Support Care Cancer (2010) 18:1293–1298 DOI 10.1007/s00520-009-0747-7

ORIGINAL ARTICLE

Efficacy of multifaceted interventions in reducing complications of peripherally inserted central catheter in adult oncology patients Geng Tian & Yan Zhu & Li Qi & Fengqin Guo & Haidan Xu

Received: 20 July 2009 / Accepted: 15 September 2009 / Published online: 29 September 2009 # Springer-Verlag 2009

Abstract Purpose To evaluate the efficacy of multifaceted interventions in reducing complications of peripherally inserted central venous catheter (PICC) in adult oncology patients. Methods Multifaceted interventions were implemented in our department in December 2006. These interventions include: (1) A mandatory nurse reeducation was developed by a multidisciplinary task force; (2) Modification of peripherally inserted central catheter insertion: take a chest X-ray before removal of the guidewire and cutting of the catheter. The guidewire in the catheter facilitates the accurate location of the tip of PICC on chest X-ray and make the malposition correction (withdrawing, reinsertion, even reinsertion following withdrawal) easily; (3) Using a 2% chlorhexidine preparation, replace 10% povidone iodine for skin antisepsis; (4) Maintenance of maximum sterile barrier precautions during PICC insertion and aftercare; (5) Designing of a PICC archive form and establishing a PICC archive for each patient. The PICC complication rates of groups before and after interventions were evaluated and compared. Results Sixty-nine PICC lines were inserted before these interventions, and 165 were inserted after implementation of these interventions. Compared with preintervention group, the postintervention group was associated with a 62.14% decrease in the overall complication rate (11.52% vs 30.43%

G. Tian (*) : Y. Zhu : L. Qi : F. Guo : H. Xu Department of Tumor, Shenzhen Second People’s Hospital, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Shenzhen 518035, People’s Republic of China e-mail: [email protected]

[P=0.0004]; incidence density, 1.82 vs 4.62 per 1,000 PICC days) with a 67.48% decrease in the infective complications rate (4.24% vs 13.04% [P=0.015]) with a 58.19% decrease in the noninfective complications rate (7.27% vs 17.39% [P=0.0199]). Conclusions The results suggest that these interventions implemented in this study may be help in reducing complications of PICC in adult oncology patients. Keywords Peripherally inserted central catheter (PICC) . Chemotherapy . Complication . Oncology

Introduction Peripherally inserted central venous catheter (PICC) has been demonstrated to be an outstanding tool for providing long-term intravascular access in oncology patients [1, 2]. It has also been shown that the complication rate in cancer patients appears to be higher than that in other patients probably due to immunocompromise and prothrombotic tendency [3]. A retrospective study found that 40.7% of PICC lines (11 out of 27) inserted in medical oncology patients developed complications requiring early removal of the PICC [3]. Other published studies showed similarly or even high complication rates in cancer patients [4, 5, 23]. The PICC nursing team of our department includes four nurses who got their PICC qualification after finishing the PICC training given by the PICC company. At the early stage of using PICC in adult cancer patients, we met various kinds of PICC-associated complications. We also observed some problems in the clinical use of PICC. Although the PICC is radiopaque, sometimes the catheter

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tips cannot be localized clearly on the standard frontal chest radiograph. The blind-placed PICC had a nonoptimal initial PICC tip position required additional manipulation, such as reinsertion or withdrawal. Withdrawing a catheter without guidewire from the vein is easy, but reinsertion is difficult, and most of time, it is impossible. In order to improve the PICC insertion skills and reduce the rate of PICC complications at our department, several interventions have been implemented in the area of PICC insertion practice and aftercare. Here, we carried out a clinical investigation to determine whether these interventions could decrease the rate of PICC-associated complications in the tumor department of a teaching hospital.

Materials and methods Study population and design Multifaceted interventions have been implemented in our department in the area of PICC insertion practice and aftercare since December 2006. Two patient groups are investigated in this study. Preintervention group include all medical oncology patients at our department who underwent PICC line insertion between 1 August 2004 and 31 November 2006. Postintervention group include patients between 1 January 2007 and 31 October 2008, after implementation of the interventions. The data was collected retrospectively for preintervention group and prospectively for postintervention group. Patient selection criteria for PICC remain unchanged. The written informed consents were obtained from all patients before PICC insertion. All PICC lines of two groups are inserted by a nurse of PICC nursing team of four nurses of our department. The PICC aftercare of two groups is conducted by a nurse of the IV team of our department. The singlelumen Bard Groshong PICC (Bard Access Systems, Salt Lake City, UT) 4 Fr catheters are used in our oncology patients. The project was approved by the hospital ethics committee as a quality improvement project. Interventions The interventions include: (1) A mandatory nurse reeducation was developed by a multidisciplinary task force; (2) Modification of peripherally inserted central catheter insertion: take a chest X-ray before removal of the guidewire and cutting of the catheter; (3) Using a 2% chlorhexidine preparation, replace 10% povidone iodine for skin antisepsis; (4) Maintenance of maximum sterile barrier precautions during PICC insertion and aftercare; (5) Designing of a PICC archive form and establishing a PICC archive for each patient.

