso
ciat
edw
ithC
LAB
SIw
ere
dia
bet
es,
imm
une
sup
pre
ssio
n,an
dnu
mb
ero
flu
men
s;lu
men
sw
ere
asso
ciat
edw
ithri
skfo
rD
VT
and
cath
eter
thro
mb
osi
sB
axie
tal,
2013
(110
)16
52R
etro
spec
tive
coho
rtst
udy
Eval
uate
the
asso
ciat
ion
bet
wee
np
ost
-pla
cem
enta
ndri
skfo
rPI
CC
-rel
ated
BSI
and
DV
T
Ho
spita
lized
pat
ient
sfr
om
Feb
ruar
yto
Aug
ust
2007
ata
qua
tern
ary
med
ical
cent
erin
Mic
hig
anPI
CC
Post
-pla
cem
enta
dju
stm
ento
fPIC
Cs
was
not
asso
ciat
edw
ithC
LAB
SIo
rD
VT.
Fact
ors
asso
ciat
edw
ithC
LAB
SIw
ere
po
wer
-cap
able
PIC
Cs,
dia
bet
es,i
mm
une-
sup
pre
ssio
nan
dnu
mb
ero
flum
ens;
lum
ens
wer
eal
soas
soci
ated
with
risk
for
DV
Tan
dth
rom
bo
sis
Bri
tish
Co
mm
ittee
for
Stan
dar
ds
inH
aem
ato
log
y,19
97(6
9)
NA
Gui
del
ines
Bri
tish
Co
mm
ittee
for
Stan
dar
ds
inH
aem
ato
log
yg
uid
elin
esth
atre
view
bas
icp
rinc
iple
so
fthe
care
ofp
atie
nts
with
CV
Cs
2007
upd
ate
toth
e19
97g
uid
elin
esth
atp
rovi
de
maj
or
reco
mm
end
atio
nsfo
rus
eo
fsev
eral
dev
ices
inho
spita
lized
and
amb
ulat
ory
pat
ient
s
CV
C,P
ICC
,p
ort
Maj
or
reco
mm
end
atio
nsin
this
upd
ate
incl
ude
use
ofU
Sd
urin
gin
sert
ion,
use
ofC
VC
sfo
rsh
ort
-ter
mac
cess
whe
np
erip
hera
lacc
ess
isno
tpo
ssib
le,a
ndus
eo
ftun
nele
dca
thet
ers
or
po
rts
for
long
er-t
erm
acce
ss.T
hese
gui
del
ines
reco
mm
end
avo
idan
ceo
fPIC
Cs
inin
patie
ntse
tting
sb
ecau
seof
thro
mb
osis
risk
Bel
lesi
etal
,201
3(5
8)24
Pro
spec
tive
coho
rtst
udy
Eval
uate
the
effic
acy
and
safe
tyo
fPIC
Cs
aslo
ng-t
erm
VA
Ds
for
chem
oth
erap
yad
min
istr
atio
n
Patie
nts
und
erg
oin
ghe
mat
op
oie
ticst
emce
lltr
ansp
lant
atio
nw
ithPI
CC
sin
sert
edb
etw
een
May
and
No
vem
ber
2008
inIta
ly
PIC
CTh
era
teo
fCLA
BSI
with
PIC
Cs
was
sim
ilar
toth
ato
fco
nven
tiona
lCV
Cs
Bo
ncia
relli
etal
,201
1(1
11)
NA
Gui
del
ine
Defi
nere
com
men
dat
ions
for
the
corr
ecta
ndsa
feus
eo
fim
pla
ntab
leve
nous
acce
ssd
evic
esfo
rd
iag
nost
icp
roce
dur
es
Patie
nts
usin
gp
ort
sfo
rra
dio
dia
gno
stic
sPo
rtPa
tient
safe
ty,c
ost
-effe
ctiv
enes
s,an
def
ficie
ncy
are
imp
ort
anta
spec
tsin
the
use
of
po
rts
inra
dio
dia
gno
stic
s,es
pec
ially
inp
atie
nts
with
canc
erB
oni
zzo
liet
al,2
011
(112
)23
9Pr
osp
ectiv
eco
hort
stud
yA
sses
sra
tes
oft
hro
mb
osi
saf
ter
PIC
Cp
lace
men
tin
aco
hort
ofc
ritic
ally
illp
atie
nts
Patie
nts
dis
char
ged
fro
mth
eIC
Uw
itha
cent
ral
veno
usd
evic
eat
Car
egg
iTea
chin
gH
osp
ital,
Flo
renc
e,Ita
ly,f
rom
Janu
ary
toA
ugus
t200
8
CV
C,P
ICC
Hig
her
risk
for
DV
Tin
pat
ient
sw
ithPI
CC
sw
asno
ted
(27.
2%vs
.9.6
%).
Fem
ale
sex
and
the
left
bas
ilic
vein
asth
eac
cess
site
wer
eas
soci
ated
with
PIC
C-r
elat
edD
VT
Bo
ttin
oet
al,1
979
(113
)81
Pro
spec
tive
coho
rtst
udy
Ass
ess
risk
sre
late
dto
long
-ter
mus
eo
fp
erip
hera
llyin
sert
edsi
lico
neel
asto
mer
CV
Cs
inca
ncer
po
pul
atio
ns
Patie
nts
with
canc
erre
qui
ring
pro
long
edIV
ther
apy,
incl
udin
gch
emo
ther
apy
PIC
CA
ltho
ugh
6%o
fcat
hete
rsw
ere
rem
ove
dfo
rp
hleb
itis,
per
iphe
rally
inse
rted
silic
one
elas
tom
erC
VC
sm
ayb
eus
edfo
rlo
ng-t
erm
cent
ralv
eno
usac
cess
Bur
gan
dM
yles
,200
5(1
14)
79C
ross
-sec
tiona
lsu
rvey
Iden
tify
com
plic
atio
nsas
soci
ated
with
ante
par
tum
PIC
Cus
eA
ntep
artu
mp
atie
nts
with
IVth
erap
yre
cord
sat
St.
Mar
y's
Hea
lthC
ente
rfr
om
Janu
ary
2000
toM
arch
2005
PIC
CPI
CC
sha
da
low
risk
for
com
plic
atio
nsan
dw
ere
oth
erw
ise
effe
ctiv
efo
rlo
ng-t
erm
IVac
cess
.One
pat
ient
had
aD
VT,
and
6%ha
dPI
CC
sre
mo
ved
for
oth
erco
mp
licat
ions
Bur
nsan
dLa
mb
erth
,201
0(5
)N
AR
evie
wD
iscu
ssre
sour
ces,
cost
s,p
olic
ies,
and
pro
ced
ures
rela
ted
tod
evel
op
ing
vasc
ular
acce
sste
ams
Are
view
oft
hefo
rmat
ion
ofv
ascu
lar
acce
sste
ams
in2
hosp
itals
and
the
cost
san
db
enefi
tsas
soci
ated
with
thes
ep
rog
ram
s
PIC
C,
mid
line
cath
eter
,C
VC
Vas
cula
rac
cess
team
s,th
oug
has
soci
ated
with
upfr
ont
cost
s,ha
veim
po
rtan
tdo
wns
trea
mb
enefi
tsan
dco
stsa
ving
s
But
ler
etal
,201
1(1
15)
185
Ret
rosp
ectiv
eco
hort
stud
yEx
amin
eth
eas
soci
atio
nb
etw
een
PIC
Cp
lace
men
tand
sub
seq
uent
risk
for
cath
eter
-rel
ated
infe
ctio
nin
hem
od
ialy
sis
pat
ient
s
Patie
nts
req
uiri
nghe
mo
dia
lysi
sw
ithca
thet
erp
lace
men
tsan
dex
chan
ges
at1
univ
ersi
tyho
spita
lfro
mSe
pte
mb
er20
03to
Sep
tem
ber
2008
PIC
CPr
ior
PIC
Cus
ew
as2.
46tim
esm
ore
likel
yto
be
asso
ciat
edw
ithca
thet
er-r
elat
edin
fect
ion
com
par
edw
ithp
atie
nts
who
neve
rre
ceiv
edth
isd
evic
eC
apar
asan
dH
u,20
14(3
8)54
Pro
spec
tive,
cont
rolle
d,
rand
om
ized
clin
ical
tria
l
Ass
ess
whe
ther
vanc
om
ycin
can
be
safe
lyad
min
iste
red
thro
ugh
ane
wm
idlin
eca
thet
erco
mp
ared
with
PIC
Cs
Patie
nts
sche
dul
edto
rece
ive
sho
rt-t
erm
IVva
nco
myc
inat
asi
ngle
med
ical
cent
erin
Que
ens,
New
Yo
rk
Mid
line
cath
eter
,PI
CC
Sho
rt-t
erm
mid
line
cath
eter
sw
ere
safe
and
cost
-effe
ctiv
efo
rd
eliv
erin
gva
nco
myc
info
rd
urat
ions
≤6
d
Cap
eet
al,2
013
(116
)66
Ret
rosp
ectiv
eco
hort
stud
yA
naly
zePI
CC
-rel
ated
com
plic
atio
nsin
pre
gna
ntw
om
enw
hore
ceiv
edPI
CC
sfo
rva
rio
uscl
inic
alin
dic
atio
ns
Preg
nant
wo
men
with
PIC
Cs
inse
rted
bet
wee
nJa
nuar
y20
00an
dJu
ne20
06at
1m
edic
alce
nter
PIC
CPI
CC
inse
rtio
nin
pre
gna
ntw
om
enw
asas
soci
ated
with
hig
hra
tes
ofb
acte
rem
iaan
dth
rom
bo
sis.
Con
tinue
don
follo
win
gp
age
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S26 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
Downloaded From: http://annals.org/ by a Ebling Library Information Research User on 10/08/2015
Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Cat
alan
oet
al,2
011
(117
)50
0Pr
osp
ectiv
eco
hort
stud
yA
naly
zera
tes
ofc
athe
ter-
rela
ted
tho
raci
cD
VT
inp
atie
nts
with
canc
erb
yus
ing
mul
tidet
ecto
rC
T
Can
cer
pat
ient
sw
hoha
da
CV
AD
and
und
erw
ent
CT
for
any
reas
on
CV
C,P
ICC
,p
ort
CV
C-r
elat
edth
rom
bo
sis
isco
mm
on
inp
atie
nts
with
canc
eran
dca
nb
ed
ifficu
ltto
det
ectb
ycl
inic
alm
eans
Cha
krav
arth
yet
al,
2005
(118
)31
Ran
do
miz
ed,
cont
rolle
dcl
inic
altr
ial
Eval
uate
the
inci
den
ceo
fPIC
C-r
elat
edD
VT
inIC
Up
atie
nts
Cri
tical
lyill
pat
ient
sw
hore
ceiv
eda
PIC
Cd
urin
gro
utin
ecl
inic
alca
reat
1ac
adem
icm
edic
alce
nter
PIC
CPI
CC
-rel
ated
DV
Tin
criti
cally
illp
atie
nts
isco
mm
on
(65%
)and
larg
ely
asym
pto
mat
ic;
vig
ilanc
efo
rD
VT
inth
isp
op
ulat
ion
issu
gg
este
dC
hem
aly
etal
,200
2(1
19)
2063
Ret
rosp
ectiv
eco
hort
stud
yA
sses
sth
esa
fety
ofP
ICC
sus
edfo
rlo
ng-t
erm
IVan
tibio
ticad
min
istr
atio
nPa
tient
sat
the
Cle
vela
ndC
linic
Foun
dat
ion
who
had
aPI
CC
pla
ced
for
IVan
tibio
tics
bet
wee
nJa
nuar
y19
94an
dO
cto
ber
1996
PIC
CPI
CC
use
was
asso
ciat
edw
ithU
EDV
T.Pa
tient
sw
how
ere
youn
ger
,had
pri
or
VT,
or
rece
ived
amp
hote
rici
nin
fusi
on
thro
ugh
the
PIC
Cw
ere
atg
reat
erri
skfo
rD
VT
Che
ong
etal
,200
4(1
20)
17R
etro
spec
tive
coho
rtst
udy
Do
cum
entt
hefr
eque
ncy
ofP
ICC
com
plic
atio
nsin
pat
ient
sw
ithso
lidtu
mo
rs
Patie
nts
with
solid
tum
ors
trea
ted
atFl
ind
ers
Med
ical
Cen
tre,
Sout
hA
ustr
alia
,bet
wee
nJa
nuar
y20
00an
dM
arch
2001
PIC
CC
om
par
edw
ithp
atie
nts
with
out
canc
er,a
hig
hra
teo
fco
mp
licat
ions
(sep
sis,
thro
mb
osi
s,b
lock
age,
and
leak
age)
was
foun
din
pat
ient
sw
ithca
ncer
who
rece
ived
PIC
Cs
Chi
ttic
ket
al,2
013
(121
)26
5Pr
osp
ectiv
eco
hort
stud
yC
om
par
ep
atie
nts
with
earl
y-an
dla
te-o
nset
PIC
C-r
elat
edC
LAB
SIto
asse
ssri
skfa
cto
rsPa
tient
sw
hod
evel
op
edPI
CC
-rel
ated
CLA
BSI
at1
acad
emic
cent
erPI
CC
Ther
ear
esi
gni
fican
tdiff
eren
ces
inth
em
icro
bio
log
ical
char
acte
rist
ics
ofp
atie
nts
with
earl
y-an
dla
te-o
nset
CLA
BSI
;the
sed
iffer
ence
sm
ayin
fluen
cech
oic
eo
fan
tibio
tican
dst
rate
gy
ofp
reve
ntio
nC
hop
raet
al,2
012
(17)
NA
Rev
iew
Des
crib
eev
olu
tion
ofP
ICC
san
dth
eir
ado
ptio
nin
mo
der
nm
edic
ine;
eval
uate
earl
yst
udie
so
fDV
Tan
dC
LAB
SI;p
rovi
de
focu
sfo
rar
eas
ofu
ncer
tain
tyan
dri
sk
Hum
anst
udie
sw
ithsp
ecifi
cke
ywo
rds
rela
ted
toPI
CC
s,C
LAB
SI,a
ndD
VT;
full
text
,ab
stra
cts,
and
po
ster
sw
ere
incl
uded
PIC
CIn
tro
duc
tion
ofa
conc
eptu
alm
od
el,
hig
hlig
htin
gun
cert
aint
ies
and
kno
wle
dg
eg
aps
per
tain
ing
toPI
CC
san
dsp
ecifi
cad
vers
eo
utco
mes
Cho
pra
etal
,201
2(9
)N
AR
evie
wEx
amin
eth
eri
skan
db
enefi
tofP
ICC
use
inho
spita
lized
pat
ient
sEv
alua
tion
ofP
ICC
dec
isio
nm
akin
gan
dch
ang
esin
the
epid
emio
log
yo
fCV
Cus
ein
hosp
ital
sett
ing
s
PIC
CH
ighl
ight
sth
ene
edfo
rm
ore
PIC
Cre
sear
chan
dca
utio
nin
pla
cing
PIC
Cs,
giv
enth
eri
skfo
rad
vers
eev
ents
Cho
pra
etal
,201
3(2
2)14
4C
ross
-sec
tiona
lsu
rvey
Web
-bas
edsu
rvey
des
igne
dto
und
erst
and
hosp
italis
texp
erie
nce,
pra
ctic
e,o
pin
ions
,an
dkn
ow
led
ge
rela
ted
toPI
CC
use,
care
,an
dm
anag
emen
tin
Mic
hig
an
Ho
spita
lists
fro
m10
acad
emic
and
com
mun
ityho
spita
lsin
Mic
hig
anPI
CC
Sub
stan
tialv
aria
tion
inho
spita
liste
xper
ienc
e,p
ract
ice,
op
inio
ns,a
ndkn
ow
led
ge
reg
ard
ing
PIC
Cs
was
ob
serv
ed
Cho
pra
etal
,201
3(2
1)21
12C
ross
-sec
tiona
lsu
rvey
Web
-bas
edsu
rvey
des
igne
dto
und
erst
and
hosp
italis
texp
erie
nce,
pra
ctic
e,o
pin
ions
and
kno
wle
dg
ere
late
dto
PIC
Cus
e,ca
re,
and
man
agem
enta
cro
ssth
eU
nite
dSt
ates
Ho
spita
listp
rovi
der
sw
hoar
em
emb
ers
oft
heSo
ciet
yo
fHo
spita
lMed
icin
eac
ross
the
Uni
ted
Stat
es
PIC
CH
osp
italis
tkno
wle
dg
ean
dex
per
ienc
esre
late
dto
PIC
Cs
vari
ed,w
ithkn
ow
led
ge
gap
sre
late
dto
the
ratio
nale
for
PIC
Ctip
po
sitio
ning
and
out
com
esre
late
dto
PIC
Cus
e.Tr
eatm
ento
fco
mp
licat
ions
vari
edsu
bst
antia
lly,i
nclu
din
gin
dur
atio
no
fan
tico
agul
atio
nan
dca
thet
erre
mo
vali
nth
ese
ttin
go
fPIC
C-r
elat
edD
VT
Cho
pra
etal
,201
3(1
5)57
250
Syst
emat
icre
view
and
met
a-an
alys
isR
isk
for
CLA
BSI
with
PIC
Cs
vs.C
VC
sTw
enty
-thr
eest
udie
sin
clud
ing
adul
tsw
hoha
dei
ther
aPI
CC
or
CV
Can
dre
po
rted
CLA
BSI
PIC
C,C
VC
Ho
spita
lized
pat
ient
sar
eju
stas
likel
yto
dev
elo
pC
LAB
SIw
ithPI
CC
sas
with
CV
Cs;
ino
utp
atie
nts,
PIC
Cs
wer
eas
soci
ated
with
alo
wer
risk
for
CLA
BSI
Cho
pra
etal
,201
3(1
6)29
503
Syst
emat
icre
view
and
met
a-an
alys
isR
isk
for
DV
Tw
ithPI
CC
svs
.no
ntun
nele
dC
VC
s64
stud
ies
incl
udin
gad
ultp
atie
nts
with
PIC
Cs
or
CV
Cs
CV
C,P
ICC
Patie
nts
with
canc
eran
dth
ose
with
criti
cal
illne
ssha
dth
ehi
ghe
stra
teo
fPIC
C-r
elat
edD
VT;
PIC
Cs
wer
eas
soci
ated
with
2.5
times
gre
ater
risk
for
DV
Tco
mp
ared
with
CV
Cs
Cho
pra
etal
,201
4(1
22)
747
Ret
rosp
ectiv
eco
hort
stud
yId
entif
yra
tes;
pat
tern
s;an
dp
atie
nt,
pro
vid
er,a
ndd
evic
ech
arac
teri
stic
sas
soci
ated
with
PIC
C-r
elat
edC
LAB
SI
Patie
nts
who
und
erw
entP
ICC
pla
cem
entb
etw
een
June
2009
and
July
2012
ata
VA
med
ical
cent
erin
Mic
hig
an
PIC
CPI
CC
-rel
ated
BSI
was
asso
ciat
edw
ithho
spita
lle
ngth
ofs
tay,
ICU
stat
us,a
ndnu
mb
ero
fPI
CC
lum
ens
Co
rtel
ezzi
aet
al,2
003
(123
)12
6R
etro
spec
tive
coho
rtst
udy
Ana
lyze
the
inci
den
ceo
fthr
om
bo
tican
din
fect
ious
com
plic
atio
nsin
CV
Cs
vs.P
ICC
sin
canc
erp
atie
nts
Patie
nts
with
hem
ato
log
icca
ncer
and
low
pla
tele
tco
untw
ithei
ther
aC
VC
or
aPI
CC
;pat
ient
sre
ceiv
edD
VT
pro
phy
laxi
sat
the
dis
cret
ion
of
the
pro
vid
er
CV
C,P
ICC
Thro
mb
osi
so
ccur
red
mo
refr
eque
ntly
with
PIC
Cs
than
with
CV
Cs;
pat
ient
sw
hore
ceiv
edLM
WH
wer
ele
sslik
ely
toex
per
ienc
eD
VT
than
tho
sew
hore
ceiv
edhe
par
inC
oto
gni
etal
,201
3(5
9)25
4Pr
osp
ectiv
eco
hort
stud
yEv
alua
teth
ein
cid
ence
ofV
AD
-rel
ated
com
plic
atio
nsin
canc
erp
atie
nts
who
rece
ive
hom
ep
aren
tera
lnut
ritio
n
Can
cer
pat
ient
sw
hore
ceiv
edp
aren
tera
lnut
ritio
nb
etw
een
June
2008
toN
ove
mb
er20
09at
aun
iver
sity
hosp
itali
nIta
ly
PIC
C,
tunn
eled
cath
eter
,p
ort
Ho
me
par
ente
raln
utri
tion
was
safe
and
wel
lto
lera
ted
inp
atie
nts
with
canc
er;r
isk
for
com
plic
atio
nsac
ross
dev
ices
was
low
and
acce
pta
ble
Co
uban
etal
,200
5(1
24)
255
Mul
ticen
ter,
rand
om
ized
,p
lace
bo
-co
ntro
lled
clin
ical
tria
l
Ass
esse
whe
ther
low
-do
sed
aily
war
fari
nre
duc
esth
ein
cid
ence
ofs
ymp
tom
atic
CV
Cth
rom
bo
sis
inp
atie
nts
with
canc
er
Patie
nts
who
req
uire
da
CV
Cfo
rat
leas
t7d
wer
era
ndo
mly
assi
gne
dto
rece
ive
1m
gw
arfa
rin
dai
lyvs
.pla
ceb
o
CV
CSy
mp
tom
atic
CV
C-a
sso
ciat
edth
rom
bo
sis
was
less
com
mo
nth
anp
revi
ous
lyth
oug
htin
this
po
pul
atio
n;d
aily
1-m
gd
ose
so
fwar
fari
nd
idno
tred
uce
sym
pto
mat
icC
VC
-rel
ated
thro
mb
otic
even
tsC
rnic
han
dM
aki,
2002
(125
)N
AR
evie
wIn
vite
dar
ticle
that
exam
ined
use
ofn
ove
lap
pro
ache
s,su
chas
secu
rem
entd
evic
es,
dre
ssin
gs,
cath
eter
coat
ing
s,an
dlo
ckso
lutio
ns,i
np
reve
ntin
gC
LAB
SI
Exam
inin
gth
eri
skfo
rIV
D-r
elat
edin
fect
ions
,p
atho
gen
esis
,pre
vent
ion,
and
nove
ltec
hno
log
yav
aila
ble
for
cont
rolo
fBSI
asso
ciat
edw
ithlo
ng-t
erm
dev
ices
CV
C,p
ort
,PI
CC
New
erte
chno
log
ies
may
help
red
uce
CLA
BSI
.;id
entifi
catio
n,ad
apta
tion,
and
eval
uatio
no
fth
ese
nove
lap
pro
ache
sis
nece
ssar
y
Con
tinue
don
follo
win
gp
age
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S27
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Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Cur
iglia
noet
al,2
007
(126
)18
8Pr
osp
ectiv
eco
hort
stud
yEv
alua
teth
eef
ficac
yan
dsa
fety
ofl
ow
-do
seas
pir
info
rp
reve
ntio
no
fVTE
Patie
nts
with
stag
eII–
IVb
reas
tcan
cer
with
CV
Cs
for
cont
inuo
usch
emo
ther
apy
fro
mA
pri
l200
0to
Mar
ch20
04in
asi
ngle
cent
er
CV
CA
ltho
ugh
noco
ntro
lor
com
par
iso
nar
mw
asin
clud
ed,l
ow
-do
seas
pir
inw
asa
reas
ona
bly
wel
lto
lera
ted
met
hod
ofD
VT
pre
vent
ion
inth
isp
op
ulat
ion
Dan
eman
etal
,201
2(1
27)
348
Ret
rosp
ectiv
eco
hort
stud
yA
sses
sth
eri
skfo
rre
curr
entb
acte
rem
iain
pat
ient
sw
ithre
cent
CLA
BSI
with
in6
wee
ks
Bac
tere
mic
pat
ient
sun
der
go
ing
PIC
Cin
sert
ion
atan
acad
emic
heal
thce
nter
wer
ere
view
edfo
rri
skfo
rre
curr
enti
nfec
tion
PIC
CR
ecur
rent
bac
tere
mia
with
in30
do
fPIC
Cin
sert
ion
occ
urre
din
33p
atie
nts
but
oft
enin
volv
eda
diff
eren
torg
anis
m(2
5p
atie
nts)
;af
ter
adju
dic
atio
n,o
nly
3o
f8re
curr
ent
infe
ctio
nsw
ere
det
erm
ined
tob
e"t
rue"
rela
pse
s(0
.9%
)D
ariu
shni
aet
al,2
010
(68)
NA
Gui
del
ines
Gui
del
ines
fro
mth
eSo
ciet
yo
fInt
erve
ntio
nal
Rad
iolo
gy
that
wer
ew
ritt
enfo
rq
ualit
yim
pro
vem
entp
rog
ram
sse
ekin
gto
asse
ssce
ntra
lven
ous
acce
ssp
roce
dur
es
Co
mp
rehe
nsiv
ere
view
ofi
ndic
atio
nsfo
rce
ntra
lve
nous
acce
ss,Q
Ieffo
rts,
and
man
agem
ento
fco
mp
licat
ions
PIC
C,C
VC
,p
ort
Thes
eg
uid
elin
esp
rovi
de
targ
etsu
cces
sra
tes
for
inse
rtio
no
fvar
ious
cath
eter
sas
wel
las
maj
or
com
plic
atio
nra
tes
and
sug
ges
ted
thre
sho
lds
for
veno
usac
cess
dev
ices
Daw
son
etal
,201
3(1
28)
NA
Rev
iew
Exam
ined
pub
lishe
dev
iden
ceo
nm
idlin
eca
thet
ers
inre
duc
ing
the
risk
for
CLA
BSI
Cal
lsfo
rg
reat
erus
eo
fmid
line
cath
eter
sas
par
tof
am
ultif
acet
edef
fort
tore
duc
eC
LAB
SIin
hosp
itals
CV
AD
,C
VC
,PI
CC
,m
idlin
eca
thet
er
Mid
line
cath
eter
sar
eef
fect
ive
too
lsfo
rin
term
edia
te-d
urat
ion
infu
sio
nsth
atar
ep
erip
hera
llyco
mp
atib
le.T
hey
can
be
used
for
blo
od
dra
ws
and
infu
sio
nan
d,a
sp
arto
fa
mul
tifac
eted
app
roac
h,ca
nre
duc
eho
spita
lrat
eso
fCLA
BSI
Deb
our
dea
uet
al,2
013
(36)
NA
Gui
del
ines
Esta
blis
hmen
tofg
oo
dcl
inic
alp
ract
ices
gui
del
ines
for
the
man
agem
ento
fCR
Tin
pat
ient
sw
ithca
ncer
Gui
del
ine
exam
ined
pro
phy
laxi
san
dtr
eatm
ento
fth
rom
bo
sis
asso
ciat
edw
ithC
VC
sin
pat
ient
sw
ithca
ncer
CV
CD
isse
min
atio
nan
dim
ple
men
tatio
no
fthe
seg
uid
elin
esis
ap
ublic
heal
thp
rio
rity
ino
rder
tore
duc
eC
RT
DeL
emo
set
al,2
011
(129
)35
Pro
spec
tive
coho
rtst
udy
Eval
uatio
no
fPIC
Cs
asan
alte
rnat
ive
toC
VC
sin
neur
osu
rgic
alcr
itica
lcar
ese
ttin
gs
Neu
rolo
gic
criti
calc
are
pat
ient
sat
1ce
nter
who
had
PIC
Cs
(as
op
po
sed
toC
VC
s)fo
rIV
acce
ssan
dm
oni
tori
ng
PIC
C,C
VC
Use
ofP
ICC
s(r
athe
rth
anC
VC
so
rp
ulm
ona
ryar
tery
cath
eter
s)re
duc
edp
roce
dur
alan
din
fect
ion
risk
Del
Prin
cip
eet
al,2
013
(56)
71R
etro
spec
tive
coho
rtA
sses
sra
tes
ofc
athe
ter-
rela
ted
thro
mb
osi
sin
rela
tion
toca
thet
erex
itsi
tein
fect
ion
Patie
nts
with
acut
em
yelo
idle
ukem
iaw
houn
der
wen
tCV
Cp
lace
men
tbef
ore
each
chem
oth
erap
ycy
cle
CV
CPa
tient
sw
ithse
psi
san
dex
it-si
tein
fect
ions
had
sig
nific
antly
hig
her
rate
so
fthr
om
bo
sis
than
tho
sew
itho
utth
ese
even
ts,i
ndep
end
ento
fo
ther
fact
ors
Dia
zet
al,2
012
(130
)50
Pro
spec
tive
coho
rtst
udy
Det
erm
ine
bas
elin
eC
LAB
SIra
tes
for
ED-in
sert
edC
VC
san
dd
escr
ibe
ind
icat
ions
,dur
atio
no
fuse
,and
natu
ral
hist
ory
oft
hese
dev
ices
Patie
nts
ata
leve
lItr
aum
a,ac
adem
icED
who
req
uire
dce
ntra
lcat
hete
rin
sert
ion
CV
CN
oC
LAB
SIev
ents
occ
urre
d;n
ota
bly
,42%
of
CV
Cs
had
nod
ate
ofr
emo
val,
sug
ges
ting
the
need
toim
pro
ved
ocu
men
tatio
nin
this
reg
ard
DiN
isio
etal
,201
0(1
31)
NA
Syst
emat
icre
view
Exam
ine
the
utili
tyo
fUS
tod
iag
nose
PIC
C-r
elat
edD
VT
17ar
ticle
sas
sess
ing
dia
gno
stic
accu
racy
oft
ests
for
clin
ical
lysu
spec
ted
UED
VT
CV
C,P
ICC
Co
mp
ress
ion
US
isan
acce
pta
ble
alte
rnat
ive
tove
nog
rap
hy,g
iven
hig
hse
nsiti
vity
and
spec
ifici
tyfo
rca
thet
erth
rom
bo
sis
Due
rkse
net
al,1
999
(132
)N
RPr
osp
ectiv
eco
hort
stud
yA
sses
sty
pe
ofC
VC
and
com
plic
atio
nsas
soci
ated
with
del
iver
yo
fpar
ente
ral
nutr
itio
n
Patie
nts
atSt
.Bo
nifa
ceG
ener
alH
osp
itali
nW
inni
peg
,Man
itob
a,C
anad
a,w
hore
ceiv
eda
CV
Cfo
rnu
triti
on
bet
wee
n19
87an
d19
97
CV
C,P
ICC
,tu
nnel
edca
thet
er
Ove
rth
e10
-yea
rst
udy,
use
ofP
ICC
sin
crea
sed
tore
pla
ceC
VC
sin
pro
vid
ing
par
ente
ral
nutr
itio
n;PI
CC
sd
idno
tinc
reas
eri
skfo
rse
psi
so
rth
rom
bo
sis
com
par
edw
ithhi
sto
rica
lco
hort
sD
urra
ni,2
009
(133
)62
3R
etro
spec
tive
coho
rtst
udy
Test
whe
ther
antic
oag
ulan
tsca
np
reve
ntV
Tin
pat
ient
sw
ithPI
CC
sPa
tient
sad
mitt
edto
asi
ngle
med
ical
cent
erb
etw
een
Janu
ary
2004
toJu
ly20
09w
hore
ceiv
eda
PIC
Can
dan
tipla
tele
tag
ents
PIC
CR
ecei
pto
fasp
irin
or
clo
pid
og
reld
urin
gho
spita
lizat
ion
did
nota
ffect
the
risk
for
PIC
C-r
elat
edD
VT
Elia
etal
,201
2(4
1)10
0R
and
om
ized
cont
rolle
dtr
ial
Co
mp
are
surv
ival
rate
sb
etw
een
stan
dar
d-le
ngth
cath
eter
svs
.lo
ngp
erip
hera
lcat
hete
rsin
sert
edb
yU
S
100
pat
ient
sin
anur
ban
hig
h-d
epen
den
cyun
itw
ere
rand
om
lyas
sig
ned
tore
ceiv
eei
ther
sho
rto
rlo
ngp
erip
hera
lcat
hete
rs
PIV
CB
oth
sho
rtan
dlo
ngp
erip
hera
lcat
hete
rsp
lace
dw
ithU
Sha
vea
hig
hsu
cces
sra
te;
cath
eter
failu
reo
ccur
red
mo
refr
eque
ntly
inth
esh
ort
cath
eter
gro
up(4
5%vs
.14%
;P
=0.
001)
ElTe
rset
al,2
012
(49)
282
Cas
e–co
ntro
lstu
dy
Ass
ess
the
asso
ciat
ion
bet
wee
nhi
sto
ryo
fPI
CC
use
and
sub
seq
uent
mal
func
tioni
ngo
rno
nfun
ctio
ning
arte
rio
veno
usfis
tula
Hem
od
ialy
sis
out
pat
ient
sin
7M
ayo
Clin
icun
itsin
Ro
ches
ter,
Min
neso
taPI
CC
Ast
rong
and
ind
epen
den
tass
oci
atio
n(3
.2tim
esg
reat
ero
dd
so
fano
nfun
ctio
ning
fistu
la)w
asno
ted
inp
atie
nts
who
had
rece
ived
pri
or
PIC
Cs
Evan
set
al,2
010
(73)
1728
Pro
spec
tive
coho
rtst
udy
Ass
ess
the
pre
vale
nce
and
risk
fact
ors
asso
ciat
edw
ithsy
mp
tom
atic
PIC
C-r
elat
edD
VT
inho
spita
lized
pat
ient
s
Patie
nts
with
PIC
Cin
sert
ions
ata
larg
eun
iver
sity
-bas
edhe
alth
syst
emPI
CC
PIC
Cin
sert
ion
inp
atie
nts
who
have
canc
er,
und
erg
osu
rger
yla
stin
gg
reat
erth
an1
h,o
rha
veex
per
ienc
edp
rio
rth
rom
bo
sis
isas
soci
ated
with
gre
ater
risk
for
DV
T;C
athe
ter
gau
ge
isa
stro
ngan
dm
od
ifiab
lefa
cto
ras
soci
ated
with
PIC
CD
VT
Evan
set
al,2
013
(74)
5018
Pro
spec
tive
coho
rtst
udy
Ass
ess
whe
ther
smal
l-dia
met
erPI
CC
sm
ayre
duc
eth
eri
skfo
rD
VT
inho
spita
lized
pat
ient
s
All
pat
ient
sw
ithPI
CC
inse
rtio
nsat
1ho
spita
lfro
mJa
nuar
y20
08to
Dec
emb
er20
10PI
CC
Use
ofs
mal
ler-
gau
ge
PIC
Cs
was
asso
ciat
edw
ithsu
bst
antia
llylo
wer
rate
so
fDV
T
Fag
anan
ieta
l,20
07(1
34)
1410
Pro
spec
tive
coho
rtst
udy
Eval
uate
the
asso
ciat
ion
bet
wee
nan
tipla
tele
tthe
rap
yan
dri
sko
fsu
bse
que
ntca
thet
er-r
elat
edth
rom
bo
sis
Patie
nts
atte
ndin
g1
of1
8p
artic
ipat
ing
hosp
itals
who
had
solid
or
hem
ato
log
ical
tum
ors
and
aC
VC
,PIC
C,o
rp
ort
CV
C,P
ICC
,p
ort
Ant
ithro
mb
otic
pro
phy
laxi
sd
idno
tpre
vent
cath
eter
-rel
ated
VT
inth
ishi
gh-
risk
coho
rt
Fear
onc
eet
al,2
010
(135
)31
Ret
rosp
ectiv
eco
hort
stud
yC
om
par
eth
eus
ean
dsa
fety
ofP
ICC
svs
.C
VC
sin
aco
hort
ofp
atie
nts
adm
itted
toa
bur
nIC
U
Bur
np
atie
nts
ata
sing
lece
nter
who
rece
ived
one
or
mo
rePI
CC
sb
etw
een
July
2005
and
June
2007
PIC
C,C
VC
Co
mp
ared
with
PIC
Cs,
CV
Cs
had
ahi
ghe
rra
teo
fcat
hete
r-re
late
dB
SI;P
ICC
sw
ere
asso
ciat
edw
ithg
reat
erri
skfo
rD
VT
Con
tinue
don
follo
win
gp
age
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S28 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
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Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Flet
cher
and
Bo
den
ham
,20
00(7
0)50
1R
etro
spec
tive
coho
rtst
udy
Ass
ess
the
inci
den
cera
tean
dcl
inic
alsi
gni
fican
ceo
fPIC
C-r
elat
edD
VT
incr
itica
llyill
pat
ient
sin
ane
uro
log
icIC
U
479
pat
ient
sw
hore
ceiv
ed50
1PI
CC
sd
urin
gcl
inic
alca
rein
ane
uro
log
icIC
Uat
aq
uate
rnar
yac
adem
icm
edic
alce
nter
PIC
CTh
ein
cid
ence
ofs
ymp
tom
atic
PIC
C-r
elat
edD
VT
was
8.1%
;PE
attr
ibut
able
toth
ePI
CC
occ
urre
din
15%
ofp
atie
nts,
oft
enre
qui
ring
antic
oag
ulat
ion
or
sup
erio
rve
naca
vafil
ter
pla
cem
ent
Flet
cher
etal
,201
1(1
36)
2150
Ret
rosp
ectiv
eco
hort
stud
yU
nder
stan
dth
ein
cid
ence
rate
and
sig
nific
ance
ofs
ymp
tom
atic
PIC
C-r
elat
edD
VT
incr
itica
llyill
pat
ient
sin
ane
uro
surg
ical
ICU
PIC
Cs
pla
ced
inne
uro
surg
ical
ICU
pat
ient
sb
etw
een
Mar
ch20
08an
dFe
bru
ary
2010
PIC
C,C
VC
PIC
Cs
are
asso
ciat
edw
itha
hig
hra
teo
fDV
T;p
lace
men
tin
ahe
mip
aret
icar
man
din
fusi
on
ofm
anni
tolo
rva
sop
ress
ors
thro
ugh
the
PIC
Cw
ere
asso
ciat
edw
ithg
reat
ero
dd
so
fD
VT
Frei
xas
etal
,201
3(1
37)
2176
heal
thca
rew
ork
ers
Qua
si-e
xper
imen
tal
bef
ore
-aft
erst
udy
Det
erm
ine
the
effe
cto
fam
ultim
od
alin
terv
entio
nto
red
uce
the
inci
den
ceo
fC
LAB
SIo
utsi
de
the
ICU
Ad
ultp
atie
nts
hosp
italiz
edin
non-
ICU
sett
ing
sb
etw
een
2009
and
2010
at11
affil
iate
dho
spita
lsin
Cat
alo
nia,
Spai
n
PIV
C,C
VC
Imp
lem
enta
tion
oft
hep
rog
ram
red
uced
CLA
BSI
and
CV
Cut
iliza
tion;
PIV
Cut
iliza
tion
rem
aine
dun
chan
ged
Friz
zelli
etal
,200
8(1
38)
848
Pro
spec
tive
coho
rtst
udy
Eval
uate
risk
for
US-
confi
rmed
DV
Tin
pat
ient
sw
hore
ceiv
eda
CV
Cd
urin
gca
rdia
csu
rger
y
Patie
nts
reco
veri
ngin
the
ICU
afte
rhe
arts
urg
ery
for
5–7
dfr
om
6ce
nter
sw
ere
incl
uded
CV
CC
VC
-rel
ated
DV
Tw
asa
freq
uent
out
com
e,o
ccur
ring
in38
6p
atie
nts
(48%
).Pa
tient
sw
hore
ceiv
edp
rop
hyla
ctic
antic
oag
ulat
ion
did
note
xper
ienc
ePE
.Scr
eeni
ngvi
aU
Sin
this
high
-ris
kco
hort
may
be
valu
able
topr
even
tPE
Furu
yaet
al,2
011
(139
)44
1ho
spita
lsC
ross
-sec
tiona
lstu
dy
Ass
ess
the
imp
lem
enta
tion
ofe
lem
ents
emb
edd
edw
ithin
the
cent
rall
ine
"bun
dle
"ac
ross
US
hosp
itals
and
effe
cto
nsu
bse
que
ntC
LAB
SIra
tes
Ho
spita
lsm
usth
ave
cond
ucte
dN
atio
nal
Hea
lthca
reSa
fety
Net
wo
rkC
LAB
SIsu
rvei
llanc
ein
2007
tob
ein
clud
ed
CV
CR
educ
tion
inC
LAB
SIw
aso
nly
ob
serv
edin
ICU
sth
atha
da
CLA
BSI
po
licy,
mo
nito
red
adhe
renc
e,an
dha
d>
95%
adhe
renc
era
te
Go
nget
al,2
012
(140
)18
0Pr
osp
ectiv
eco
hort
stud
yC
om
par
ePI
CC
com
plic
atio
nsvi
aus
eo
fam
od
ified
Seld
ing
erte
chni
que
with
US
gui
dan
cevs
.the
trad
itio
nalm
etho
do
fp
lace
men
t
Patie
nts
with
canc
erw
hoha
dPI
CC
sat
the
Dep
artm
ento
fChe
mo
ther
apy
inJi
ang
suC
ance
rH
osp
ital
PIC
CPI
CC
sp
lace
dus
ing
am
od
ified
Seld
ing
erap
pro
ach
and
US
wer
ele
sslik
ely
toex
per
ienc
eth
rom
bo
ticco
mp
licat
ions
Gö
rans
son
and
Joha
nsso
n,20
12(1
41)
83Pr
osp
ectiv
eco
hort
stud
yIn
vest
igat
eth
eas
soci
atio
nb
etw
een
pre
hosp
italP
IVC
pla
cem
enta
ndfr
eque
ncy
ofp
hleb
itis
Ho
spita
lized
pat
ient
sw
houn
der
wen
tPIV
Cp
lace
men
tbef
ore
hosp
italiz
atio
nb
yam
bul
ance
crew
sin
Sto
ckho
lm,S
wed
en
PIV
CO
f83
pat
ient
s,45
%d
evel
op
edth
rom
bo
phl
ebiti
s(5
4%);
noas
soci
atio
nb
etw
een
thro
mb
op
hleb
itis
and
pre
hosp
ital
risk
fact
ors
was
foun
dG
rant
etal
,200
8(1
42)
189
Ret
rosp
ectiv
eco
hort
stud
yEx
amin
ech
arac
teri
stic
so
fpat
ient
sw
hod
evel
op
edPI
CC
UED
VT
Patie
nts
who
und
erw
entP
ICC
pla
cem
enta
tUC
LAM
edic
alC
ente
rb
etw
een
Janu
ary
2003
and
Dec
emb
er20
06
PIC
CPa
tient
sw
hoex
per
ienc
edm
ultip
lePI
CC
inse
rtio
nsha
da
4-fo
ldg
reat
erri
skfo
rD
VT
than
tho
sew
hoha
do
nly
1in
sert
ion
Gra
ntet
al,2
012
(143
)N
AR
evie
wPr
ovi
de
asu
mm
ativ
ean
dcl
inic
ally
rele
vant
app
roac
hfo
rth
ed
iag
nosi
s,m
anag
emen
tan
dp
reve
ntio
no
fUED
VT
inhi
gh-
risk
pat
ient
sw
ithan
dw
itho
utca
thet
ers
Nar
rativ
ere
view
PIC
C,C
VC
,p
ort
Phar
mac
olo
gic
thro
mb
osi
sp
rop
hyla
xis
isno
tef
fect
ive
inre
duc
ing
risk
for
UED
VT
inp
atie
nts
with
CV
Cs;
antic
oag
ulat
ion
isco
mm
onl
yus
edfo
rtr
eatm
ento
fUED
VT
and
isre
com
men
ded
larg
ely
fro
mex
trap
ola
tion
ofs
tud
ies
invo
lvin
glo
wer
-ext
rem
ityD
VT
Gre
gg
etal
,201
0(1
44)
59R
etro
spec
tive
coho
rtst
udy
Rep
ort
succ
ess
and
com
plic
atio
nsre
late
dto
US-
gui
ded
PIV
Cp
lace
men
tin
criti
cally
illp
atie
nts
Cri
tical
lyill
pat
ient
sw
houn
der
wen
tUS-
gui
ded
PIV
Cp
lace
men
tas
par
toft
heir
rout
ine
care
ata
sing
lem
edic
alce
nter
inth
eU
nite
dSt
ates
PIV
C,C
VC
Oft
he14
8PI
VC
sre
que
sted
,147
wer
ep
lace
dsu
cces
sful
lyb
yU
Sg
uid
ance
;co
mp
licat
ions
incl
uded
infil
trat
ion
(3.4
%),
inad
vert
ent
rem
ova
l(2.
7%),
and
phl
ebiti
s(0
.7%
).A
sa
resu
lto
fsuc
cess
fulP
IVC
pla
cem
ent,
40C
VC
sw
ere
dis
cont
inue
dan
d34
CV
Cs
wer
eav
oid
edG
riffi
ths,
2007
(145
)N
AR
evie
wO
verv
iew
ofm
idlin
eca
thet
ers
inse
rted
by
nurs
esfo
rsh
ort
-and
long
-ter
mIV
infu
sio
ns
Nar
rativ
ere
view
Mid
line
cath
eter
Nur
sein
volv
emen
tin
det
erm
inin
gth
eap
pro
pri
aten
ess
ofv
eno
usac
cess
can
help
imp
rove
pat
ient
out
com
es;m
idlin
eca
thet
ers
are
one
exam
ple
ofa
dev
ice
that
can
pro
vid
eb
oth
sho
rtan
dlo
ng-t
erm
infu
sio
nsw
ithlo
wri
skfo
rco
mp
licat
ions
Gro
vean
dPe
vec,
2000
(146
)67
8R
etro
spec
tive
coho
rtst
udy
Det
erm
ine
risk
fact
ors
that
may
lead
toD
VT
inp
atie
nts
who
rece
ive
PIC
Cs
Patie
nts
with
PIC
Cin
sert
ions
in19
97cr
oss
-ref
eren
ced
with
veno
usd
uple
xex
ams
at1
hosp
ital
PIC
CPI
CC
-rel
ated
DV
Tra
tes
wer
e4.
5%fo
rnu
rses
and
2.7%
for
IRs;
the
smal
lest
-gau
ge
cath
eter
sho
uld
be
used
tod
ecre
ase
risk
for
thro
mb
osi
sG
unst
etal
,201
1(2
)12
1Pr
osp
ectiv
eco
hort
stud
yA
sses
sw
heth
erus
eo
fPIC
Cs
resu
ltsin
red
uced
rate
ofB
SIco
mp
ared
toan
tisep
tic-c
oat
edC
VC
s
Patie
nts
adm
itted
toa
surg
ical
ICU
for
≥14
db
etw
een
July
2005
and
July
2006
PIC
C,C
VC
The
onl
yin
dep
end
entp
red
icto
ro
finf
ectio
nw
asd
wel
ltim
e;ca
thet
erco
atin
gan
dPI
CC
use
did
notp
red
icti
nfec
tion,
tho
ugh
PIC
Cs
wer
eas
soci
ated
with
infe
ctio
nsle
ssfr
eque
ntly
than
CV
Cs
Guy
atte
tal,
2012
(35)
NA
Gui
del
ines
Sum
mar
yo
fevi
den
cefo
rth
ere
com
men
dat
ions
on
antit
hro
mb
otic
ther
apy
and
pre
vent
ion
oft
hro
mb
osi
s
Sum
mar
yre
com
men
dat
ions
rela
ted
toth
erap
yan
dp
reve
ntio
no
fthr
om
bo
sis
incl
udin
gca
thet
er-r
elat
edD
VT
PIC
C,C
VC
This
sum
mar
yis
the
9th
editi
on
oft
heA
mer
ican
Co
lleg
eo
fChe
stPh
ysic
ians
Ant
ithro
mb
otic
Gui
del
ines
;am
etho
ds
artic
lew
ithre
com
men
dat
ions
and
gra
din
go
fthe
evid
ence
are
incl
uded
Had
away
,200
1(1
47)
NA
Rev
iew
Ad
dre
ssth
eri
skfo
rca
thet
er-r
elat
edB
SIan
dhu
bd
isin
fect
ion
met
hod
san
dp
ract
ice
Nar
rativ
ere
view
CV
C,P
ICC
Clin
icia
nssh
oul
dcl
ose
lyfo
llow
man
ufac
ture
rin
stru
ctio
nsre
gar
din
gd
isin
fect
ion
tech
niq
uean
dch
emic
alco
mp
osi
tion
of
dis
infe
ctan
tuse
d
Con
tinue
don
follo
win
gp
age
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S29
Downloaded From: http://annals.org/ by a Ebling Library Information Research User on 10/08/2015
Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Had
away
etal
,201
1(1
48)
554
heal
thca
rew
ork
ers
Surv
ey-b
ased
stud
yA
sses
sth
ekn
ow
led
ge
gap
ofh
ealth
care
wo
rker
sab
out
pra
ctic
ew
ithne
edle
less
conn
ecto
rs
Hea
lthca
rew
ork
ers
wer
ein
vite
dto
par
ticip
ate
ina
22-q
uest
ion
surv
eyC
VC
,PIC
CA
mo
ngre
spo
nden
ts(r
esp
ons
era
te,�
14%
),a
sig
nific
antg
apo
fkno
wle
dg
ere
gar
din
gne
edle
less
conn
ecto
rs;c
lean
sing
pra
ctic
es;
and
flush
ing
,cla
mp
ing
seq
uenc
eH
adaw
ay,2
012
(149
)N
AR
evie
wA
naly
sis
of4
5st
udie
sto
asse
sskn
ow
led
ge
gap
san
din
adeq
uate
clin
ical
pra
ctic
esas
soci
ated
with
cath
eter
-rel
ated
BSI
Nar
rativ
ere
view
CV
AD
s,IV
Inse
rtio
nte
chni
que
san
do
ther
clin
ical
pra
ctic
esd
iffer
gre
atly
amo
ngco
untr
ies;
thes
eva
riat
ions
may
incr
ease
the
risk
for
BSI
.Cat
hete
rssh
oul
db
ech
ang
edo
nly
whe
ncl
inic
ally
ind
icat
edH
adaw
ay,2
012
(150
)N
AR
evie
wD
escr
ibe
curr
ently
used
need
lele
ssco
nnec
tors
and
thei
rp
ote
ntia
lfo
rco
mp
licat
ions
asso
ciat
edw
ithd
iffer
ing
med
ical
pra
ctic
es
Nar
rativ
ere
view
Nee
dle
less
conn
ecto
rsD
evic
ed
esig
n,us
erkn
ow
led
ge
defi
cits
,and
imp
rop
erhy
gie
neca
nin
fluen
ceri
skfo
rin
fect
ions
;suc
hin
terv
entio
nsas
scru
bb
ing
the
conn
ectio
nsu
rfac
e,flu
shin
g,c
hang
ing
the
need
lele
ssco
nnec
tors
,and
inte
rmitt
ent
IVad
min
istr
atio
nca
nre
duc
eri
skfo
rin
fect
ion
Har
nag
e,20
07(1
51)
32IC
Ub
eds
Pro
spec
tive
coho
rtA
sses
sth
eef
fect
ofa
new
lyd
evel
op
edPI
CC
bun
dle
on
cath
eter
-rel
ated
BSI
Patie
nts
with
PIC
Cs
in2
ICU
units
in1
Cal
iforn
iaho
spita
lPI
CC
API
CC
bun
dle
that
com
bin
edp
ract
ice
and
tech
nolo
gy
succ
essf
ully
dec
reas
edca
thet
er-r
elat
edB
SIH
arna
ge,
2012
(152
)N
RR
etro
spec
tive
coho
rtst
udy
Eval
uate
sust
aina
bili
tyan
dle
sso
nsle
arne
daf
ter
imp
lem
enta
tion
ofa
PIC
Cb
und
leat
1m
edic
alce
nter
Patie
nts
in1
Cal
iforn
iaho
spita
lPI
CC
Cat
hete
rst
abili
zatio
nan
dze
ro-d
isp
lace
men
tIV
conn
ectio
nshe
lped
red
uce
CLA
BSI
Ho
rnsb
yet
al,2
005
(88)
NR
Pro
spec
tive
coho
rtst
udy
Ana
lysi
so
fthe
crea
tion
and
effe
cto
f2fu
ll-tim
eva
scul
arac
cess
spec
ialty
po
sitio
nsat
1m
edic
alce
nter
500-
bed
faci
lity
inSa
gin
aw,M
ichi
gan
PIV
CPI
CC
Mo
rePI
CC
sw
ere
pla
ced
pro
activ
ely
atth
eb
egin
ning
ofh
osp
itals
tays
.Per
iphe
ral
cath
eter
rest
arts
wer
ere
pla
ced
with
PIC
Cs
and
del
ayed
dis
char
ges
rela
ted
toPI
CC
pla
cem
entw
ere
red
uced
Ho
shal
,197
5(8
6)35
Pro
spec
tive
coho
rtst
udy
Exam
ine
the
feas
ibili
tyo
fusi
ngp
erip
hera
llyin
sert
edsi
lico
neel
asto
mer
CV
Cs
for
tota
lIV
nutr
itio
n
Patie
nts
rece
ivin
gto
talI
Vnu
triti
on
at1
med
ical
faci
lity
PIC
CTh
isfir
st-e
ver
rep
ort
ofP
ICC
sfo
und
that
per
iphe
rally
inse
rted
silic
one
elas
tom
erC
VC
sw
ere
safe
,effe
ctiv
e,an
dd
urab
lefo
rd
eliv
ery
oft
ota
lIV
nutr
itio
nin
out
pat
ient
sH
ughe
s,20
11(1
53)
NA
Syst
emat
icre
view
Exam
ine
PIC
C-r
elat
edth
rom
bo
sis
inci
den
ce,
mo
rbid
ityan
def
fect
ofU
Sg
uid
ance
on
out
com
es
Syst
emat
icre
view
PIC
CPI
CC
-rel
ated
DV
Tis
com
mo
n,es
pec
ially
amo
ngp
atie
nts
with
canc
er.A
ltho
ugh
limite
d,a
vaila
ble
evid
ence
sug
ges
tsU
Sca
nre
duc
eri
skfo
rth
rom
bo
sis
Hug
hes,
2014
(154
)31
Pro
spec
tive
coho
rtst
udy
Ass
essi
ngth
efe
asib
ility
ofS
ecur
Aca
th(In
terr
adM
edic
al,P
lym
out
h,M
inne
sota
),a
sub
cuta
neo
usd
evic
e,o
nin
adve
rten
tPIC
Cm
igra
tion
Patie
nts
at1
canc
erho
spita
lwho
rece
ived
PIC
Cs
and
the
Secu
rAca
thd
evic
ed
urin
gcl
inic
alca
rePI
CC
Asi
ngle
case
ofm
igra
tion
amo
ng32
pat
ient
sw
asre
cord
ed;h
ow
ever
,so
me
initi
alp
rob
lem
sw
ithin
fect
ion
and
pai
no
ccur
red
Infu
sio
nN
urse
sSo
ciet
y,20
11(3
2)N
AG
uid
elin
esR
evie
wo
fcur
rent
liter
atur
efo
rth
ed
evel
op
men
tofs
tand
ard
so
fpra
ctic
efo
rnu
rses
wo
rkin
gw
ithV
AD
s
Stan
dar
ds
for
inse
rtio
n,ca
re,a
ndm
anag
emen
tof
VA
Ds
for
nurs
ing
pro
fess
iona
lsPI
VC
,CV
C,
PIC
C,
tunn
eled
cath
eter
,p
ort
Top
ics
rang
ing
fro
mp
atie
ntca
re,a
cces
sd
evic
es,a
ndin
fusi
on
ther
apie
sto
safe
and
effe
ctiv
em
etho
ds
for
wo
rkin
gw
ithV
AD
sw
ere
incl
uded
;bas
icre
qui
rem
ents
ined
ucat
ion
and
com
pet
enci
esfo
rin
sert
ion
and
man
agem
ento
fdev
ices
are
also
outli
ned
Itkin
etal
,201
4(1
55)
332
RC
TEv
alua
teth
eri
skfo
rD
VT
inPI
CC
sth
atar
ere
vers
e-ta
per
edvs
.PIC
Cs
that
are
not
Patie
nts
18–9
0ye
ars
ofa
ge
req
uiri
ngPI
CC
inse
rtio
nat
aq
uate
rnar
yac
adem
icm
edic
alce
nter
PIC
CA
ltho
ugh
tap
erin
go
fPIC
Cs
did
noti
nflue
nce
risk
for
PIC
C-r
elat
edD
VT,
upto
thre
eq
uart
ers
ofp
atie
nts
exp
erie
nced
asym
pto
mat
icth
rom
bo
sis
inth
isst
udy,
sug
ges
ting
ahi
gh
ove
rall
rate
oft
hro
mb
osi
sJi
net
al,2
013
(156
)N
ASy
stem
atic
revi
ewD
escr
ibe
po
tent
ialr
epo
sitio
ning
tech
niq
ues
for
PIC
Cs
that
wer
em
alp
osi
tione
dd
urin
go
raf
ter
inse
rtio
n
Syst
emat
icre
view
PIC
CM
alp
osi
tioni
ngo
fPIC
Cs
can
occ
urfr
om
the
rig
htve
ntri
cle
top
erip
hera
lvei
ns.
Rep
osi
tioni
ngte
chni
que
s,in
clud
ing
man
ual
adva
ncem
ento
rca
thet
erre
pla
cem
ent,
are
oft
enne
cess
ary
Joffe
and
Go
ldha
ber
,20
02(1
57)
Rev
iew
Exam
ine
the
pat
hog
enes
is,s
igns
,and
sym
pto
ms
ofU
EDV
Tan
dth
eas
soci
atio
nb
etw
een
the
incr
easi
ngin
cid
ence
of
UED
VT
and
CV
Cs
Nar
rativ
ere
view
CV
C,P
ICC
Seco
ndar
yth
rom
bo
sis
rela
ted
toC
VC
use
iso
nth
eri
se;t
hro
mb
oly
sis
rese
rved
for
spec
ific
inst
ance
s
Joha
nsso
net
al,2
013
(6)
NA
Syst
emat
icre
view
Exam
ine
the
adva
ntag
esan
dd
isad
vant
ages
ofP
ICC
svs
.CV
Cs
on
the
bas
iso
fava
ilab
leev
iden
ce
48st
udie
sw
ere
asse
ssed
for
elig
ibili
ty,o
fwhi
ch11
wer
ein
clud
edin
the
qua
litat
ive
anal
ysis
;9o
fth
e11
wer
eex
clud
edo
win
gto
low
qua
lity
PIC
C,C
VC
,p
ort
PIC
Cs
are
com
mo
nly
used
ino
nco
log
y;ho
wev
erth
eq
ualit
yo
fthe
evid
ence
sup
po
rtin
gus
eo
fthe
sed
evic
esis
limite
dJo
hans
son
etal
,201
3(1
58)
23o
nco
log
yd
epar
tmen
tsSu
rvey
-bas
edst
udy
Nat
iona
lsur
vey
toex
amin
eus
eo
fPIC
Cs
inad
ulto
nco
log
yd
epar
tmen
tsin
Swed
enH
ead
so
f23
adul
tonc
olo
gy
dep
artm
ents
inSw
eden
PIC
CTw
enty
-tw
oo
f23
site
sre
spo
nded
(96%
).V
ascu
lar
nurs
esm
ost
oft
enp
lace
dPI
CC
sw
ithU
Sin
mo
stsi
tes;
9o
f16
site
sre
po
rted
havi
ngsp
ecifi
cin
dic
atio
nsfo
rty
pe
ofd
evic
eus
ed;o
neth
ird
ofd
epar
tmen
tsd
idno
tp
lace
PIC
Cs
Con
tinue
don
follo
win
gp
age
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S30 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
Downloaded From: http://annals.org/ by a Ebling Library Information Research User on 10/08/2015
Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
John
sto
net
al,2
012
(159
)10
2R
and
om
ized
tria
lTe
stw
heth
erPI
CC
valv
ete
chno
log
yin
fluen
ces
rate
ofo
cclu
sio
n10
2IC
Up
atie
nts
who
rece
ived
PIC
Cs
wer
era
ndo
mly
assi
gne
dto
rece
ive
to1
of3
diff
eren
tPI
CC
sin
asi
ngle
hosp
ital
PIC
CTh
est
udy
was
term
inat
edea
rly
bec
ause
of4
epis
od
eso
fhem
oly
sis
inb
loo
dsa
mp
les
take
nfr
om
asi
ngle
typ
eo
fPIC
C;v
alve
dPI
CC
sd
idno
tsee
mto
influ
ence
rate
so
fPI
CC
occ
lusi
on
on
the
bas
iso
fava
ilab
led
ata
Jone
set
al,2
010
(160
)10
1Pr
osp
ectiv
eco
hort
stud
yD
eter
min
efa
cto
rsas
soci
ated
with
,and
rate
so
fres
olu
tion
afte
r,ca
thet
er-a
sso
ciat
edU
EDV
T
Sym
pto
mat
icp
atie
nts
po
sitiv
efo
rU
EDV
Taf
ter
und
erg
oin
gd
uple
xU
Sfr
om
Janu
ary
2001
toJu
ne20
06at
1m
edic
alce
nter
CV
CC
athe
ter-
asso
ciat
edU
EDV
Tm
ayre
solv
eif
the
cath
eter
isre
mo
ved
with
in48
hour
so
fd
iag
nosi
s;C
VC
rein
sert
ion
isas
soci
ated
with
ahi
gh
rate
ofU
EDV
Tre
gar
dle
sso
fan
tico
agul
atio
nK
alle
net
al,2
010
(161
)N
AR
evie
wEm
pha
size
the
imp
ort
ance
ofp
reve
ntio
nan
dre
duc
tion
ofC
LAB
SIo
utsi
de
the
ICU
inhe
alth
care
faci
litie
s
Shed
slig
hto
nth
ech
ang
ing
epid
emio
log
yo
fC
VC
s,w
ithm
any
dev
ices
now
bei
ngfo
und
out
sid
eth
eIC
U;t
heau
tho
rsca
llfo
rat
tent
ion
toC
LAB
SIo
utsi
de
the
ICU
PIC
C,C
VC
Imp
rove
men
tofe
pid
emio
log
icp
ract
ices
toin
clud
eno
n-IC
Usi
tes
isne
eded
tom
oni
tor
and
red
uce
rate
so
fCLA
BSI
Kel
ly,2
013
(162
)N
AR
evie
wA
gui
de
tohe
lpp
ract
itio
ners
safe
tyin
sert
VA
Ds
and
red
uce
com
plic
atio
nsFo
cuse
so
np
rovi
din
gup
-to
-dat
ekn
ow
led
ge
and
evid
ence
rela
ted
toPI
CC
inse
rtio
n,us
e,an
do
utco
mes
PIC
CPr
actit
ione
rssh
oul
dha
veac
cess
totr
aini
ngp
rog
ram
sth
atar
ed
esig
ned
tom
inim
ize
risk
and
imp
rove
pat
ient
safe
ty;k
now
led
ge
of
anat
om
yan
dp
hysi
olo
gy
can
help
red
uce
PIC
C-r
elat
edco
mp
licat
ions
Kin
get
al,2
006
(163
)12
96C
ase–
cont
rols
tud
yEv
alua
tecl
inic
alco
nditi
ons
and
ther
apie
sas
soci
ated
with
incr
ease
dri
skfo
rPI
CC
-rel
ated
DV
T
Patie
nts
who
und
erw
entP
ICC
pla
cem
enta
t1ho
spita
love
r3
year
sPI
CC
The
ove
rall
inci
den
ceo
fPIC
C-r
elat
edD
VT
was
2%.P
atie
nts
with
canc
erw
ere
2.5
times
mo
relik
ely
tod
evel
op
PIC
C-r
elat
edD
VT;
pro
phy
lact
ican
tico
agul
atio
nd
idno
tlo
wer
this
risk
Lam
per
tiet
al,2
012
(164
)N
ASy
stem
atic
revi
ewIn
tern
atio
nalp
anel
reco
mm
end
atio
nso
nU
S-g
uid
edva
scul
arac
cess
Stud
ies
pub
lishe
db
etw
een
1985
and
2010
wer
ein
clud
ed;t
heG
RA
DE
and
GR
AD
E–R
AN
Dm
etho
ds
wer
eus
edfo
rre
com
men
dat
ions
CV
C,P
IVC
US
use
issa
fe,e
ffect
ive,
and
nece
ssar
yw
hen
inse
rtin
gC
VC
san
dar
teri
alca
thet
ers
Lath
amet
al,2
013
(165
)10
Invi
tro
and
invi
voD
eter
min
eth
eeq
uiva
lenc
yo
fhem
od
ynam
icp
ress
ure
mea
sure
men
tsfr
om
PIC
Cs
vs.
CV
Cs
Med
ical
ICU
pat
ient
sin
anac
adem
icho
spita
lwith
bo
tha
PIC
Can
dC
VC
inp
lace
PIC
C,C
VC
PIC
Cs
are
equi
vale
ntto
CV
Cs
whe
nst
atic
and
dyn
amic
pre
ssur
ein
vitr
ow
ere
mea
sure
din
ase
lect
edco
hort
ofI
CU
pat
ient
sLe
eet
al,2
006
(55)
444
Pro
spec
tive
coho
rtst
udy
Exam
ine
the
inci
den
ce,r
isk
fact
ors
,and
long
-ter
mco
mp
licat
ions
asso
ciat
edw
ithC
VC
use
inp
atie
nts
with
canc
er
Co
nsec
utiv
ep
atie
nts
with
canc
erw
houn
der
wen
tC
VC
inse
rtio
nat
1m
edic
alce
nter
inC
anad
aC
VC
His
tory
ofp
rio
rC
VC
inse
rtio
nw
asas
soci
ated
with
gre
ater
risk
for
sub
seq
uent
thro
mb
osi
s
Lee,
2008
(79)
NA
Rev
iew
Cur
rent
stan
dar
ds
ofp
ract
ice
for
dia
gno
sis,
pre
vent
ion,
and
trea
tmen
tofV
TEin
canc
erp
atie
nts
Nar
rativ
ere
view
CV
C,P
ICC
,p
ort
Patie
nts
with
canc
erar
ea
uniq
uesu
bse
twith
reg
ard
toth
rom
bo
sis;
cons
ider
atio
no
fthe
risk
for
DV
Tin
rela
tion
tod
evic
ety
pe
isne
cess
ary
Lelk
eset
al,2
013
(166
)38
4R
etro
spec
tive
coho
rtst
udy
Eval
uate
the
effic
acy
ofe
lect
rom
agne
ticd
etec
tion
via
the
Sher
lock
IIsy
stem
for
op
timal
PIC
Cp
osi
tioni
ng
384
pat
ient
sw
houn
der
wen
tbed
sid
ePI
CC
pla
cem
entu
sing
the
Sher
lock
IItip
loca
tion
syst
em
PIC
C97
.7%
ofp
atie
nts
who
und
erw
entp
lace
men
tha
da
cath
eter
tipth
atw
asd
eem
edap
pro
pri
atel
yp
osi
tione
do
nfo
llow
-up
ches
tra
dio
gra
phy
Lero
yer
etal
,201
3(1
67)
222
Pro
spec
tive
coho
rtst
udy
Rep
ort
com
plic
atio
nsaf
ter
PIC
Cp
lace
men
tin
aFr
ench
teac
hing
hosp
ital
Patie
nts
havi
ngun
der
go
nePI
CC
pla
cem
enti
nIR
ata
teac
hing
hosp
itali
nB
ord
eaux
,Fra
nce
PIC
CPI
CC
sw
ere
asso
ciat
edw
ithse
vera
lco
mp
licat
ions
incl
udin
go
bst
ruct
ion
(20.
5%),
DV
T(2
.5%
),an
din
fect
ion
(10%
);34
%o
fPI
CC
sw
ere
rem
ove
do
win
gto
com
plic
atio
nsLe
ung
etal
,200
6(1
68)
120
Ret
rosp
ectiv
eco
hort
stud
yR
evie
win
dic
atio
nsfo
rPI
CC
inse
rtio
n,d
wel
ltim
e,an
dre
mo
vali
nC
hine
sep
atie
nts
soas
tod
eter
min
ete
chni
calr
equi
rem
ents
for
new
cath
eter
s
Patie
nts
who
rece
ived
fluo
rosc
op
ical
lyg
uid
edPI
CC
into
dis
tals
uper
ior
vena
cava
via
the
ante
cub
italr
egio
no
fthe
fore
arm
PIC
CO
ozi
ng,p
hleb
itis,
and
occ
lusi
on
oft
eno
ccur
red
inp
atie
nts
with
thro
mb
ocy
top
enia
and
leuk
emia
;dev
ices
that
pre
vent
pla
tele
tco
nsum
ptio
nm
ayb
eva
luab
lein
pre
vent
ing
thes
ety
pes
ofe
vent
sLe
ung
etal
,201
1(1
4)27
6R
etro
spec
tive
coho
rtst
udy
Eval
uate
fact
ors
asso
ciat
edw
ithPI
CC
failu
reb
yco
mp
arin
gp
erio
ds
afte
rth
ero
llout
of
nurs
ing
care
imp
rove
men
ts
Patie
nts
with
med
ical
reco
rds
who
und
erw
ent
silic
one
-rub
ber
–co
nstr
ucte
d4-
Fren
chsi
ngle
-lum
enPI
CC
sin
Taip
ei,C
hina
PIC
CA
fter
nurs
ing
educ
atio
n–b
ased
inte
rven
tions
,co
mp
licat
ions
such
aso
ozi
ng,w
oun
dle
akag
e,an
dp
hleb
itis
wer
ere
duc
edLi
etal
,201
4(1
3)10
0R
CT
Co
mp
are
the
effe
cts
ofP
ICC
pla
cem
ent
usin
gB
-mo
de
US
with
mo
difi
edSe
ldin
ger
tech
niq
uevs
.blin
din
sert
ion
100
pat
ient
sun
der
go
ing
chem
oth
erap
yw
ere
recr
uite
dan
dra
ndo
mly
assi
gne
dto
blin
dvs
.g
uid
edp
lace
men
tgro
up
PIC
CB
-mo
de
US
with
mo
difi
edSe
ldin
ger
tech
niq
uere
duc
edco
mp
licat
ions
and
pat
ient
cost
sco
mp
ared
with
the
blin
dap
pro
ach
Liu
etal
,201
4(3
9)N
ASy
stem
atic
revi
ewEx
amin
eth
eef
ficac
yo
fUS
gui
dan
cefo
rth
ep
lace
men
tofP
IVC
sPa
tient
sw
ithd
ifficu
ltPI
VC
acce
ssPI
VC
Ro
utin
eus
eo
fPIV
Cg
uid
ance
with
US
isno
tst
rong
lysu
pp
ort
edb
yth
elit
erat
ure;
use
of
this
tech
nolo
gy
sho
uld
be
rese
rved
for
pro
vid
ers
who
are
adeq
uate
lytr
aine
dun
der
app
rop
riat
eco
nditi
ons
Con
tinue
don
follo
win
gp
age
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S31
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Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Lob
oet
al,2
009
(7)
777
Ret
rosp
ectiv
eco
hort
stud
yA
sses
sri
skfo
rV
Tin
gen
eral
hosp
italiz
edp
atie
nts
who
rece
ived
PIC
Cs
Patie
nts
who
rece
ived
aPI
CC
whi
leho
spita
lized
ata
sing
lefa
cilit
yas
par
toft
heir
clin
icca
rePI
CC
The
inci
den
ceo
fPIC
C-r
elat
edD
VT
was
4.89
%;
PIC
Cs
that
did
nott
erm
inat
ein
the
SVC
had
a2.
61tim
esg
reat
erfo
rth
rom
bo
sis
than
tho
sein
this
area
.PIC
C-r
elat
edD
VT
was
10-f
old
gre
ater
inp
atie
nts
with
ahi
sto
ryo
fth
rom
bo
sis
Loup
uset
al,2
008
(169
)44
Ret
rosp
ectiv
eco
hort
stud
yR
epo
rtth
eri
skfo
rPI
CC
-rel
ated
DV
Tin
pat
ient
sw
ithce
rvic
alsp
ine
cord
inju
ries
com
par
edw
itho
ther
po
pul
atio
ns
Qua
dri
ple
gic
pat
ient
sw
ithPI
CC
sat
1m
edic
alce
nter
PIC
CTh
ein
cid
ence
ofP
ICC
-rel
ated
DV
Tw
as7.
1%p
erPI
CC
inse
rtio
nan
d9.
1%p
erp
erso
n
Mak
ieta
l,20
06(1
70)
NA
Syst
emat
icre
view
Defi
nean
dre
po
rtth
eri
skfo
rB
SIw
ithva
rio
usIV
Ds
200
stud
ies
rep
ort
ing
BSI
rate
sth
atw
ere
pro
spec
tive,
pub
lishe
d,a
ndin
clud
eda
dev
ice
ofi
nter
est
PIV
C,
mid
line
cath
eter
,C
VC
,PI
CC
Exp
ress
ing
BSI
per
1000
IVD
-day
sis
ab
ette
res
timat
eo
fris
k;al
ltyp
eso
fIV
Ds
po
sea
risk
for
BSI
.Dw
ellt
ime
isa
sig
nific
anta
spec
tof
risk
;ris
kfo
rB
SIva
ries
by
dev
ice
typ
e.
Mal
ino
skie
tal,
2013
(171
)18
4Pr
osp
ectiv
eco
hort
stud
yD
eter
min
ew
hich
CV
Cis
asso
ciat
edw
ithth
eg
reat
estr
isk
for
DV
Tin
surg
ical
criti
cal
care
pat
ient
s
Patie
nts
with
aC
VC
ina
surg
ical
ICU
at2
trau
ma
cent
ers
CV
C,P
ICC
CV
Cs
pla
ced
inth
ein
tern
alju
gul
arve
inan
dPI
CC
sp
lace
din
arm
vein
sha
dth
eg
reat
est
risk
for
cath
eter
-ass
oci
ated
DV
TM
arne
jon
etal
,201
2(1
72)
400
Cas
e–co
ntro
lstu
dy
Iden
tifica
tion
ofr
isk
fact
ors
asso
ciat
edw
ithPI
CC
-rel
ated
DV
Tb
yco
mp
arin
gca
ses
of
PIC
C-D
VT
toco
ntro
ls
Co
nsec
utiv
ep
atie
nts
with
and
with
out
DV
Taf
ter
PIC
Cin
sert
ion
at1
hosp
itali
nO
hio
PIC
CPa
tient
sw
itha
hist
ory
oft
raum
ao
rre
nal
failu
re,t
hose
with
had
left
-sid
edin
sert
ions
,an
dth
ose
who
rece
ived
vanc
om
ycin
wer
eat
gre
ater
risk
for
thro
mb
osi
sth
anco
ntro
lsM
arsc
hall
etal
,201
4(1
73)
NA
Gui
del
ine
Pro
vid
eev
iden
ce-b
ased
reco
mm
end
atio
nsto
assi
stac
ute
care
hosp
itals
inC
LAB
SIp
reve
ntio
n
Exp
ert-
gui
dan
ced
ocu
men
ttha
twas
spo
nso
red
by
mul
tiple
med
ical
soci
etie
sai
min
gto
iden
tify
bes
tpra
ctic
esto
pre
vent
CLA
BSI
CV
C,P
ICC
,p
ort
This
com
pen
diu
mo
fevi
den
ce-b
ased
stra
teg
ies
pro
vid
eske
yd
irec
tion
for
focu
sing
on
hig
h-ri
skp
op
ulat
ions
and
max
imiz
ing
stra
teg
ies
pro
ven
tore
duc
eri
skfo
rC
LAB
SIM
erm
elet
al,1
995
(40)
238
Pro
spec
tive
coho
rtst
udy
Eval
uate
risk
and
ben
efits
fro
mus
eo
f2m
idlin
eca
thet
ers
inth
eho
spita
lset
ting
238
pat
ient
sin
asi
ngle
med
ical
cent
erre
ceiv
ed25
1m
idlin
eca
thet
ers
toas
sess
the
risk
asso
ciat
edw
ithus
eo
fthi
sd
evic
ein
hosp
italiz
edp
atie
nts
Mid
line
cath
eter
The
mea
nd
urat
ion
ofm
idlin
eca
thet
erus
ew
as9
d,a
ndth
eo
vera
llri
skfo
rC
RB
SIw
as0.
8p
er10
00ca
thet
er-d
ays;
2se
vere
unex
pec
ted
reac
tions
occ
urre
dd
urin
gth
est
udy
that
may
have
bee
nre
late
dto
ap
artic
ular
mid
line
cath
eter
man
ufac
ture
ran
d/o
rca
thet
erm
ater
ial
Mer
mis
etal
,201
4(1
74)
117
Ret
rosp
ectiv
eco
hort
stud
yA
sses
sp
ote
ntia
lris
kfa
cto
rsfo
rsy
mp
tom
atic
PIC
C-r
elat
edD
VT
and
imp
lem
enta
QI
pro
ject
tore
duc
ePI
CC
-rel
ated
DV
Tin
pat
ient
sw
ithcy
stic
fibro
sis
Ad
ultp
atie
nts
with
cyst
icfib
rosi
sw
hore
ceiv
eda
PIC
Cb
etw
een
July
2006
toM
arch
2013
PIC
CQ
Istr
ateg
ies
that
focu
so
nus
ing
smal
ler-
dia
met
er4-
Fren
chPI
CC
san
dav
oid
ing
PIC
Cs
inhi
gh-
risk
pat
ient
sar
elik
ely
tom
eetw
ithsu
cces
sin
pat
ient
sw
ithC
FM
erre
llet
al,1
994
(175
)46
0Pr
osp
ectiv
eco
hort
stud
yEv
alua
teth
eus
eo
fPIC
Cs
for
ong
oin
gve
nous
acce
ssin
gen
eral
med
ical
and
surg
ical
pat
ient
sin
aV
Am
edic
alce
nter
Gen
eral
and
surg
ical
pat
ient
sw
ithPI
CC
sin
aV
Am
edic
alce
nter
bet
wee
n19
85an
d19
88;
inse
rtio
nw
asd
one
by
trai
ned
nurs
es
PIC
CPI
CC
sw
ere
asso
ciat
edw
itha
mea
nd
urat
ion
of
use
of2
7d
.Co
mp
licat
ions
,inc
lud
ing
phl
ebiti
s,b
acte
rem
ia,m
echa
nica
lfai
lure
,an
dlo
cali
nfec
tion,
wer
eun
com
mo
nM
eyer
,201
1(1
76)
1307
Ret
rosp
ectiv
eco
hort
stud
yEv
alua
teth
eef
fect
iven
ess
ofc
linic
alp
ract
ice
chan
ges
tore
duc
ePI
CC
-rel
ated
thro
mb
osi
s
Patie
nts
who
und
erw
entP
ICC
inse
rtio
nat
Duk
eU
nive
rsity
Med
ical
Cen
ter
for
vari
ous
clin
ical
ind
icat
ions
PIC
CPr
actic
esfo
rre
duc
tion
ofP
ICC
-rel
ated
DV
Tin
clud
edU
Sg
uid
ance
and
veri
ficat
ion
oft
iplo
catio
n;ro
utin
em
easu
rem
ento
fvei
nd
iam
eter
sal
sop
rove
dhe
lpfu
lin
red
ucin
gth
rom
bo
sis
risk
Mey
er,2
012
(3)
NA
Rev
iew
Exp
lore
the
effe
cto
fan
alte
rnat
ive
wo
rkflo
w,
incl
udin
ga
cent
raliz
edp
roce
dur
ero
om
Patie
nts
who
und
erw
entP
ICC
inse
rtio
nat
Duk
eU
nive
rsity
Med
ical
Cen
ter
for
vari
ous
clin
ical
ind
icat
ions
PIC
CC
entr
aliz
ing
PIC
Co
per
atio
nsin
med
ical
faci
litie
sis
anef
ficie
ntm
od
elfo
rd
evic
ep
lace
men
t,im
pro
ved
nurs
ing
pro
duc
tivity
and
wo
rkcu
lture
,and
dec
reas
edp
atie
ntca
red
elay
sM
ilsto
nean
dSe
ngup
ta,
2010
(177
)N
AR
evie
wEx
amin
eth
ere
latio
nshi
pb
etw
een
PIC
Cd
wel
ltim
ean
dC
LAB
SIri
sk,a
sw
ella
sst
rate
gie
ssu
chas
cath
eter
rep
lace
men
tto
pre
vent
CLA
BSI
Nar
rativ
ere
view
PIC
CTh
eha
zard
risk
for
CLA
BSI
with
PIC
Cs
isno
nlin
ear
but
cons
tant
lyin
crea
sing
ove
rtim
e;re
pla
cem
ento
fPIC
Cs
asa
stra
teg
yto
pre
vent
CLA
BSI
cann
otb
ere
com
men
ded
on
the
bas
iso
fava
ilab
led
ata
Min
kovi
chet
al,2
011
(178
)26
9R
etro
spec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
cean
dri
skfa
cto
rsas
soci
ated
with
PIC
Cm
alp
osi
tion
inp
atie
nts
with
head
and
neck
canc
erw
how
ere
und
erg
oin
gsu
rger
y
Patie
nts
und
erg
oin
gfr
eefla
pre
cons
truc
tive
surg
ery
for
head
and
neck
canc
erat
1ac
adem
icm
edic
alce
nter
PIC
CPI
CC
sin
sert
edw
itho
utim
agin
gg
uid
ance
wer
em
ore
com
mo
nly
asso
ciat
edw
ithm
alp
osi
tioni
ng;l
eft-
sid
edPI
CC
sha
da
low
erri
skfo
rm
alp
osi
tioni
ngM
iyag
akie
tal,
2012
(179
)26
RC
TC
om
par
eth
ep
erfo
rman
ceo
f2m
ajo
rPI
CC
sw
ithd
iffer
entm
ater
iala
ndtip
des
ign
Patie
nts
und
erg
oin
gg
astr
oin
test
inal
surg
ery
who
und
erw
entP
ICC
pla
cem
entb
etw
een
Aug
ust
2010
and
Dec
emb
er20
10at
1fa
cilit
yin
Osa
ka,
Jap
an
PIC
CN
od
iffer
ence
ind
urab
ility
and
com
plic
atio
nsb
etw
een
the
Gro
sho
ng(w
ithd
ista
lsid
esl
its)
and
po
lyur
etha
neca
thet
er(w
itho
pen
-end
edtip
)was
note
dM
olle
eet
al,2
011
(52)
727
Pro
spec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
ceo
fand
risk
fact
ors
for
CLA
BSI
inp
atie
nts
with
canc
erA
dul
tsw
houn
der
wen
tCV
Cp
lace
men
tin
one
hem
ato
log
y–o
nco
log
yun
itin
Aus
tral
iaPI
CC
,CV
C,
tunn
eled
cath
eter
No
ntun
nele
dan
dtu
nnel
edca
thet
ers
had
gre
ater
risk
for
CLA
BSI
than
PIC
Cs
(od
ds
ratio
,3.5
5an
d1.
77,r
esp
ectiv
ely)
Con
tinue
don
follo
win
gp
age
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S32 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
Downloaded From: http://annals.org/ by a Ebling Library Information Research User on 10/08/2015
Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Mo
rden
etal
,201
4(1
80)
NA
Invi
tro
Det
erm
ine
the
rate
and
caus
eo
fd
isp
lace
men
tofC
Tp
ow
er-in
ject
able
PIC
Cs
dur
ing
cont
rast
mat
eria
land
salin
eflu
shin
ject
ion
Inth
ela
bo
rato
ryse
ttin
g,i
nvi
tro
mo
del
ing
of
CT-
ind
uced
PIC
Cd
isp
lace
men
twas
exam
ined
whi
leva
ryin
gra
tes
and
natu
reo
fpo
wer
inje
ctio
n
PIC
CH
ighe
rra
tes
ofs
alin
eflu
shw
ere
asso
ciat
edw
ithg
reat
erm
ove
men
tso
fthe
PIC
Ctip
Mo
urea
uet
al,2
002
(181
)50
470
Ret
rosp
ectiv
eco
hort
stud
yD
ocu
men
tthe
natu
ralh
isto
ryo
fCV
Cs
and
det
erm
ine
the
rate
ofc
om
plic
atio
nsin
pat
ient
sre
ceiv
ing
hom
ein
fusi
ons
Patie
nts
who
und
erw
enth
om
ein
fusi
on
care
and
pla
cem
ento
faC
VC
PIC
C,C
VC
,m
idlin
eca
thet
er,
po
rt,
tunn
eled
cath
eter
Cat
hete
rd
ysfu
nctio
nis
alm
ost
twic
eas
likel
yas
infe
ctio
nin
this
po
pul
atio
n;th
isre
sults
ind
elay
sin
ther
apy,
reho
spita
lizat
ions
,and
dev
ice
rep
lace
men
t
Mo
urea
uet
al,2
013
(89)
NA
Gui
del
ines
Stan
dar
diz
ed
efini
tions
ofa
ndre
com
men
dat
ions
for
trai
ning
and
inse
rtio
no
fCV
AD
sb
yth
eW
orl
dC
ong
ress
ofV
ascu
lar
Acc
ess
Co
nsen
sus
ofa
nex
per
tpan
elto
dev
elo
pm
inim
alcr
iteri
afo
rtr
aini
ngan
dce
rtifi
catio
no
fcat
hete
rp
lace
men
ts
CV
C,P
ICC
Ag
lob
alra
ting
scal
era
ther
than
num
ber
of
pro
ced
ures
per
form
edsh
oul
db
eus
edto
det
erm
ine
clin
ical
com
pet
ence
;st
and
ard
ized
educ
atio
n,si
mul
atio
ns,a
ndsu
per
vise
din
sert
ions
are
reco
mm
end
edfo
ro
per
ato
rsp
laci
ngth
ese
dev
ices
Muk
herj
eeet
al,2
001
(182
)38
5PI
CC
sR
etro
spec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
ceo
fand
risk
fact
ors
for
CR
Tin
pat
ient
sw
ithg
astr
oin
test
inal
canc
er
All
PIC
Cin
sert
ions
bet
wee
nJu
ne19
99an
dM
ay20
00,f
oun
din
the
PIC
Cre
gis
ter
in1
hosp
itali
nth
eU
nite
dK
ing
do
m
PIC
CTh
eo
vera
llra
teo
fthr
om
bo
sis
was
5.2%
.B
ecau
seo
fthe
risk
for
ble
edin
g,
antic
oag
ulat
ion
was
notd
eem
edw
ise
inth
isse
ttin
g.F
utur
est
udie
sex
amin
ing
upp
ervs
.lo
wer
gas
tro
inte
stin
altr
actt
umo
rsar
ene
eded
Nas
het
al,2
009
(183
)52
4R
etro
spec
tive
coho
rtst
udy
Det
erm
ine
inci
den
ceo
fPIC
C-r
elat
edD
VT
inp
atie
nts
with
and
with
out
Bur
khol
der
iace
pac
iaco
mp
lex
infe
ctio
n;in
vest
igat
eas
soci
atio
nb
etw
een
PIC
C-r
elat
edD
VT
and
eryt
hro
cyte
sed
imen
tatio
nra
te
Patie
nts
with
cyst
icfib
rosi
sw
houn
der
wen
tPIC
Cin
sert
ion
ata
sing
lein
stitu
tion
ove
r6
yPI
CC
Patie
nts
with
B.c
epac
iaco
mp
lex
had
ahi
ghe
rin
cid
ence
ofD
VT;
hig
her
eryt
hro
cyte
sed
imen
tatio
nra
tes
inp
atie
nts
with
PIC
C-r
elat
edD
VT
may
sug
ges
ttha
tin
flam
mat
ion
isa
risk
fact
or
for
sub
seq
uent
thro
mb
osi
sN
atio
nalK
idne
yFo
und
atio
n,20
02(4
8)N
AG
uid
elin
esD
efine
the
app
roac
hto
dia
gno
sis,
eval
uatio
n,m
anag
emen
tand
veno
usac
cess
inp
atie
nts
with
CK
D
NA
PIC
C,C
VC
,sm
all-
bo
reca
thet
ers
Use
ofP
ICC
sis
notr
eco
mm
end
edin
pat
ient
sw
ithad
vanc
edo
rp
rog
ress
ive
rena
lin
suffi
cien
cy
Nat
iona
lKid
ney
Foun
dat
ion,
2013
(44)
NA
Gui
del
ines
Up
dat
eto
the
earl
ier
gui
del
ines
top
rovi
de
reco
mm
end
atio
nso
nd
iag
nosi
s,ev
alua
tion,
man
agem
ent,
and
veno
usac
cess
inp
atie
nts
with
CK
D
NA
PIC
C,C
VC
,sm
all-
bo
reca
thet
ers
Ven
ous
pre
serv
atio
nfo
rfis
tula
pla
cem
enti
sa
corn
erst
one
ofm
anag
ing
pat
ient
sw
ithC
KD
Nifo
ngan
dM
cDev
itt,
2011
(184
)N
AIn
vitr
oex
per
imen
tal
stud
yC
alcu
late
dre
lativ
eflo
wra
tes
asre
late
dto
the
ratio
oft
heca
thet
erto
vein
dia
met
erSi
mul
atio
nst
udy
that
exam
ined
risk
for
thro
mb
osi
sin
rela
tion
tocr
oss
-sec
tiona
lves
seld
iam
eter
PIC
CPI
CC
sm
ayd
ecre
ase
veno
usflo
wra
tes
by
asm
uch
as93
%b
yo
ccup
ying
muc
ho
fthe
lum
inal
dia
met
er.U
sing
the
smal
lest
-gau
ge
cath
eter
may
pre
vent
veno
usst
asis
and
red
uce
risk
for
DV
TN
uno
oet
al,2
011
(185
)16
48Pr
osp
ectiv
eco
hort
stud
yIn
vest
igat
eth
eco
ntri
but
ion
ofP
ICC
sto
VTE
rate
sin
pat
ient
sun
der
go
ing
colo
nic
rese
ctio
n
Patie
nts
who
und
erw
entm
ajo
rb
ow
elre
sect
ion
ove
r3
yin
asi
ngle
hosp
itals
yste
mPI
CC
Patie
nts
with
PIC
Cs
wer
e11
times
mo
relik
ely
tod
evel
op
sub
seq
uent
VTE
O'B
rien
etal
,201
3(7
5)13
28Q
uasi
-exp
erim
enta
lb
efo
re–a
fter
stud
yA
dd
ress
the
freq
uenc
yo
fina
pp
rop
riat
eve
nous
cath
eter
use
and
effe
cto
faQ
Ip
rog
ram
tore
duc
ePI
CC
lum
ens
Patie
nts
rece
ivin
gC
VC
sat
McG
illU
nive
rsity
Hea
lthC
ente
rfr
om
May
2011
toJa
nuar
y20
12PI
CC
Aho
spita
l-wid
eef
fort
tod
ecre
ase
the
inse
rtio
no
fmul
tilum
enPI
CC
sw
itho
utan
app
rop
riat
era
tiona
lere
sulte
din
dec
reas
edco
sts
and
com
plic
atio
nsfr
om
PIC
Cs
O'G
rad
yan
dC
hert
ow
,20
11(1
86)
NA
Rev
iew
Rev
iew
for
dia
gno
sis,
man
agem
ent,
and
trea
tmen
tofC
LAB
SIo
utsi
de
the
ICU
spec
ifica
llyd
irec
ted
tow
ard
sno
n–cr
itica
lca
rep
rovi
der
s
Det
ectio
n,su
rvei
llanc
e,an
dm
anag
emen
tof
CLA
BSI
out
sid
eIC
Us
isch
alle
ngin
gan
dm
ayre
qui
reun
ique
and
nove
lap
pro
ache
sas
com
par
edto
the
ICU
sett
ing
CV
C,P
ICC
Infe
ctio
usd
isea
sesp
ecia
lists
sho
uld
be
cons
ulte
dw
hen
nece
ssar
y;in
put
reg
ard
ing
reta
inin
go
rre
mo
ving
the
cath
eter
and
typ
eo
fant
ibio
ticth
erap
yar
eke
yto
ensu
ring
safe
out
com
esO
liver
and
Jone
s,20
14(1
87)
NA
Rev
iew
Det
erm
ine
whe
ther
EKG
-gui
ded
PIC
Cp
lace
men
tis
the
pre
fera
ble
met
hod
for
PIC
Cp
osi
tioni
ng
Nar
rativ
ere
view
oft
helit
erat
ure
that
sum
mar
izes
avai
lab
leev
iden
cefo
rEK
G-g
uid
edp
lace
men
tPI
CC
,CV
CB
estp
ract
ices
and
reco
mm
end
atio
nssh
oul
db
ees
tab
lishe
dto
use
EKG
asa
go
ldst
and
ard
for
chec
king
CV
Cp
lace
men
tO
nget
al,2
006
(188
)31
7R
etro
spec
tive
coho
rtst
udy
Det
erm
ine
the
freq
uenc
yan
dri
skfa
cto
rsfo
rPI
CC
-rel
ated
DV
Tat
1m
edic
alce
nter
Sym
pto
mat
icp
atie
nts
with
ap
osi
tive
upp
er-e
xtre
mity
veno
usd
uple
xsc
ano
ver
3y
wer
ere
view
edto
det
erm
ine
risk
fact
ors
asso
ciat
edw
ithU
EDV
T
PIC
CPa
tient
sw
ithPI
CC
s,th
ose
rece
ivin
gch
emo
ther
apy,
and
tho
sew
ithca
ncer
wer
em
ost
likel
yto
exp
erie
nce
DV
T
Paau
wet
al,2
008
(189
)56
Pro
spec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
ceo
fPIC
C-a
sso
ciat
edD
VT
with
and
with
out
pro
phy
lact
ican
tico
agul
ants
Inp
atie
nts
with
PIC
Cs
used
for
par
ente
raln
utri
tion
or
antib
iotic
sat
1m
edic
alce
nter
PIC
CPr
op
hyla
xis
for
DV
Tw
ithhe
par
inan
dLM
WH
was
asso
ciat
edw
itha
low
erra
teo
fDV
Tin
pat
ient
sw
ithPI
CC
s,al
tho
ugh
thes
ere
sults
wer
eno
tad
just
edfo
rco
nfo
und
ers
Pari
etal
,201
1(1
90)
70Pr
osp
ectiv
eco
hort
stud
yIn
itial
app
licat
ion
and
resu
ltso
fim
ple
men
tatio
no
facl
inic
alp
athw
ayto
cho
ose
the
bes
tven
ous
acce
ssfo
rin
div
idua
lpat
ient
s
Patie
nts
with
PIC
Cs
inse
rted
thro
ugh
the
new
'Sha
red
Clin
ical
Path
way
'to
ola
t1ca
ncer
cent
erPI
CC
Use
oft
hep
athw
ayim
pro
ved
pat
ient
qua
lity
of
life,
dec
reas
edco
sts,
and
imp
rove
dw
ork
flow C
ontin
ued
onfo
llow
ing
pag
e
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S33
Downloaded From: http://annals.org/ by a Ebling Library Information Research User on 10/08/2015
Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Pate
leta
l,20
07(1
91)
1788
Ret
rosp
ectiv
eco
hort
stud
yD
eter
min
ew
heth
erth
eus
eo
fop
en-e
nded
PIC
Cs
for
inva
sive
mo
nito
ring
can
dec
reas
eth
eri
skfo
rC
LAB
SI
Patie
nts
bef
ore
and
afte
rth
ein
tro
duc
tion
ofa
hem
od
ynam
icm
oni
tori
ngw
ithPI
CC
sin
acl
ose
dm
edic
al–s
urg
ical
ICU
atan
acad
emic
med
ical
cent
er
PIC
CO
pen
-end
edPI
CC
sm
ayb
eas
soci
ated
with
ash
ort
erca
thet
erd
wel
ltim
e,re
duc
edB
SIs,
and
ano
vera
lld
ecre
ase
inan
tibio
ticus
e
Pate
leta
l,20
14(1
92)
70R
CT
Co
mp
are
the
safe
tyan
dco
sto
fPIC
Cs
vs.
po
rts
used
tod
eliv
erch
emo
ther
apy
Patie
nts
with
nonh
emat
olo
gic
canc
erre
ceiv
ing
chem
oth
erap
yei
ther
thro
ugh
aPI
CC
or
ap
ort
PIC
C,p
ort
Port
sw
ere
asso
ciat
edw
itha
low
erri
skfo
rco
mp
licat
ions
inth
isp
op
ulat
ion;
ther
ew
asno
diff
eren
cein
cost
usin
ga
PIC
Cvs
.po
rtap
pro
ach
Paz-
Fum
agal
liet
al,
1997
(193
)11
3Pr
osp
ectiv
eco
hort
stud
yIn
vest
igat
eth
eef
fect
ofP
ICC
pla
cem
enti
np
atie
nts
with
spin
alco
rdin
jury
who
wer
eat
hig
hri
skfo
rin
fusi
on
phl
ebiti
s
All
pat
ient
sw
itha
spin
alco
rdin
jury
and
ap
erip
hera
lIV
fro
mJu
ly19
93to
Dec
emb
er19
94w
how
ere
eval
uate
dat
leas
tonc
eb
yth
enu
rsin
gIV
team
PIC
C,C
VC
Alth
oug
hth
eyw
ere
asso
ciat
edw
ithD
VT,
PIC
Cus
ew
asas
soci
ated
with
are
duc
edri
skfo
rp
hleb
itis
Penn
ey-T
imm
ons
and
Seve
dg
e,20
04(1
94)
NA
Ret
rosp
ectiv
eco
hort
stud
yEv
alua
teo
utco
me
dat
afo
rPI
CC
sp
lace
din
hosp
italiz
edp
atie
nts,
by
usin
gan
exis
ting
dat
ase
t
Ho
spita
lized
pat
ient
sw
ithPI
CC
sPI
CC
Co
mp
licat
ions
,inc
lud
ing
exit-
site
and
BSI
s,p
hleb
itis,
and
thro
mb
osi
s,o
ccur
red
freq
uent
lyin
this
po
pul
atio
n;ch
ang
esin
nurs
ing
pra
ctic
ein
form
edb
yac
cum
ulat
ing
evid
ence
help
edd
ecre
ase
the
risk
for
thes
eev
ents
Peri
ard
etal
,200
8(1
95)
60R
CT
Co
mp
are
the
safe
ty,e
ffica
cy,a
ndco
st-e
ffect
iven
ess
ofP
ICC
sto
PIV
Cs
Ho
spita
lized
pat
ient
sre
qui
ring
IVth
erap
yfo
r≥
5d
ays
wer
era
ndo
mly
assi
gne
dto
rece
ive
eith
erPI
CC
so
rPI
VC
sin
this
sing
le-c
ente
rst
udy
PIV
C,P
ICC
PIC
Cs
are
effic
ient
for
hosp
italiz
edp
atie
nts
req
uiri
ngIV
ther
apy
for
≥5
dho
wev
er,r
isk
for
asym
pto
mat
icD
VT
may
be
hig
her
than
pre
vio
usly
rep
ort
edin
per
sons
who
rece
ive
PIC
Cs
Peri
ard
,201
0(1
96)
NA
Rev
iew
Rev
iew
oft
here
latio
nshi
pb
etw
een
inse
rtio
nsi
tean
dri
skfo
rth
rom
bo
sis
inp
atie
nts
with
canc
er
Patie
nts
with
leuk
emia
and
PIC
Cs
pla
ced
atd
iffer
ents
ites
PIC
CSt
udie
ssu
gg
estt
here
may
be
anas
soci
atio
nb
etw
een
PIC
Cp
lace
men
tand
thro
mb
osi
sri
sk;s
mal
ler
PIC
Cs
inse
rted
into
larg
erve
ins
are
leas
tlik
ely
tod
evel
op
thro
mb
osi
sPe
tree
etal
,201
2(1
97)
NA
Syst
emat
icre
view
Det
erm
ine
effe
ctiv
em
etho
ds
for
heal
thca
rep
rovi
der
sto
red
uce
PIC
C-r
elat
edB
SId
urin
gd
evic
ein
sert
ion
Eval
uate
and
rep
ort
on
pra
ctic
esat
the
time
of
inse
rtio
nth
atm
ayre
duc
eth
eri
skfo
rC
LAB
SIin
hosp
italiz
edp
atie
nts
PIC
CC
ont
inui
nged
ucat
ion
isle
ssex
pen
sive
than
the
cost
ofC
LAB
SI;n
eed
lele
ssco
nnec
tors
,p
osi
tive-
pre
ssur
eva
lves
,and
pro
per
secu
rem
entw
ithan
cho
ring
dev
ices
wer
em
ost
effe
ctiv
ein
red
ucin
gC
LAB
SIPi
kwer
etal
,201
2(1
2)N
ASy
stem
atic
revi
ewEx
amin
eri
sks
and
com
plic
atio
nsas
soci
ated
with
cent
ralv
s.p
erip
hera
lro
utes
for
cent
ralv
eno
usca
nnul
atio
n
Co
mp
are
risk
sas
soci
ated
with
PIC
Cs
with
tho
seo
ftr
aditi
ona
lCV
Cs
PIC
C,C
VC
Cat
hete
rtip
mal
po
sitio
ning
,thr
om
bo
phl
ebiti
s,an
dca
thet
erd
ysfu
nctio
no
ccur
red
mo
refr
eque
ntly
with
PIC
Cs
than
CV
Cs.
No
diff
eren
cein
rate
so
finf
ectio
nb
etw
een
CV
Cs
and
PIC
Cs
wer
efo
und
inth
e12
incl
uded
stud
ies
Ping
leto
net
al,2
013
(80)
NA
Qua
si-e
xper
imen
tal
bef
ore
–aft
erst
udy
Red
uctio
no
fVTE
inho
spita
lized
pat
ient
sb
yus
ing
educ
atio
nan
dsy
stem
-wid
eo
per
atio
nalp
lans
Ho
spita
lized
pat
ient
sat
asi
ngle
univ
ersi
ty-b
ased
med
ical
cent
erin
the
Uni
ted
Stat
esPI
CC
Aft
erim
ple
men
tatio
no
fsp
ecifi
cac
tion
pla
ns,
use
ofP
ICC
sd
rop
ped
fro
m36
0in
sert
ions
to<
200
inse
rtio
nso
ver
2ye
ars;
rate
so
fVTE
inho
spita
lized
pat
ient
ssi
mila
rly
dec
lined
Pitt
irut
ieta
l,20
09(1
98)
NA
Gui
del
ines
Gui
del
ines
for
CV
Cac
cess
,car
e,d
iag
nosi
s,an
dth
erap
yo
fco
mp
licat
ions
Gui
del
ine
stat
emen
tdra
fted
by
the
Euro
pea
nSo
ciet
yfo
rC
linic
alN
utri
tion
and
Met
abo
lism
PIC
C,C
VC
,p
ort
Pro
vid
esre
com
men
dat
ions
on
use,
care
,and
man
agem
ento
fpro
ble
ms
rela
ted
tova
scul
ard
evic
esfo
rp
aren
tera
lnut
ritio
nPi
ttir
utie
tal,
2012
(199
)89
Ret
rosp
ectiv
eco
hort
stud
yEx
amin
eo
utco
mes
rela
ted
tous
eo
fp
ow
er-in
ject
able
PIC
Cs
inIC
Use
ttin
gs
Cri
tical
lyill
pat
ient
sun
der
go
ing
po
wer
-inje
ctab
lePI
CC
pla
cem
ent
PIC
CPI
CC
sth
atw
ere
po
wer
-cap
able
wer
eas
soci
ated
with
mul
tiple
ther
apeu
ticad
vant
ages
and
low
risk
for
com
plic
atio
nsin
criti
cally
illp
atie
nts
Pitt
irut
iand
Lam
per
ti,20
15(7
1)N
AR
evie
wR
evie
wth
elit
erat
ure
on
the
inci
den
ceo
fca
rdia
cta
mp
ona
de
afte
rPI
CC
inse
rtio
nC
ase
rep
ort
san
dca
sese
ries
ofP
ICC
rece
ipt;
revi
ewo
fsen
tinel
even
tsPI
CC
Late
card
iac
tam
po
nad
eaf
ter
PIC
Cin
sert
ion
inad
ults
isra
rePo
ngru
ang
po
rnet
al,
2013
(200
)16
2N
este
dca
se–c
ont
rol
stud
yEv
alua
teth
ero
leo
fpat
ient
-,p
rovi
der
-,an
dd
evic
e-sp
ecifi
cri
skfa
cto
rsin
PIC
C-r
elat
edB
SI
Ho
spita
lized
pat
ient
sat
asi
ngle
univ
ersi
tyho
spita
lin
the
Uni
ted
Stat
esPI
CC
The
PIC
CB
SIra
tew
as3.
13p
er10
00ca
thet
er-d
ays
(sim
ilar
toth
ato
foth
erC
VC
s);
PIC
CB
SIw
asas
soci
ated
with
dev
ice
(num
ber
ofl
umen
s)an
dp
atie
ntfa
cto
rs,
such
asC
lost
rid
ium
diffi
cile
infe
ctio
nan
dco
nges
tive
hear
tfai
lure
Pote
teta
l,20
13(6
1)10
1Pr
osp
ectiv
eco
hort
stud
yEx
amin
eth
esa
fety
ofP
ICC
inse
rtio
nin
pat
ient
sw
ithp
rofo
und
thro
mb
ocy
top
enia
143
PIC
Cin
sert
ions
in10
1p
atie
nts
with
canc
erat
1ca
ncer
cent
erPI
CC
PIC
Cp
lace
men
twas
asso
ciat
edw
itha
hig
hra
teo
ftec
hnic
alsu
cces
san
dfe
wad
vers
eev
ents
inp
atie
nts
with
seve
reth
rom
bo
cyto
pen
iaQ
uiet
al,2
014
(201
)55
1R
etro
spec
tive
coho
rtst
udy
Stud
yth
ein
cid
ence
of,
risk
fact
ors
for,
and
out
com
eso
fsp
ont
aneo
usPI
CC
dis
lod
gem
ents
inp
atie
nts
with
canc
erin
Chi
na
551
pat
ient
sw
ithca
ncer
dia
gno
ses
rece
ivin
gca
reat
1ce
nter
inC
hina
PIC
CTh
ein
cid
ence
rate
ofs
po
ntan
eous
dis
lod
gem
entw
as4.
1%;p
atie
nts
who
dev
elo
ped
dis
lod
gem
enth
ada
sub
stan
tially
gre
ater
risk
for
sub
seq
uent
PIC
C-r
elat
edD
VT
(rel
ativ
eri
sk,1
7.46
)
Con
tinue
don
follo
win
gp
age
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S34 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
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Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Raa
det
al,1
994
(202
)72
Cas
ese
ries
Ass
ess
the
freq
uenc
yo
fthr
om
bo
tican
din
fect
ious
com
plic
atio
nso
fCV
Cus
ein
pat
ient
sw
ithca
ncer
72ca
ncer
pat
ient
sin
a50
0-b
edte
rtia
ryca
rece
nter
wer
ein
clud
ed;p
ost
mo
rtem
exam
inat
ions
of
cath
eter
ized
vein
sw
ere
per
form
ed
CV
CTh
rom
bo
sis
resu
lting
fro
mva
scul
arca
thet
ers
incl
uded
fibri
nsl
eeve
too
cclu
sive
thro
mb
osi
s.Se
ptic
emia
was
mo
reco
mm
on
inp
atie
nts
with
occ
lusi
veth
rom
bo
sis
than
inp
atie
nts
with
nonm
ural
thro
mb
osi
s,su
gg
estin
gan
asso
ciat
ion
bet
wee
nth
ese
2o
utco
mes
Ric
hter
set
al,2
014
(203
)43
9R
etro
spec
tive
coho
rtst
udy
Rep
ort
the
inci
den
cean
dri
skfa
cto
rsfo
rg
ram
po
sitiv
eb
acte
rem
iaan
dth
rom
bo
sis
inp
atie
nts
who
rece
ived
CV
Cs
439
pat
ient
sun
der
go
ing
stem
cell
tran
spla
ntat
ion
CV
CD
urat
ion
ofn
eutr
op
enia
and
left
-sid
edp
lace
men
twas
asso
ciat
edw
ithb
acte
rem
ia.
Pers
iste
ntb
acte
rem
iaan
dtip
colo
niza
tion
wer
eas
soci
ated
with
thro
mb
osi
sR
icka
rdet
al,2
012
(84)
3283
RC
TR
out
ine
vs.c
linic
ally
war
rant
edre
pla
cem
ent
ofp
erip
hera
lIV
sin
hosp
itals
ettin
gH
osp
italiz
edp
atie
nts
at3
hosp
itals
inA
ustr
alia
PIV
CC
om
par
edw
ithro
utin
ere
mo
val,
PIV
Cs
can
be
rem
ove
das
clin
ical
lyin
dic
ated
with
out
incr
easi
ngad
vers
eev
ents
;thi
sp
ract
ice
can
red
uce
cost
sub
stan
tially
,acc
ord
ing
toth
eau
tho
rsR
ob
inso
net
al,2
005
(204
)N
APr
osp
ectiv
eco
hort
stud
yEf
fect
ofd
edic
ated
PIC
Cte
amo
np
atie
ntca
rean
dco
sts
asso
ciat
edw
ithPI
CC
inse
rtio
n
Ho
spita
lized
pat
ient
sre
ceiv
ing
care
ata
sing
lem
edic
alce
nter
inB
ost
on,
Mas
sach
uset
tsPI
CC
Intr
od
uctio
no
fad
edic
ated
PIC
Cte
amd
ecre
ased
inap
pro
pri
ate
PIC
Cp
lace
men
t,w
aitt
imes
toin
sert
ion,
and
ove
rall
cost
sR
om
agno
liet
al,2
010
(205
)49
Pro
spec
tive
coho
rtst
udy
Ris
kfo
rPI
CC
-rel
ated
DV
Tin
pat
ient
sw
ithca
ncer
52PI
CC
sp
lace
din
49p
atie
nts
with
canc
erin
asi
ngle
med
ical
cent
erin
Feltr
e,Ita
lyPI
CC
3p
atie
nts
(5.7
%)d
evel
op
edPI
CC
-rel
ated
DV
T;al
lpat
ient
sre
ceiv
edan
tico
agul
atio
nw
ithLM
WH
for
≥3
mo
;no
PEw
asre
po
rted
Ro
od
enet
al,2
005
(206
)N
ASy
stem
atic
revi
ewR
evie
wo
fthe
liter
atur
eo
nd
iag
nosi
so
f,ri
skfa
cto
rsfo
r,an
dco
mp
licat
ions
of
CV
C-r
elat
edD
VT
NA
CV
C,P
ICC
US
isre
com
men
ded
asth
ed
iag
nost
icte
sto
fch
oic
e;va
rio
usp
atie
ntan
dd
evic
efa
cto
rsar
eas
soci
ated
with
DV
T;an
dro
utin
ep
rop
hyla
xis
top
reve
ntth
rom
bo
sis
isno
tw
arra
nted
on
the
bas
iso
fthe
avai
lab
led
ata
Ro
set
al,2
005
(207
)36
Ret
rosp
ectiv
eco
hort
stud
yEv
alua
tePI
CC
-rel
ated
DV
Tin
pat
ient
sw
ithhe
adan
dne
ckca
ncer
36p
atie
nts
with
head
and
neck
canc
erat
1m
edic
alho
spita
lin
Spai
nPI
CC
The
rate
ofP
ICC
-rel
ated
DV
Tw
as11
.1%
,su
gg
estin
ga
hig
hra
teo
fthr
om
bo
sis
inth
isp
atie
ntp
op
ulat
ion
Ro
sent
hal,
2008
(208
)N
AR
evie
wEv
alua
tead
vant
ages
,co
nsid
erat
ions
,and
man
agem
ento
fmid
line
cath
eter
sco
mp
ared
with
oth
erd
evic
es,w
ithth
eai
mo
fid
entif
ying
utili
tyo
fthe
sed
evic
esin
pat
ient
s
Nar
rativ
ere
view
Mid
line
cath
eter
Mid
line
cath
eter
sar
eid
ealf
or
iso
toni
cin
fusi
ons
that
may
last
bey
ond
5d
Rup
pet
al,2
012
(34)
NA
Gui
del
ines
Prac
tice
gui
del
ines
for
cent
ralv
eno
usac
cess
pre
par
edb
yth
eA
mer
ican
Soci
ety
of
Ane
sthe
sio
log
ists
Pro
vid
esup
dat
edre
com
men
dat
ions
on
inse
rtio
nsi
tese
lect
ion,
use
ofU
S,an
dve
rific
atio
no
fca
thet
erlo
catio
n
CV
C,P
ICC
The
gui
del
ines
ind
icat
ea
pre
fere
nce
for
upp
er-e
xtre
mity
inse
rtio
nsi
tes,
use
ofU
Sto
gui
de
inse
rtio
nw
hen
pla
cing
CV
Cs
and
PIC
Cs,
and
confi
rmat
ion
oft
heve
nous
loca
tion
oft
heca
thet
eran
dca
thet
ertip
loca
tion
usin
gva
rio
uste
chni
que
sR
utko
ff,20
14(2
09)
257
Qua
si-e
xper
imen
tal
bef
ore
–aft
erd
esig
n
Eval
uate
the
effic
acy
ofa
ntim
icro
bia
l(m
ino
cycl
ine–
rifa
mp
in)–
coat
edPI
CC
sin
red
ucin
gPI
CC
-rel
ated
BSI
Ho
spita
lized
pat
ient
sat
1m
edic
alce
nter
inC
alifo
rnia
PIC
CA
ntim
icro
bia
lPIC
Cs
resu
lted
insi
gni
fican
td
ecre
ases
inC
LAB
SIfr
om
4.10
to0.
47in
fect
ions
per
1000
cath
eter
-day
sSa
ber
etal
,201
1(5
4)N
APa
tient
-leve
lsy
stem
atic
revi
ewan
dm
eta-
anal
ysis
Exam
ine
risk
fact
ors
for
CR
Tin
pat
ient
sw
ithca
ncer
Patie
nts
fro
m5
RC
Tsan
d7
pro
spec
tive
stud
ies
incl
udin
g56
36p
atie
nts
wer
ein
clud
edC
VC
,PIC
C,
po
rtTh
rom
bo
sis
risk
was
incr
ease
dw
ithPI
CC
s,hi
sto
ryo
fDV
T,su
bcl
avia
nve
nip
unct
ure
inse
rtio
n,an
dim
pro
per
cath
eter
tipp
osi
tion
Safd
aran
dM
aki,
2005
(81)
115
Pro
spec
tive
coho
rtst
udy
Exam
ine
risk
for
infe
ctio
nw
ithPI
CC
sin
hosp
italiz
edp
atie
nts
com
par
edw
ithth
atas
soci
ated
with
CV
Cs
115
hosp
italiz
edp
atie
nts
who
had
251
PIC
Cs
pla
ced
wer
ein
clud
ed(fr
om
with
ina
larg
erR
CT)
PIC
CR
isk
for
PIC
C-r
elat
edB
SIw
as2–
5p
er10
00ca
thet
er-d
ays,
anu
mb
erth
atw
asg
reat
erth
anra
tes
rep
ort
edin
out
pat
ient
sett
ing
san
dth
ose
rela
ted
tocu
ffed
or
tunn
eled
CV
Cs
Sans
iver
oet
al,2
011
(210
)50
Pro
spec
tive
coho
rtst
udy
Eval
uate
the
effic
acy
ofa
nove
lcat
hete
rse
cure
men
tdev
ice
50p
atie
nts
refe
rred
for
PIC
Cin
sert
ion
toa
nurs
ing
vasc
ular
acce
sste
aman
dto
IRPI
CC
Ano
vels
ecur
emen
tsys
tem
resu
lted
ina
favo
rab
leco
mp
licat
ion
pro
file,
with
cost
savi
ngs
rela
ted
tore
duc
edd
ress
ing
san
dd
isp
osa
ble
secu
rem
ents
yste
ms
Sant
olim
etal
,201
2(2
11)
NA
Qua
si-e
xper
imen
tal
bef
ore
–aft
erd
esig
n
Und
erst
and
the
effe
cto
fap
roto
colt
ose
lect
IVD
sin
aB
razi
lian
hosp
itali
na
QIp
roje
ctU
nive
rsity
pat
ient
sin
Bra
zila
ndva
scul
arac
cess
nurs
ing
team
PIC
C,C
VC
,p
ort
Imp
lem
enta
tion
ofa
pro
toco
lres
ulte
din
dec
reas
edra
tes
ofp
hleb
itis
and
imp
rove
dnu
rsin
gsa
tisfa
ctio
nSa
sad
uesz
etal
,199
9(5
0)34
Pro
spec
tive
coho
rtst
udy
Eval
uate
the
effe
cto
fsm
all-b
ore
tunn
eled
cath
eter
sas
am
eans
top
rese
rve
vein
sco
mp
ared
with
PIC
Cs
34p
atie
nts
with
end
-sta
ge
rena
ldis
ease
at1
sing
leac
adem
icm
edic
alce
nter
PIC
C,
smal
l-b
ore
cath
eter
Two
min
or
inse
rtio
nco
mp
licat
ions
(art
eria
lp
unct
ure
and
cath
eter
dam
age
dur
ing
sutu
ring
)occ
urre
d.T
his
app
roac
hre
sulte
din
ano
velf
orm
ofa
cces
s,p
rese
rvin
gp
erip
hera
lvei
nsan
dlim
iting
risk
for
cent
ral
vein
sten
osi
sin
this
pat
ient
po
pul
atio
nSc
him
pet
al,2
003
(212
)26
4R
etro
spec
tive
coho
rtst
udy
Eval
uate
inci
den
cean
do
utco
mes
rela
ted
toU
EDV
Tin
pat
ient
sw
ithg
ynec
olo
gic
canc
er
264
wo
men
who
rece
ived
325
tota
lcat
hete
rsat
aun
iver
sity
hosp
ital
PIC
C,p
ort
13p
atie
nts
dev
elo
ped
cath
eter
-rel
ated
DV
T;11
oft
hep
atie
nts
had
po
rts
and
2ha
dPI
CC
s.N
op
atie
nts
dev
elo
ped
PE
Con
tinue
don
follo
win
gp
age
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S35
Downloaded From: http://annals.org/ by a Ebling Library Information Research User on 10/08/2015
Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Seel
eyet
al,2
007
(213
)23
3R
etro
spec
tive
coho
rtst
udy
Dev
elo
pa
risk
-pre
dic
tion
mo
del
and
iden
tify
fact
ors
asso
ciat
edw
ithPI
CC
-rel
ated
DV
TH
osp
italiz
edp
atie
nts
rece
ivin
gca
reat
aM
idw
est
com
mun
ityho
spita
lPI
CC
17p
atie
nts
dev
elo
ped
DV
T;lo
gis
ticre
gre
ssio
nm
od
els
foun
dth
atb
edre
st,l
oca
lized
tend
erne
ss,s
mo
king
,ant
ico
agul
antu
se,
and
ost
eom
yelit
isw
ere
asso
ciat
edw
ithPI
CC
-rel
ated
DV
TSh
arp
etal
,201
4(6
3)64
Ret
rosp
ectiv
eco
hort
stud
yEv
alua
tesa
fety
and
effic
acy
ofm
idlin
eca
thet
ers
com
par
edw
ithPI
CC
sin
adul
tsw
ithcy
stic
fibro
sis
231
mid
line
cath
eter
san
d97
PIC
Cs
wer
ep
lace
din
64p
atie
nts
PIC
C,
mid
line
cath
eter
Rat
eso
fad
vers
eev
ents
with
PIC
Cs
and
mid
line
cath
eter
sw
ere
sim
ilar,
but
rem
ova
lra
tes
for
mid
line
cath
eter
sw
ere
twic
eth
ato
fPI
CC
sSh
eaet
al,2
006
(214
)57
5R
etro
spec
tive
coho
rtst
udy
Eval
uate
risk
for
PIC
C-r
elat
edD
VT
inp
atie
nts
with
infla
mm
ato
ryb
ow
eld
isea
se15
pat
ient
sm
etin
clus
ion
and
excl
usio
ncr
iteri
a,an
d3
had
PIC
C-r
elat
edD
VT
PIC
CA
20%
inci
den
ceo
fPIC
C-r
elat
edD
VT
inho
spita
lized
pat
ient
sw
ithin
flam
mat
ory
bo
wel
dis
ease
and
PIC
Cs
was
note
d.T
hein
cid
ence
rate
ofP
ICC
-rel
ated
DV
Tw
as2.
17%
per
day
Sim
cock
,200
8(2
15)
191
Qua
si-e
xper
imen
tal
des
ign
Und
erst
and
the
effe
cto
fuse
ofU
So
nra
teo
fPI
CC
com
plic
atio
nsPa
tient
sad
mitt
edto
aU
Kho
spita
lwho
rece
ived
PIC
Cs
atva
rio
ustim
ep
oin
tsPI
CC
Rat
eso
fDV
T,in
fect
ions
,and
oth
erco
mp
licat
ions
dec
lined
afte
rus
eo
fUS
Sim
ono
vaet
al,2
012
(76)
NA
Invi
tro
stud
yEv
alua
teth
eab
ility
oft
issu
ead
hesi
ves
and
cyan
oac
ryla
teg
lue
tose
cure
intr
aven
ous
cath
eter
sco
mp
ared
with
Stat
Lock
dev
ices
(Bar
dM
edic
al,C
ovi
ngto
n,G
eorg
ia)i
nan
imal
mo
del
s
NA
PIC
C,C
VC
Tiss
uead
hesi
ves
com
par
edfa
vora
bly
with
Stat
Lock
dev
ices
and
tran
spar
ent
po
lyur
etha
ned
ress
ing
sto
incr
ease
the
"pul
l-out
"fo
rce
ofc
athe
ters
Skaf
feta
l,20
12(2
16)
147
Ret
rosp
ectiv
eco
hort
stud
yC
om
par
ean
dco
ntra
stth
eus
eo
fHic
kman
(tun
nele
d)c
athe
ters
and
PIC
Cs
inp
atie
nts
with
acut
ele
ukem
iare
ceiv
ing
ind
uctio
nch
emo
ther
apy
147
pat
ient
sw
ithne
wly
dia
gno
sed
acut
ele
ukem
iaw
hore
ceiv
edei
ther
aH
ickm
anca
thet
ero
ra
PIC
C(w
itho
rw
itho
utU
Sg
uid
ance
)
PIC
C,
tunn
eled
cath
eter
Hic
kman
cath
eter
sin
sert
edaf
ter
2007
by
IRw
ere
asso
ciat
edw
ithfe
wer
com
plic
atio
ns(b
acte
rem
iaan
dex
it-si
tein
fect
ion)
;PIC
Cs
wer
eas
soci
ated
with
less
loca
linfl
amm
atio
nb
uthi
ghe
rra
tes
ofp
hleb
itis
and
blo
ckag
ere
qui
ring
lytic
trea
tmen
ts.
Skie
stet
al,2
000
(217
)66
Pro
spec
tive
coho
rtst
udy
Det
erm
ine
risk
for
com
plic
atio
nsin
pat
ient
sw
ithH
IVin
fect
ion
who
req
uire
dlo
ng-t
erm
veno
usac
cess
or
trea
tmen
tsan
dre
ceiv
edPI
CC
s
97PI
CC
sw
ere
inse
rted
in66
pat
ient
sfo
rva
rio
uscl
inic
alin
dic
atio
nsPI
CC
53%
(51
of9
7)o
fPIC
Cs
wer
eas
soci
ated
with
aco
mp
licat
ion,
for
ano
vera
llco
mp
licat
ion
rate
of6
.1p
er10
00ca
thet
er-d
ays;
med
ian
time
toa
cath
eter
-rel
ated
com
plic
atio
nw
as11
5d
.Ele
ven
cath
eter
sw
ere
infe
cted
,7o
fw
hich
wer
eas
soci
ated
with
ab
acte
rem
ia.
The
ove
rall
noni
nfec
tious
com
plic
atio
nra
tew
as4.
6p
er10
00ca
thet
er-d
ays
Smith
etal
,199
8(2
18)
441
Ret
rosp
ectiv
eco
hort
stud
yC
om
par
ein
dic
atio
nsfo
rin
sert
ion,
com
plic
atio
ns,a
ndec
ono
mic
effe
cto
fC
VC
svs
.PIC
Cs
441
men
who
rece
ived
838
(283
CV
C,5
55PI
CC
)co
nsec
utiv
ely
pla
ced
veno
usca
thet
ers
refle
ctin
g49
365
CV
C-d
ays
and
1181
4PI
CC
-day
s
PIC
C,C
VC
Ato
talo
f57
(19%
)co
mp
licat
ions
wer
eid
entifi
edin
the
CV
Cg
roup
and
197
(35%
)co
mp
licat
ions
inth
ePI
CC
gro
up.T
here
wer
esi
gni
fican
tlyfe
wer
tota
lco
mp
licat
ions
,ca
thet
erm
alfu
nctio
ns,e
pis
od
eso
fphl
ebiti
s,an
d"o
ther
"co
mp
licat
ions
inth
eC
VC
gro
upth
anin
the
PIC
Cg
roup
Smith
and
No
lan,
2013
(219
)N
ASy
stem
atic
revi
ewPr
ovi
de
ano
verv
iew
ofC
VC
san
din
sert
ion
tech
niq
ues,
and
cons
ider
the
pre
vent
ion
and
man
agem
ento
fco
mm
on
com
plic
atio
ns
NA
PIC
C,C
VC
Tore
duc
era
tes
oft
hro
mb
osi
sre
late
dto
long
-ter
mca
thet
ers
inp
atie
nts
with
canc
er,
the
cath
eter
tipsh
oul
dlie
atth
eju
nctio
no
fth
eSV
Can
dri
ght
atri
um.M
ultil
umen
cath
eter
sm
ayb
eas
soci
ated
with
asl
ight
lyhi
ghe
rri
skfo
rin
fect
ion
than
sing
le-lu
men
one
s.Pr
op
hyla
ctic
antib
iotic
sb
efo
relin
ein
sert
ion,
antib
iotic
lock
solu
tions
,or
antib
iotic
oin
tmen
tsap
plie
dto
the
inse
rtio
nsi
tear
eno
trec
om
men
ded
Snel
ling
etal
,200
1(2
20)
28R
etro
spec
tive
coho
rtst
udy
Co
mp
are
trea
tmen
tsuc
cess
with
tunn
eled
cath
eter
svs
.PIC
Cs
and
exam
ine
rate
of
and
risk
for
com
plic
atio
nsw
ithb
oth
dev
ices
inp
atie
nts
with
gas
tro
inte
stin
alca
ncer
16tu
nnel
edca
thet
ers
and
18PI
CC
sw
ere
inse
rted
in28
pat
ient
sun
der
go
ing
pro
trac
ted
IVin
fusi
on
ther
apy
PIC
C,
tunn
eled
cath
eter
Aft
er12
0d
,tun
nele
dca
thet
ersu
rviv
alw
asb
ette
rth
anth
ato
fPIC
Cs
(P=
0.05
1).
Co
mp
licat
ions
occ
urre
din
61%
ofp
atie
nts
with
tunn
eled
cath
eter
san
d67
%o
fpat
ient
sw
ithPI
CC
sSo
ngan
dLi
,201
3(1
1)30
12R
etro
spec
tive
coho
rtst
udy
Ob
serv
ean
dan
alyz
eth
eca
uses
of
mis
pla
cem
ento
fPIC
Ctip
sin
pat
ient
sw
ithca
ncer
3012
pat
ient
sw
ithca
ncer
who
rece
ived
aPI
CC
(159
0m
en,1
121
wo
men
,and
301
child
ren;
age
rang
e,1–
94y
[med
ian
age,
52y]
)fo
rch
emo
ther
apy
or
nutr
itio
nals
upp
ort
PIC
CM
alp
osi
tion
was
ob
serv
edin
237
case
s(7
.87%
),w
ithth
em
ost
freq
uent
site
bei
ngth
ein
tern
alju
gul
ar,f
ollo
wed
by
the
axill
ary
vein
;PIC
Cs
wer
ere
loca
ted
bac
kto
the
SVC
or
sub
clav
ian
vein
usin
gva
rio
uste
chni
que
sSp
erry
etal
,201
2(2
21)
798
Ret
rosp
ectiv
eco
hort
stud
yEv
alua
teth
ein
fluen
ceo
flat
eral
ityo
fPIC
Cin
sert
ion
(rig
htar
mvs
.lef
tarm
)on
the
risk
for
sub
seq
uent
PIC
C-r
elat
edD
VT
798
seq
uent
ialP
ICC
pla
cem
ents
at1
med
ical
cent
erin
Was
hing
ton,
DC
PIC
CA
rmo
fPIC
Cp
lace
men
twas
nota
sso
ciat
edw
ithsy
mp
tom
atic
VTE
Sto
kow
skie
tal,
2009
(222
)53
8R
etro
spec
tive
coho
rtst
udy
Eval
uatio
no
fthe
effe
cto
fUS
on
risk
for
PIC
Cco
mp
licat
ions
538
pat
ient
s(b
oth
inp
atie
ntan
do
utp
atie
nt)w
hore
ceiv
edPI
CC
sat
aC
anad
ian
med
ical
cent
erPI
CC
Co
mp
ared
with
pal
pat
ion,
PIC
Cs
pla
ced
via
US
had
low
ersu
bse
que
ntra
tes
oft
hro
mb
osi
sSt
rahi
levi
tzet
al,2
001
(223
)40
Ret
rosp
ectiv
eco
hort
stud
yEx
amin
eo
utco
mes
rela
ted
toPI
CC
use
inp
atie
nts
with
acut
em
yelo
idle
ukem
iaFo
rty
pat
ient
sw
hore
ceiv
ed52
PIC
Cs
dur
ing
the
stud
yp
erio
dPI
CC
PIC
Cs
wer
eas
soci
ated
with
earl
ym
echa
nica
lco
mp
licat
ions
and
infe
ctio
ns;h
ow
ever
,the
com
plic
atio
nra
tew
asd
eem
ed"a
ccep
tab
le"
inth
isp
atie
ntp
op
ulat
ion
Con
tinue
don
follo
win
gp
age
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S36 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
Downloaded From: http://annals.org/ by a Ebling Library Information Research User on 10/08/2015
Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Teje
do
ret
al,2
012
(18)
89R
etro
spec
tive
coho
rtst
udy
Des
crib
ep
atte
rns
ofu
seo
ftem
po
rary
CV
Cs
and
PIC
Cs
inno
n-IC
Uw
ard
s89
pat
ient
sw
ith14
6C
VC
s(5
6%o
fwhi
chw
ere
PIC
Cs)
at1
acad
emic
med
ical
cent
erPI
VC
,CV
C,
PIC
CA
nav
erag
eo
f4.1
idle
day
sw
itha
CV
Can
da
mea
no
f3.4
idle
day
sw
ithb
oth
aC
VC
and
aPI
VC
wer
eno
ted
;pat
ient
sw
itha
PIC
Cha
d5.
4d
inw
hich
they
also
had
aPI
VC
,co
mp
ared
with
10d
inp
atie
nts
with
aC
VC
Thak
arar
etal
,201
4(2
24)
3273
Ret
rosp
ectiv
eco
hort
stud
yEv
alua
tion
oft
PAus
eas
am
arke
rfo
rin
situ
thro
mb
osi
san
dri
skfo
rsu
bse
que
ntPI
CC
-rel
ated
CLA
BSI
3273
pat
ient
sat
ate
rtia
ryca
rece
nter
,40%
of
who
mre
ceiv
edtP
API
CC
Use
oft
PAw
asas
soci
ated
with
3.59
times
gre
ater
risk
for
CLA
BSI
com
par
edw
ithp
atie
nts
who
did
notr
ecei
veth
istr
eatm
ent
Tim
site
tal,
1998
(225
)26
5Pr
osp
ectiv
eco
hort
stud
yA
sso
ciat
ion
bet
wee
nca
thet
erth
rom
bo
sis
and
cath
eter
infe
ctio
n26
5p
atie
nts
rece
ivin
gIC
Uca
rein
aFr
ench
hosp
ital
CV
CC
athe
ter
thro
mb
osi
sw
asas
soci
ated
with
2.62
-fo
ldg
reat
erri
skfo
rca
thet
er-r
elat
edse
psi
sTi
war
ieta
l,20
11(2
26)
436
Pro
spec
tive
coho
rtst
udy
Ap
pro
pri
aten
ess
ofv
ascu
lar
dev
ice
use
inho
spita
lized
pat
ient
s43
6ho
spita
lized
pat
ient
sw
hore
ceiv
ed87
6IV
Ds
ove
r29
09ho
spita
l-day
sPI
VC
,CV
C31
%o
fto
talc
athe
ter-
day
sw
ere
adju
dic
ated
asin
app
rop
riat
e(u
sing
the
auth
ors
'cri
teri
afo
rap
pro
pri
ate
vs.i
nap
pro
pri
ate
use)
Tour
éet
al,2
015
(227
)19
6Pr
osp
ectiv
eco
hort
stud
yC
om
par
eth
era
tes
ofc
om
plic
atio
nsas
soci
ated
with
tunn
eled
cath
eter
s(B
rovi
ac)a
ndPI
CC
inp
atie
nts
rece
ivin
gho
me
par
ente
raln
utri
tion
204
cath
eter
sw
ere
inse
rted
in19
6p
atie
nts
who
rece
ived
care
ina
hom
ep
aren
tera
lnut
ritio
np
rog
ram
PIC
C,
tunn
eled
cath
eter
Co
mp
licat
ions
wer
esi
mila
rb
etw
een
bo
thca
thet
erg
roup
s;ho
wev
er,c
athe
ter
infe
ctio
nra
tes
wer
elo
wer
inth
ePI
CC
gro
up
Tran
etal
,201
0(6
0)47
8R
etro
spec
tive
coho
rtst
udy
Det
erm
ine
the
inci
den
cean
do
utco
mes
asso
ciat
edw
ithPI
CC
-rel
ated
DV
TSi
ngle
-cen
ter
anal
ysis
ofp
atie
nts
with
hem
ato
log
icca
ncer
,PIC
Cs,
and
sym
pto
mat
icU
EDV
TPI
CC
Hig
hin
cid
ence
ofD
VT
asso
ciat
edw
ithPI
CC
sin
pat
ient
sre
ceiv
ing
mye
losu
pp
ress
ive
chem
oth
erap
y;ce
ntra
llyp
osi
tione
dPI
CC
stu
nnel
edin
toth
ein
tern
alju
gul
arve
inw
ere
asso
ciat
edw
ithlo
win
cid
ence
oft
hro
mb
osi
sTr
ero
tola
etal
,200
7(2
28)
1654
PIC
Cs
Ret
rosp
ectiv
eco
hort
stud
yD
eter
min
eth
ein
cid
ence
and
loca
tion
of
PIC
Ctip
mal
po
sitio
nSi
ngle
-cen
ter
anal
ysis
of2
367
bed
sid
eat
tem
pts
atin
sert
ion
PIC
CTi
pm
alp
osi
tion
occ
urre
din
163
case
saf
ter
bed
sid
ein
sert
ion;
mo
stm
alp
osi
tioni
ngs
wer
eco
rrec
ted
by
cath
eter
exch
ang
e(5
8%)
and
rep
osi
tioni
ng(3
6%)
Trer
oto
laet
al,2
010
(229
)50
Pro
spec
tive
coho
rtst
udy
Eval
uate
out
com
esas
soci
ated
with
use
ofa
trip
le-lu
men
PIC
Cin
the
ICU
sett
ing
Cri
tical
lyill
pat
ient
sw
hore
ceiv
edtr
iple
-lum
enPI
CC
sPI
CC
The
stud
yw
asst
op
ped
afte
ran
inte
rim
anal
ysis
dem
ons
trat
edex
trem
ely
hig
hra
tes
of
sym
pto
mat
icD
VT
in20
%o
fpat
ient
sTr
ick
etal
,200
4(2
30)
320
Cro
ss-s
ectio
nal
surv
eyEv
alua
teho
wo
ften
CV
Cs
wer
ep
lace
dw
itho
utcl
inic
alju
stifi
catio
nin
the
med
ical
reco
rd
Ho
spita
lized
adul
tpat
ient
sin
a60
0-b
edp
ublic
hosp
ital
CV
CU
njus
tified
use
ofC
VC
sw
asm
ore
com
mo
nin
pat
ient
sre
ceiv
ing
care
out
sid
eth
eIC
U;
how
ever
,mo
stp
atie
nts
rece
ived
CV
Cs
whi
lein
anIC
Use
ttin
gTu
ffaha
etal
,201
4(8
5)N
AC
ost
-effe
ctiv
enes
san
alys
isA
sses
sth
eco
st-e
ffect
iven
ess
ofc
linic
ally
ind
icat
edvs
.ro
utin
ere
pla
cem
ento
fPIV
Cs
Dat
afr
om
anR
CT
wer
eus
edto
det
erm
ine
cost
-effe
ctiv
enes
sPI
VC
Clin
ical
lyin
dic
ated
rep
lace
men
tstr
ateg
yw
asas
soci
ated
with
cost
-sav
ing
sp
erp
atie
nto
fA
U$7
.60
(95%
CI,
AU
$4.9
6–A
U$1
0.62
)Tu
rco
tte
etal
,200
6(2
31)
NA
Syst
emat
icre
view
Eval
uate
infe
ctio
us,t
hro
mb
otic
,phl
ebiti
c,an
do
ther
com
mo
nco
mp
licat
ions
of
PIC
Cs
com
par
edw
ithC
VC
48ar
ticle
sw
ere
incl
uded
;co
mp
licat
ions
fro
mPI
CC
sw
ere
com
par
edw
ithth
ose
fro
mC
VC
sac
ross
seve
rals
tud
yp
op
ulat
ions
PIC
C,C
VC
PIC
Cs
wer
eas
soci
ated
with
aco
mp
licat
ion
pro
file
that
was
sim
ilar
too
rex
ceed
edth
ato
fCV
Cs.
PIC
Cs
wer
em
ore
com
mo
nly
asso
ciat
edw
ithp
hleb
itis
and
mal
po
sitio
ning
than
CV
Cs
Ug
aset
al,2
012
(232
)N
ASy
stem
atic
revi
ewR
evie
wth
eev
iden
ceo
nth
ein
cid
ence
of
cent
rala
ndp
erip
hera
lven
ous
CR
BSI
sin
criti
cally
illsu
rgic
alp
atie
nts,
and
out
line
pat
hway
sfo
rp
reve
ntio
nan
din
terv
entio
n
Cri
tical
lyill
ICU
pat
ient
sin
surg
ical
ICU
sett
ing
sPI
CC
,CV
CD
iver
sed
efini
tions
oft
hed
iag
nosi
so
fcen
tral
and
per
iphe
ralv
eno
usC
RB
SIs
and
asm
all
po
pul
atio
no
fpat
ient
sw
ithPI
CC
sle
dto
inco
nsis
tent
conc
lusi
ons
and
find
ing
sV
esel
y,20
03(6
6)N
AR
evie
wSu
mm
ariz
eth
eev
iden
cere
late
dto
op
timal
tipp
osi
tion
ofa
CV
CN
arra
tive
revi
ewPI
CC
,CV
CTh
esc
ient
ific
evid
ence
atth
etim
ed
idno
tp
rovi
de
suffi
cien
tevi
den
ceto
sup
po
rto
rco
ndem
nth
ep
lace
men
tofa
cath
eter
tipin
the
rig
htat
rium
Vid
alet
al,2
008
(233
)11
5Pr
osp
ectiv
eco
hort
stud
yEv
alua
teco
mp
licat
ions
inp
atie
nts
who
rece
ived
PIC
Cs
for
par
ente
raln
utri
tion,
antib
iotic
s,b
loo
dtr
ansf
usio
ns,a
ndo
ther
infu
sio
ns
115
hosp
italiz
edp
atie
nts
who
rece
ived
127
PIC
Cs
for
ava
riet
yo
fclin
ical
ind
icat
ions
;PIC
Cs
wer
ein
sert
edin
the
nond
om
inan
tarm
in94
oft
he11
5p
atie
nts
PIC
CO
cclu
sio
n(1
7%),
rup
ture
(1.6
%),
acci
den
tal
with
dra
wal
(2.4
%),
infe
ctio
n(3
.1%
),an
dV
T(2
.4%
)wer
eth
em
ost
com
mo
nco
mp
licat
ions
Viz
carr
aet
al,2
014
(234
)N
AIn
fusi
on
Nur
ses
Soci
ety
gui
del
ine/
po
sitio
np
aper
Iden
tify,
pro
mo
te,a
ndd
evel
op
reco
mm
end
atio
nsan
dto
ols
toim
pro
vep
atie
ntsa
fety
pra
ctic
esre
late
dto
the
use
ofs
hort
PIV
Cs
NA
;po
sitio
nst
atem
entr
evie
win
gth
elit
erat
ure
and
reco
mm
end
ing
bes
tpra
ctic
esPI
VC
Hea
lthca
rep
rovi
der
kno
wle
dg
e,ed
ucat
ion,
and
trai
ning
,alo
ngw
itho
rgan
izat
iona
lp
olic
ies
and
pro
ced
ures
,sho
uld
be
dev
elo
ped
toen
sure
PIV
Csa
fety
;in
add
itio
n,su
rvei
llanc
ep
rog
ram
sto
ensu
resa
fety
with
aud
itsan
dfe
edb
ack
are
nece
ssar
yto
imp
rove
dev
ice
safe
tyW
alke
ran
dTo
dd
,201
3(4
)Su
rvey
-bas
edst
udy
Co
mp
are
inse
rtio
nco
st,p
atie
ntsa
tisfa
ctio
n,an
din
fect
ion
rate
so
fPIC
Cs
inse
rted
by
trai
ned
nurs
esan
dra
dio
log
ists
Ho
spita
lized
pat
ient
sun
der
go
ing
PIC
Cin
sert
ion
ina
dis
tric
tgen
eral
hosp
itali
nth
eU
nite
dK
ing
do
m
PIC
CPI
CC
sp
lace
db
yIR
wer
eas
soci
ated
with
gre
ater
cost
than
nurs
e-le
dPI
CC
inse
rtio
ns.
Patie
ntsa
tisfa
ctio
nre
gar
din
gex
pla
natio
no
ftr
eatm
entw
ashi
ghe
rin
the
nurs
eg
roup
Con
tinue
don
follo
win
gp
age
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
www.annals.org Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 S37
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Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Wal
liset
al,2
014
(235
)32
83R
CT
Seco
ndar
yan
alys
iso
fan
exis
ting
RC
Td
ata
sett
oev
alua
teri
skfa
cto
rsfo
rPI
VC
failu
re32
83ad
ultm
edic
alan
dsu
rgic
alp
atie
nts
(590
7ca
thet
ers)
with
aPI
VC
with
≥4
do
fexp
ecte
dus
ePI
VC
PIV
Csu
rviv
alis
imp
rove
db
yp
refe
rent
ial
fore
arm
inse
rtio
n,se
lect
ion
ofa
pp
rop
riat
ePI
VC
dia
met
er,a
ndin
sert
ion
by
IVte
ams
or
oth
ersp
ecia
lists
Wal
she
etal
,200
2(5
1)33
5Pr
osp
ectiv
eco
hort
stud
yEv
alua
teco
mp
licat
ions
afte
rPI
CC
inse
rtio
nin
aco
hort
ofa
dul
tand
ped
iatr
icca
ncer
pat
ient
s
335
pat
ient
sw
hore
ceiv
ed35
1PI
CC
sd
urin
gho
spita
lizat
ion;
pat
ient
sw
ere
care
dfo
rei
ther
by
aho
me
infu
sio
nag
ency
(205
)or
by
the
hosp
ital
staf
f(14
6)
PIC
C11
5(3
2.8%
)of3
51PI
CC
sw
ere
rem
ove
das
are
sult
ofa
com
plic
atio
n,fo
ra
rate
of1
0.9
per
1000
cath
eter
-day
s;p
atie
nts
with
hem
ato
log
icca
ncer
or
bo
nem
arro
wtr
ansp
lant
wer
em
ore
likel
yto
dev
elo
pa
com
plic
atio
nW
ebst
eret
al,2
013
(83)
NA
Syst
emat
icre
view
Eval
uate
whe
ther
rout
ine
chan
ges
ofP
IVca
thet
ers
ever
y72
–96
hw
assu
pp
ort
edb
yev
iden
ceo
feffi
cacy
or
safe
ty
7tr
ials
with
ato
talo
f489
5p
atie
nts
wer
ein
clud
edin
the
revi
ewPI
VC
No
evid
ence
was
foun
dto
sup
po
rtro
utin
ePI
VC
chan
ges
ever
y72
–96
h;co
nseq
uent
ly,
heal
thca
reo
rgan
izat
ions
may
cons
ider
po
licie
sw
here
by
cath
eter
sar
ech
ang
edo
nly
ifcl
inic
ally
ind
icat
edW
ilso
net
al,2
012
(64)
431
Ret
rosp
ectiv
eco
hort
stud
yA
naly
zean
did
entif
yri
skfa
cto
rsas
soci
ated
with
larg
eve
inth
rom
bo
sis
inp
atie
nts
with
PIC
Cs
Neu
rosu
rgic
alIC
Up
atie
nts
PIC
CSu
rger
yfo
r>
1h,
hist
ory
ofV
TE,r
ecei
pto
fm
anni
tol,
and
und
erg
oin
gp
lace
men
tin
ap
aret
icar
mw
ere
iden
tified
asri
skfa
cto
rsfo
rD
VT
Wils
on
etal
,201
3(2
36)
431
Ret
rosp
ectiv
eco
hort
stud
yC
om
par
eri
skfo
rco
mp
licat
ions
with
PIC
Cs
with
tho
seas
soci
ated
with
CV
Cs
incr
itica
llyill
pat
ient
s
Neu
rosu
rgic
alIC
Up
atie
nts
PIC
C,C
VC
Dur
ing
the
stud
yp
erio
d,4
31un
ique
PIC
Cs
wer
ep
lace
d,w
itha
cum
ulat
ive
inci
den
ceo
fsy
mp
tom
atic
thro
mb
osi
so
f8.4
%,C
LAB
SIo
f2.
8%,a
ndlin
ein
sert
ion–
rela
ted
com
plic
atio
nso
f0.0
%W
ojn
aran
dB
eam
an,
2013
(23)
260
Ret
rosp
ectiv
eco
hort
stud
yEv
alua
tecl
inic
alap
pro
pri
aten
ess
ofP
ICC
use
com
par
edw
ithav
aila
ble
reco
mm
end
atio
ns
PIC
Cin
sert
ion
dur
ing
hosp
italiz
atio
nfo
ran
ycl
inic
alin
dic
atio
n;p
atie
nts
wer
era
ndo
mly
sele
cted
fro
ma
larg
erco
hort
PIC
CR
esul
tssu
gg
estt
hate
ach
pat
ient
had
≥3
ind
icat
ions
for
PIC
Cp
lace
men
t.H
ow
ever
,in
7p
atie
nts,
use
ofP
ICC
sd
idno
tmee
tcu
rren
tCD
Can
dIn
fusi
on
Nur
ses
Soci
ety
reco
mm
end
atio
nsin
that
the
dur
atio
no
fuse
was
<7
day
sW
orl
eyet
al,2
007
(237
)46
8R
etro
spec
tive
coho
rtst
udy
Eval
uate
out
com
esre
late
dto
use
ofP
ICC
sin
asp
ecia
lized
head
ache
trea
tmen
tuni
t46
8ho
spita
lized
adul
tpat
ient
sin
asp
ecia
lized
head
ache
trea
tmen
tuni
tPI
CC
Onl
y2
pat
ient
s(0
.80%
)exp
erie
nced
PIC
C-r
elat
edD
VT;
the
inve
stig
ato
rsco
nclu
ded
that
pat
ient
sw
ithPI
CC
sar
eno
tat
incr
ease
dri
skfo
rU
EDV
Tco
mp
ared
with
oth
erho
spita
lized
pat
ient
sW
ort
het
al,2
009
(238
)66
Pro
spec
tive
coho
rtst
udy
Det
erm
ine
the
natu
ralh
isto
ryan
dra
teo
f,an
dri
skfa
cto
rsfo
r,C
VC
-rel
ated
com
plic
atio
nso
fCLA
BSI
ina
hem
ato
log
yp
op
ulat
ion
106
CV
Cs
(75
PIC
Cs,
31C
VC
s)w
ere
eval
uate
din
66p
atie
nts,
ove
r23
99C
VC
-day
sin
anam
bul
ato
ryco
hort
PIC
C,C
VC
DV
To
ccur
red
in16
case
s(1
5.1%
),ex
it-si
tein
fect
ion
in2
case
s(1
.9%
),an
dC
LAB
SIin
18ca
ses
(7.5
per
1000
CV
C-d
ays)
.No
sig
nific
antd
iffer
ence
sw
ere
foun
dw
hen
com
plic
atio
nra
tes
bet
wee
nPI
CC
and
CV
Cs
wer
eco
mp
ared
Xin
get
al,2
012
(239
)18
7R
etro
spec
tive
coho
rtst
udy
Stud
yth
ein
cid
ence
,dia
gno
sis,
pre
vent
ion,
and
trea
tmen
tofP
ICC
-rel
ated
UED
VT
inp
atie
nts
with
bre
astc
ance
r
187
pat
ient
sw
ithb
reas
tcan
cer
who
rece
ived
aPI
CC
for
chem
oth
erap
yPI
CC
Four
(2.1
%)o
f188
PIC
Cs
wer
ere
mo
ved
asa
resu
lto
fPIC
C-r
elat
edU
EDV
Tin
14–1
12ca
thet
er-d
ays,
ata
rate
of0
.28
per
1000
cath
eter
-day
sY
amad
aet
al,2
010
(240
)21
9Pr
osp
ectiv
eco
hort
stud
yC
lari
fyth
ed
egre
eo
fpat
ient
-per
ceiv
edco
mfo
rtan
dco
nven
ienc
e,in
add
itio
nto
pro
ced
ure-
rela
ted
dis
tres
s,re
sulti
ngfr
om
use
ofP
ICC
sin
term
inal
lyill
pat
ient
sw
ithca
ncer
Am
ong
219
pat
ient
sad
mitt
edto
ap
allia
tive
care
unit,
39(1
8%)u
nder
wen
tPIC
Cp
lace
men
t(a
tota
lof4
4p
roce
dur
esw
ere
per
form
edb
ecau
se5
pat
ient
sun
der
wen
tPIC
Cin
sert
ion
twic
e)
PIC
CPI
CC
sw
ere
safe
lyin
sert
edin
90%
oft
erm
inal
lyill
pat
ient
sw
ithca
ncer
with
in20
min
utes
;al
tho
ugh
30%
oft
hep
atie
nts
exp
erie
nced
tran
sien
tpro
ced
ure-
rela
ted
dis
tres
s,>
90%
felt
that
the
par
ente
ralr
out
ew
asm
ore
com
fort
able
and
conv
enie
ntY
apet
al,2
006
(241
)88
Pro
spec
tive
coho
rtst
udy
Eval
uate
PIC
Cco
mp
licat
ion
rate
sin
2003
afte
rin
tro
duc
tion
ofs
afet
ym
easu
res
and
com
par
eth
emw
ithth
ose
rep
ort
edin
the
sam
ece
nter
in20
01(a
hist
ori
calc
oho
rt)
88PI
CC
lines
wer
ein
sert
edin
73p
atie
nts
und
erra
dio
log
icg
uid
ance
PIC
CTh
eo
vera
llco
mp
licat
ion
rate
was
15.9
%.
Infe
ctio
nsd
evel
op
edin
5.7%
and
thro
mb
otic
even
tso
ccur
red
in4.
5%o
fPI
CC
s.Th
eco
mp
licat
ion
rate
for
2003
was
sig
nific
antly
low
erth
anth
era
tefo
r20
01(P
=0.
006)
,sug
ges
ting
that
stra
teg
ies
tore
duc
ePI
CC
com
plic
atio
nsw
ere
succ
essf
ulY
ieta
l,20
14(2
42)
81Pr
osp
ectiv
eco
hort
stud
yIn
vest
igat
eri
skfa
cto
rsfo
rPI
CC
-rel
ated
DV
Tin
pat
ient
sw
ithca
ncer
Ho
spita
lized
pat
ient
sw
ithca
ncer
sche
dul
edto
rece
ive
PIC
Cs
bet
wee
nSe
pte
mb
er20
09an
dM
ay20
12at
1ce
nter
PIC
CD
iab
etes
incr
ease
dth
eri
skfo
rPI
CC
-rel
ated
DV
Tin
pat
ient
sre
ceiv
ing
chem
oth
erap
y
Con
tinue
don
follo
win
gp
age
SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
S38 Annals of Internal Medicine • Vol. 163 No. 6 (Supplement) • 15 September 2015 www.annals.org
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Tabl
e1—
Co
ntin
ued
Stu
dy,
Yea
r(R
efer
ence
)P
arti
cip
ants
,n
Des
ign
Focu
so
rO
verv
iew
Stu
dy
Sam
ple
and
Ch
arac
teri
stic
sD
evic
eFi
nd
ing
san
dC
om
men
ts
Yue
etal
,201
0(2
43)
400
Pro
spec
tive
coho
rtst
udy
Exam
ine
inse
rtio
n,in
fect
ious
,and
noni
nfec
tious
com
plic
atio
nsre
late
dto
PIC
Cus
ein
pat
ient
sw
ithca
ncer
at1
med
ical
cent
erin
ap
rovi
nce
ofC
hina
400
amb
ulat
ory
pat
ient
sw
ithva
rio
usty
pes
of
canc
erw
hore
ceiv
edPI
CC
sfo
rch
emo
ther
apy
PIC
CD
urin
gin
sert
ion,
arrh
ythm
iao
ccur
red
in1.
5%(6
of4
00)o
fpat
ient
s,d
ifficu
ltca
thet
erth
read
ing
in3.
75%
(15
of4
00),
and
exce
ssiv
eo
ozi
ngo
fblo
od
in0.
3%(1
of4
00).
Dur
ing
the
cath
eter
dw
ell-i
np
erio
d,
sens
itizi
ngd
erm
atiti
so
ccur
red
in8%
(38
of
400)
,mec
hani
calp
hleb
itis
in7.
5%(3
0o
f40
0),c
athe
ter
occ
lusi
on
in9.
5%(3
8o
f400
),ca
thet
er-a
sso
ciat
edhe
mat
og
eno
usin
fect
ion
in3%
(12
of4
00),
and
VT
in2%
(8o
f400
)Zh
uet
al,2
008
(244
)21
70R
etro
spec
tive
coho
rtst
udy
Exam
ine
adve
rse
even
tsan
dri
skfa
cto
rsas
soci
ated
with
such
out
com
esSi
ngle
-cen
ter
stud
yo
fpat
ient
sun
der
go
ing
PIC
Cp
lace
men
tfo
rva
rio
usin
dic
atio
nsPI
CC
6ca
ses
ofD
VT
and
2ca
ses
ofb
acte
rem
iao
ccur
red
;DV
Tse
emed
tob
ere
late
dto
adva
nced
canc
er,n
onc
entr
alPI
CC
tipp
osi
tion,
coro
nary
arte
ryd
isea
se,d
iab
etes
,an
dhy
per
lipid
emia
Zing
get
al,2
011
(87)
292
Pro
spec
tive
coho
rtst
udy
Qua
ntify
the
ind
icat
ions
for
cath
eter
pla
cem
ento
ver
dw
ellt
ime
and
inve
stig
ate
agre
emen
tbet
wee
nhe
alth
care
wo
rker
so
nC
VC
use
378
CV
Cs
in29
2p
atie
nts,
acco
untin
gfo
r27
04ca
thet
er-d
ays
CV
CTh
em
ost
freq
uent
reas
on
(49%
)fo
rca
thet
erus
ew
asp
rolo
nged
(>7
d)a
ntib
iotic
ther
apy,
follo
wed
by
par
ente
raln
utri
tion
(22.
3%).
Ato
talo
f130
cath
eter
-day
s(4
.8%
)wer
eun
nece
ssar
y,w
itha
hig
her
pro
po
rtio
nin
non-
ICU
sett
ing
s(6
.6%
).In
35o
n-si
tevi
sits
(8.3
%)i
nno
n-IC
Use
ttin
gs,
neith
erth
enu
rse
nor
the
trea
ting
phy
sici
ankn
eww
hyth
eca
thet
erw
asin
pla
ceZo
chio
set
al,2
014
(245
)N
ASy
stem
atic
revi
ewR
evie
wth
elit
erat
ure
surr
oun
din
gPI
CC
san
dhi
ghl
ight
the
epid
emio
log
y,p
atho
phy
sio
log
y,d
iag
nosi
s,an
dm
anag
emen
tofP
ICC
-rel
ated
thro
mb
osi
sin
criti
cally
illp
atie
nts
Syst
emat
icre
view
exam
inin
gri
skfa
cto
rsfo
ran
dd
iag
nosi
san
dtr
eatm
ento
fPIC
C-r
elat
edD
VT
incr
itica
llyill
po
pul
atio
ns
PIC
CTh
ein
cid
ence
ofP
ICC
-rel
ated
thro
mb
osi
sin
criti
cally
illp
atie
nts
isun
clea
r.U
Sis
the
pre
ferr
edd
iag
nost
icim
agin
gm
od
ality
.No
RC
Tso
nb
estt
reat
men
tofP
ICC
-rel
ated
thro
mb
osi
sin
the
ICU
sett
ing
toin
form
pra
ctic
ear
eav
aila
ble
Zwic
ker
etal
,201
4(5
3)N
ASy
stem
atic
revi
ewan
dg
uid
elin
ePr
ovi
de
reco
mm
end
atio
nsfo
rd
iag
nosi
san
dm
anag
emen
tofC
VC
-ass
oci
ated
DV
Tin
pat
ient
sw
ithca
ncer
Syst
emat
icre
view
oft
helit
erat
ure
and
exp
ert
op
inio
nfr
om
ag
uid
elin
ew
ritin
gp
anel
oft
heIn
tern
atio
nalS
oci
ety
on
Thro
mb
osi
san
dH
aem
ost
asis
PIC
C,C
VC
US
isre
com
men
ded
asth
ein
itial
test
of
cho
ice.
Ro
utin
ead
min
istr
atio
no
fp
harm
aco
log
icp
rop
hyla
xis
top
reve
ntD
VT
isno
trec
om
men
ded
.Ant
ico
agul
atio
nw
ithLM
WH
with
out
rem
ova
loft
heca
thet
erif
clin
ical
lyne
cess
ary
isre
com
men
ded
BSI
=b
loo
dst
ream
infe
ctio
n;C
DC
=C
ente
rsfo
rD
isea
seC
ont
rola
ndPr
even
tion;
CK
D=
chro
nic
kid
ney
dis
ease
;CLA
BSI
=ce
ntra
llin
e–as
soci
ated
blo
od
stre
amin
fect
ion;
CR
BSI
=ca
thet
er-r
elat
edb
loo
dst
ream
infe
ctio
n;C
RT
=ca
thet
er-r
elat
edth
rom
bo
sis;
CT
=co
mp
uted
tom
og
rap
hy;
CV
AD
=ce
ntra
lven
ous
acce
ssd
evic
e;C
VC
=ce
ntra
lven
ous
cath
eter
;D
VT
=d
eep
veno
usth
rom
bo
sis;
ED=
emer
gen
cyd
epar
tmen
t;EK
G=
elec
tro
card
iog
rap
hy;
ESA
=er
ythr
op
oie
sis-
stim
ulat
ing
agen
t;G
RA
DE
=G
rad
ing
of
Rec
om
men
dat
ions
Ass
essm
ent,
Dev
elo
pm
ent
and
Eval
uatio
n;IC
U=
inte
nsiv
eca
reun
it;IR
=in
terv
entio
nalr
adio
log
y;IV
=in
trav
eno
us;
IVD
=in
trav
eno
usd
evic
e;LM
WH
=lo
w-m
ole
cula
r-w
eig
hthe
par
in;
NA
=no
tap
plic
able
;N
R=
not
rep
ort
ed;
PE=
pul
mo
nary
emb
olis
m;P
ICC
=p
erip
hera
llyin
sert
edce
ntra
lcat
hete
r;PI
VC
=p
erip
hera
lIV
cath
eter
;QI=
qua
lity
imp
rove
men
t;R
CT
=ra
ndo
miz
ed,c
ont
rolle
dtr
ial;
SVC
=su
per
ior
vena
cava
;TC
VC
=tu
nnel
edce
ntra
lven
ous
cath
eter
;tPA
=tis
sue
pla
smin
og
enac
tivat
or;
TPN
=to
talp
aren
tera
lnut
ritio
n;U
CLA
=U
nive
rsity
Cal
iforn
ia,L
os
Ang
eles
;UED
VT
=up
per
-ext
rem
ityd
eep
veno
usth
rom
bo
sis;
US
=ul
tras
ono
gra
phy
;V
A=
Vet
eran
sA
ffair
s;V
AD
=ve
nous
acce
ssd
evic
e;V
T=
veno
usth
rom
bo
sis;
VTE
=ve
nous
thro
mb
oem
bo
lism
.
Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) SUPPLEMENT
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SUPPLEMENT Michigan Appropriateness Guide for Intravenous Catheters (MAGIC)
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Appendix Table 1. Literature Search Strategy
Search Query Items Found, n
PubMed (searched9 March 2013)
#23 (#8 not (#12 or #21 or #22)) 1109#22 (("Case Reports"[pt] or "case report"[Title])) 1 664 821#21 (#19 not #20) 455 878#8 ((#3 OR #4) AND #7) 1542#20 (#16 or #17) 769 402#19 (#13 or #18) 507 993#17 ((#3 OR #4) AND #7) Filters: Adult: 19+ years 577#16 adult*[Title/Abstract] 768 894#13 ((#3 OR #4) AND #7) Filters: Child: birth-18 years 417#18 (pediatric or neonat*[Title]) 507 773#12 (#9 NOT (#10 or 11)) 56#10 ((#3 OR #4) AND #7) Filters: Humans 1435#9 ((#3 OR #4) AND #7) Filters: Other Animals 82#11 (human* or patient*[Title/Abstract]) 6 257 942#7 ("Guideline" [Publication Type] OR "Guidelines as Topic"[Mesh] OR "Practice Guideline" [Publication
Type] OR "Unnecessary Procedures" [MeSH] or (appropriate* or inappropriate* or indicat* orguideline* or unnecessary[Title/Abstract]))
2 824 018
#4 "peripherally inserted central catheter*" OR "peripherally inserted" or picc*[Title/Abstract] 1474#3 "Catheterization, Central Venous"[Majr] 8919
CINAHL 325S24 S20 not S23S23 S21 NOT S22S22 S20 Limiters–Age Groups: All AdultS21 S18 AND S19 Limiters–Age Groups: All ChildS20 S18 AND S19S19 S16 OR S17S18 TI (appropriate* or inappropriate* or indicat* or guideline* or unnecessary) OR AB ( appropriate* or
inappropriate* or indicat* or guideline* or unnecessary)S17 TI ("peripherally inserted central catheter*" OR "peripherally inserted" or picc*) OR AB (
"peripherally inserted central catheter*" OR "peripherally inserted" or picc*)S16 (MH "Catheter Care, Vascular+") OR (MH "Central Venous Catheters+")
Google Scholar "peripherally inserted central catheter*" AND (appropriate* or inappropriate* or indicat* orguideline* or unnecessary)
134 (only 131 imported)
ClinicalTrials.gov(searched 9 April2013)
peripherally inserted central catheter* or picc* 40
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Appendix Table 2. Characteristics of MAGIC Panel Members
Panelist Title Affiliation Clinical Specialty Area of Technical Expertise
Agnes Y. Lee, MD, PhD Medical Director, ThrombosisProgram; AssociateProfessor of Medicine
University of British Columbia;Vancouver Coastal Health;British Columbia CancerAgency; Vancouver, BritishColumbia, Canada
Hematology andoncology
Thrombosis in cancer patients
Anthony Courey, MD Assistant Professor ofMedicine
University of Michigan, AnnArbor, MI
Critical care Vascular access and use ofultrasound in critically illpatients
Elie Akl, MD, MPH, PhD Director, ClincialEpidemiology Unit;Co-director, Center forSystematic Reviews inHealth Policy and SystemsResearch (SPARK)
American University, Beirut,Lebanon; Department ofClinical Epidemiology andBiostatistics, McMasterUniversity, Hamilton, Ontario,Canada
Internal medicine;hospitalmedicine
Guideline development,thrombosis,evidence-based medicine
Jack LeDonne, MD Director of Vascular AccessPrograms; Past President,Association of VascularAcccess
Greater Baltimore MedicalCenter, Baltimore, MD
General surgery Vascular access in generalmedical and surgicalpatients
Mauro Pittiruti, MD Director of Vascular AccessDirector, GAVeCeLT
Catholic University, Rome, Italy General surgery Vascular access
Nancy Moureau, RN Chief Executive Office;Director of VascularEducation
PICC Excellence, Inc., Hartwell,GA
Vascular accessnursingeducation
Vascular access
Naomi O'Grady, MD,PhD
Director of Procedures,Vascular Access andConcious Sedation
National Institutes of HealthClinical Center, Bethesda,MD
Critical care Guideline development,central line–associatedbloodstream infection,critical care
Nasia Safdar, MD, PhD Associate Professor ofMedicine; Medical Director,Infection Control; AssociateChief of Staff for Research
University of Wisconsin; WilliamS. Middleton MemorialVeterans Hospital; Madison,WI
Infectiousdiseases
Central line-associatedbloodstream infection
Rajiv Saran, MD, MRCP,MS
Professor of Medicine andEpidemiology; Director, USRenal Data SystemCoordinating Center;Associate Director, KidneyEpidemiology and CostCenter, University ofMichigan
University of MichiganAnn Arbor, MI
Nephrology Chronic kidney disease;vascular access in patientswith end-stage renaldisease
Lakshmi Swaminathan,MD
Staff Hospitalist; PhysicianChampion, HMS PICCQuality ImprovementProject*
Oakwood Health System,Dearborn, MI
Internal medicine Hospital medicine; patientsafety; quality improvementin hospitalized medicalpatients
Scott O. Trerotola, MD Professor of Radiology;Associate Chair and Chief ofInterventional Radiology
University of Pennsylvania,Philadelphia, PA
Interventionalradiology
Guideline development;vascular access
Dana Wanschneider, RN Vascular Access Nurse St. Josephs Mercy HealthSystem, Ann Arbor, MI
Vascular access Vascular access; nursing
Scott C. Woller, MD Associate Professor ofMedicine
Intermountain Medical Center;University of Utah School ofMedicine, Salt Lake City, UT
Internal medicine Venous thromboembolism;anticoagulationmanagement
Stephen Wiseman,PharmD
Clinical Pharmacy Specialist;Assistant Professor ofPharmacy
University of Michigan; VA AnnArbor Healthcare SystemAnn Arbor, MI
Pharmacology Infectious diseases; homeintravenous therapy;management of parenteraltherapy
Georgiann Ziegler Patient Representative University of Michigan HealthSystem
– Personally experiencedmultiple vascular accessdevices; insights into thepatient experience
GAVeCeLT = Gruppo Aperto di Studio 'Gli Accessi Venosi Centrali a Lungo Termine; HMS = Hospital Medicine Safety Consortium; MAGIC =Michigan Appropriateness Guide for Intravenous Catheters; PICC = peripherally inserted central catheter; VA = Veterans Affairs.* A Blue Cross Blue Shield–funded collaborative quality initative focused on improving PICC use in hospitalized medical patients in 47 particiatinghositals in the State of Michigan.
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Appendix Table 3. Sample Lists of Thematic Concerns Raised by Panelists*
Theme or Area Question or Top Concern
Appropriateness of PICC placementand concerns regarding deviceselection
Is the request for a PICC appropriate for what is needed (i.e., does the entity to be infused require a PICC, orwill a midline or peripheral catheter suffice?
Overuse of PICC for long-term care when tunneled, cuffed catheters (Hickman, cuffed Groshong, Broviac, etc.)or port would be more appropriate
PICCs ordered or maintained for blood draws—is this appropriate?PICCs ordered without trying other devicesPICCs ordered when all else fails for 1–3 doses of an infusion—is insertion appropriate?
Issues related to device insertionand selection of PICCcharacteristics
Is location of the tip of the catheter in the right atrium acceptable?Are dedicated lumens for parenteral nutrition still needed?How many lumens are appropriate for a given use?
Process concerns regardingutilization
Increasing use of PICCs when peripheral catheters may work? How can we drive this down?Unnecessary number/size of PICC lumensImplications of ordering chest radiographs for "PICC placement only" that are otherwise abnormalPatient “requested” PICC line appropriatenessHow do we resolve disagreement with radiology on where a PICC is located on chest radiograph?Strategies to minimize idle PICC-daysWhen should PICC tips be adjusted for optimal positioning?
Identifying best practices fortreatment and prevention ofPICC-related DVT
Optimal treatment is undefined. That covers everything from line removal? Anticoagulation? Duration andintensity of anticoagulation
Prophylaxis: Is primary prophylaxis indicated in those with "high-risk" factors? What are these factors, and if theyare present, how do we provide primary prophylaxis?
Prophylaxis: Is secondary prophylaxis indicated? I've had many patients who had a CRT as the index thromboticevent but then re-present with a DVT/PE. Is the risk for recurrence high enough to warrant secondaryprophylaxis? If a patient develops DVT and still requires central venous access, should we leave the catheterin situ?
If a symptomatic DVT is not improving clinically with a PICC in situ, how long should we wait before removingthe PICC or calling IR?
Management of specificcomplications
If a PICC is pulled out from original position, how far can it migrate out before it has to be pulled/replaced?Is it appropriate to empirically pull a PICC without other evidence of line infection?PICC in place when bacteremia occurs but no evidence of CLABSI—remove or treat through?Optimal timing of placement in bacteremia for long-term antibiotic treatment?
CLABSI = central line–associated bloodstream infection; CRT = catheter-related thrombosis; DVT = deep venous thrombosis; IR = interventionalradiology; PE = pulmonary embolism; PICC = peripherally inserted central catheter.* Edited by the authors for readability. Questions were selected at random from several panelists to illustrate the depth and breadth of focus.
Appendix Table 4. Example Scenarios From Ratings Material
How appropriate is theuse of each of thefollowing vascularaccess devices toobtain venous accessfor infusion oftherapeutics and/orlab draws in a patientwho is likely tobe hospitalized for apotential duration of:*
PeripheralIV Catheter
US-GuidedPeripheralIV Catheter
MidlineCatheter
PICC NontunneledCVC
Tunneled,CuffedCatheter
Port
≤5 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 96–14 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 915–30 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9≥31 d? 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9
Compared with PICCs, how preferable is the use of a midline in a hospitalized medical patient who requiresvenous access for infusion of a nonirritant, nonvesicant therapy for a proposed duration of:
Preference ofMidline Catheter vs.PICC†
≤5 d? 1 2 3 4 5 6 7 8 96–14 d? 1 2 3 4 5 6 7 8 915–30 d? 1 2 3 4 5 6 7 8 9≥31 d? 1 2 3 4 5 6 7 8 9
CVC = central venous catheter; IV = intravenous; PICC = peripherally inserted central catheter; US = ultrasonography.* Rating scale: 1 = highly inappropriate; 5 = neutral or uncertain; 9 = highly appropriate.† Prefer midline catheter = 1; prefer PICC = 9.
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Question 1: The RAND/UCLA Appropriateness Method was developed to:A. Examine risks and benefits of medical and surgical procedures, regardless of their cost to estimate the over-
or underuse of specific medical and surgical proceduresB. To determine whether specific medical interventions are cost-effective.C. Develop consensus regarding appropriate medical and surgical procedures from a multidisciplinary panel.D. To determine whether insurers should cover the cost of an intervention
Question 2: According to the RAND/UCLA Appropriateness Method, which of the following is the hallmark of an“appropriate” rating?
A. When all participating panelists agree on the appropriateness of a clinical scenario.B. When the expected health benefits exceed the expected negative consequences and the panel median rating
is 7 to 9 without disagreement.C. When the majority of the panel rates the clinical scenario as highly appropriate.D. When no panel member rates the clinical scenario as inappropriate.
Question 3: According to the RAND/UCLA Appropriateness Method, which of the following indicates an “uncertain”rating?
A. When the panel median ranges from 4 to 6, or there is disagreement regardless of the median.B. When the panel median ranges from 1 to 3.C. When the panel median ranges from 7 to 9.D. When the panel median ranges from 5 to 7.
Question 4: Which of the following information sources was not used to develop the clinical scenarios for rating theappropriateness of various intravenous devices in this document?
A. Systematic reviews of the literatureB. List of controversial topics/key problems generated by expertsC. Clinical areas of ambiguity, controversy, or uncertaintyD. Medicare coverage of the procedure
Question 5: For this project, which of the following elements was NOT used to develop the clinical scenarios orindications that were rated by panelists?
A. Proposed duration of venous accessB. Device characteristicsC. Patient preferenceD. Maintenance and care practices
Question 6: In this project, a multidisciplinary panel of experts rated the appropriateness of a number of vascularaccess devices. Which of the following indications were rated as appropriate for use of peripherally inserted centralcatheters?
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A. Placement in a patient with active cancer for cyclical chemotherapy that can be administered through aperipheral vein, when the proposed duration of such treatment is 3 months or less and peripheral veins areavailable.
B. Delivery of non–peripherally compatible infusates (e.g., irritants/vesicants) regardless of proposed duration ofuse.
C. Patient or family requests for a patient who is not actively dying/on hospice for comfort from daily lab draws.D. Medical or nursing provider request in the absence of other appropriate criteria for peripherally inserted
central catheter use.
Question 7: In this project, a multidisciplinary panel of experts rated the appropriateness of practices associated witha number of venous access devices. Which of the following practices were rated as appropriate for peripherallyinserted central catheter insertion?
A. Urgent requests for peripherally inserted central catheter placement in a hemodynamically unstable patient inthe wards or intensive care unit setting.
B. Routine use of chest radiographs to verify peripherally inserted central catheter tip positioning followinguneventful placement via EKG guidance or fluoroscopy by staff who are technically proficient in this technology.
C. Preferential placement of a peripherally inserted central catheter based on the patient’s arm dominance.D. Consult with a relevant specialist (e.g., infectious disease, heme-oncology), operator (vascular access profes-
sional), and/or hospital pharmacist prior to ordering a peripherally inserted central catheter to determineoptimal device choice and characteristics.
Question 8: Which of the following were rated as an appropriate practice for peripherally inserted central cathetercare or maintenance by this multidisciplinary panel?
A. Removal of a peripherally inserted central catheter by a health care team member trained to remove centralvenous catheters, but not specifically trained to remove a peripherally inserted central catheter.
B. Removal of a peripherally inserted central catheter that is clinically necessary, centrally positioned, andotherwise functional in the setting of arm deep venous thrombosis.
C. Use of normal saline rather than heparin to flush a peripherally inserted central catheter following infusion orphlebotomy.
D. Routine removal and/or replacement of a peripherally inserted central catheter that remains clinically neces-sary without objective evidence of catheter-associated bloodstream infection in febrile patients.
Question 9: Which of the following was rated as an appropriate practice when caring for peripheral intravenouscatheters?
A. Routine replacement or continuation of a peripheral intravenous catheter in the absence of a clinical indica-tion warranting continued use.
B. Removal of a peripheral intravenous catheter in the setting of redness, swelling, pain, or phlebitis over thevein of insertion.
C. Replacement of a peripheral intravenous catheter on the basis of a routine schedule in the absence ofredness, swelling, or other signs of inflammation.
D. Removal of a functioning peripheral intravenous catheter because it was inserted in the field (e.g., ambulanceor nonhospital site) in the absence of redness, tenderness, or swelling over the insertion site.
Question 10: For the indication of infusion of peripherally compatible fluids, which of the following vascular accessdevices was rated as neutral for a proposed infusion for 6 to 14 days?
A. Ultrasound-guided peripheral intravenous cathetersB. MidlinesC. Peripherally inserted central cathetersD. Peripheral intravenous catheters
Question 11: For the infusion of peripherally compatible fluids, which of the following vascular access devices wererated as inappropriate for a proposed duration of 31 days or more?
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A. Peripherally inserted central cathetersB. Ultrasound-guided peripheral IVsC. Implanted portsD. Tunneled catheters
Question 12: According to the Fistula First Breakthrough Initiative, in what stages of chronic kidney disease may useof peripherally inserted central catheters be considered appropriate following expert consultation with nephrology?
A. Stage 1 onlyB. Stage 3b or greaterC. Stage 2 onlyD. Stage 1 to 3a
Question 13: For the infusion of peripherally noncompatible fluids in critically ill patients, which of the followingvascular access devices were rated as appropriate and preferred for a proposed duration of 5 days or less?
A. Nontunneled central venous cathetersB. Tunneled cathetersC. Peripheral intravenous cathetersD. Midlines
Question 14: For patients with difficult peripheral venous access, which of the following pairs of vascular accessdevices were rated as appropriate and preferred to peripherally inserted central catheters when the proposedduration of use is 14 days or less?
A. Midlines and portsB. Nontunneled central venous catheters and portsC. Midlines and central venous cathetersD. Tunneled-cuffed catheters and peripherally intravenous catheters
Question 15: According to our panel, which of the following was rated as appropriate for the treatment of periph-erally inserted central catheter-related deep venous thrombosis?
A. Provide at least 1 month of uninterrupted systemic anticoagulation.B. Low-molecular-weight heparin over warfarin in patients with cancer.C. Remove the peripherally inserted central catheter and replace this with another device to prevent clot
propagation.D. Refer all patients with peripherally inserted central catheter-related deep venous thrombosis to interventional
radiology for evaluation.
Question 16: Among scenarios examining use of vascular access devices in patients that require frequent phlebot-omy, which of the following statements are true?
A. Central venous catheters were rated as appropriate and preferred to peripherally inserted central catheterswhen the expected duration of venous access was 14 days or less in critically ill patients.
B. Ports were rated as appropriate to use in this population, regardless of duration of use.C. Peripheral intravenous catheters and ultrasound-guided peripheral intravenous catheters were rated as ap-
propriate for use for 5 days or less in patients that require frequent phlebotomy.D. The most appropriate vascular access device should be determined by patient preference in this setting.
Question 17: Among patients who require frequent phlebotomy for less than 5 days, which of the following resultedin panelist disagreement regarding appropriateness of device use?
A. MidlinesB. Central venous cathetersC. Peripherally inserted central cathetersD. Ports
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Question 18: Among patients receiving peripherally compatible infusions in home-based or skilled nursing facilities,which of the following expected durations of use was rated as being appropriate for peripherally inserted centralcatheter placement?
A. 6 to 14 daysB. Only 15 to 30 daysC. Only more than 30 daysD. More than 15 days
Question 19: Among patients who are likely to require lifelong venous access but are infrequently hospitalized (<5times per year), when is use of peripherally inserted central catheters considered appropriate according to thispanel?
A. When expected duration of venous access is 5 days or less.B. When the expected duration of venous access is 6 to 14 days.C. When the expected duration of venous access is 15 or more days.D. When the expected duration of access is not well-known.
Question 20: In critically ill populations, which of the following expected durations of venous access were rated asappropriate for midline insertion and use?
A. 5 days or lessB. 6 to 14 daysC. 15 to 30 daysD. More than 30 days
Question 21: A patient is diagnosed with active cancer and is recommended multiple cycles of nonvesicant, inter-mittent chemotherapy that can be administered into a peripheral vein for a total duration of 1 month. Based on therecommendations of this panel, which of the following vascular access devices is considered appropriate for this patient?
A. Peripherally inserted central cathetersB. Intermittent use of peripheral intravenous cathetersC. PortsD. Tunneled-cuffed catheters
Question 22: A patient with an unknown stage of chronic kidney disease is admitted to the hospital with pneumoniaand is likely to require venous access for 5 days or less. However, the patient is a “difficult stick” and nurses arehaving trouble establishing reliable peripheral access. According to this panel, which of the following are appropri-ate in this particular setting?
A. Because of the ambiguity regarding the stage of CKD, consultation with nephrology is appropriate prior toperipherally inserted central catheter insertion for any reason.
B. Should the patient be determined to have stage 3b or greater CKD or is possibly a candidate for hemodialysis(with estimated GFR < 45 mL/min), insertion of a peripherally inserted central catheter is appropriate.
C. If peripheral venous access for 5 days or less is likely, placement of a peripheral intravenous catheter in thedorsum of the hand is considered inappropriate.
D. Should longer-term intravenous antibiotics be necessary, placement of a small-bore central catheter forinfusion of 14 days of intravenous antibiotics is inappropriate in patients with stage 3b or greater CKD.
Question 23: A patient is being discharged from the hospital to a local skilled nursing facility for continuation of aplanned 6 weeks of intravenous antibiotics. According this panel, which of the following vascular access devices areconsidered appropriate for this patient in this scenario?
A. Nontunneled central venous catheterB. Peripheral intravenous catheterC. MidlineD. Peripherally inserted central catheter
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Question 24: A patient with an existing peripherally inserted central catheter is admitted to the hospital. A portablechest radiograph performed to ascertain the catheter tip position shows this to be located approximately 1 cm withinthe right atrium. Based on the recommendations of this panel, which of the following is the most appropriate nextcourse of action?
A. Adjust peripherally inserted central catheter so as to localize the catheter tip in the cavoatrial junction; repeatchest radiography to confirm.
B. No further action is needed; the catheter is well-positioned and okay to use.C. Withdraw tip so as to localize the catheter tip in the lower third of the superior vena cava.D. Perform computed tomography to confirm catheter placement.
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