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Nurse reeducation A mandatory education program directed toward all nurses of PICC nursing team and IV team in the tumor department was developed by a multidisciplinary task force to highlight correct practices for the prevention of catheter-associated complications. The program consisted of: (1) a 60-min lecture give by a specialist of hospital infection control team of our hospital on maintenance of maximum sterile barrier precautions during PICC insertion and aftercare. The lecture content mainly comes from the Centers for Disease Control and Prevention, Society of Critical Care Medicine, Society of Healthcare Epidemiologists of America, and Infectious Disease Society of America prevention of catheter infection guidelines [6]; (2) a 60-min lecture give by a surgeon on PICC-associated anatomy and the observation and diagnosis of complications; (3) a 60-min lecture give by a radiologist on how to determining the location of the tip of PICC by chest X-ray after insertion. Insertion modification Because the external measurement can never exactly duplicate the internal venous anatomy, sometimes, the tip of PICC is not in the superior vena cava (SVC), and sometimes, the tip of PICC is in the SVC but not in the most appropriate location, the lower third of SVC. It is difficult to reposition catheter without a guidewire. In order to place the catheter tip in the most appropriate location, the insertion practice in our department was modified. Just after PICC insertion, before removal of the guidewire and cutting of the catheter, the patient is transported to the radiology with a temporary aseptic towel dressing the arm with PICC, and for patient lying in bed, a portable X-ray equipment will be brought into the patient's room while sterile technique is maintained by the insertion team. A chest X-ray will be taken to identify where the catheter was inserted, the approximate size of the catheter, the route taken, and where the catheter tip is. With a guidewire in the catheter, the catheter and the tip can be seen clearly on the picture. If the catheter was inserted in a wrong route or the tip of PICC was not at the appropriate location, the catheter can be withdrawn and reinserted easily with the guidewire in it. Maximum sterile barrier during PICC insertion and aftercare The first lecture of reeducation was designed to increase nurse awareness of infection control practices including appropriate use of hand hygiene, chlorhexidine skin preparation, maximum sterile precautions during PICC

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insertion, maintaining a sterile field while inserting the catheter, and the care of central catheters once inserted. The importance of washing hands and wearing gloves for any contact with PICCs is emphasized during education. Peripherally inserted central catheter line dressings are changed the day after insertion to remove any clotted blood, which could serve as a nidus for infection, and thereafter, on at least a weekly basis. PICC archive form We designed a PICC nurse archive form and established a PICC nurse archive for each patient including the information of weekly PICC line review at our department. The following information was collected and recorded: gender, age, cancer type, indication for PICC, type of chemotherapy, site of insertion, date of PICC insertion, date of PICC removal, date of each PICC nurse (include change dressings, tube sealing, change heparin cap), dwell time, reason for PICC removal, and nature and timing of complication requiring PICC removal. The archive form has an appendix of “Notice for Patient with PICC” which has eight announcements about PICC care. These announcements cover information about the importance of hygiene, what the patient should do and should not do during the daily life, and teaching the patient to seek nursing or medical attention if problems such as pain, swelling, itching, or erythema develop. The patient will have a copy of the archive form after the insertion so they can consult the announcements conveniently. Complications We used the following definitions: (a) Definite catheter-related bloodstream infection (CRBSI) isolation of the same organism (identical species, antibiogram) from the catheter segment and the blood drawn from peripheral vein in the patient with clinical symptoms of BSI and no other apparent source of infection [7]. (b) Probable CRBSI - positive culture either from catheter segment or peripheral blood (in the patient with clinical symptoms of BSI and no other apparent source of infection) and defervescence within 48 h of catheter removal and initiation of appropriate antibiotic therapy [7]. (c) Entry-site infection was defined by purulence at the site [8]. (d) Phlebitis - local pain, warmth, tenderness, erythema, and a palpable cord along the vein, or by positive sonographic examination in conjunction with erythema and edema of the extremity [9].

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Statistical analysis For the analysis, we counted each PICC placement as the unit for counting. The major complications requiring premature PICC removal rather than minor complications were analyzed. Data were analyzed using the SPSS program (SPSS Inc., Chicago, IL). We considered P values of less than 0.05 to be statistically significant. The χ2 test was applied to evaluate differences in overall complication rates, infective complication rates, and noninfective complication rates between the two groups.

Results The baseline characteristics of patients in both groups are shown in Table 1. Sixty-seven PICCs were in place for a total of 4,526 PICC days (median time, 48 days; range, 2–358 days; mean, 65.62 days) in the preintervention group, and 165 PICCs were in place for a total of 10,322 PICC days (median time, 45 days; range, 3–326 days; mean, 62.62 days) in postintervention group. Two patients in preintervention group and four patients in postintervention group had two PICCs inserted in. The exact date of PICC removal for two patients in preintervention group and five patients in postintervention group was unclear, and for the analysis, the dwell time was considered to be the duration up until the next day after the PICC was last reviewed. The nature and distribution of the complications in two groups are summarized in Table 2. In preintervention group, twenty-one PICCs (30.43%) were removed due to complications—nine (13.04%) of them were removed due to infective complications, and twelve (17.39%) of them were removed due to noninfective complications. The complication rate of 30.43% equates to 4.62 complications per 1,000 PICC days. Thirteen PICCs (18.84%) were still in situ at the time of death. In the postintervention group, nineteen PICCs (11.52%) were removed due to complications—seven (4.24%) of them were removed due to infective complications, and twelve (7.27%) of them were removed due to noninfective complications. The complication rate of 11.52% equates to 1.82 complications per 1,000 PICC days. Twenty-two PICCs (13.33%) were still in situ at the time of death. There were no PICC-related deaths in both groups. In none of the patients, who died with the PICC in situ, was PICC-related complication the cause of death in both groups. Comparing the results of the two groups (Fig. 1), the overall complication rate has decreased significantly from 30.43% (21/69) to 11.52% (19/165; P=0.0004). The infective complication rate has decreased significantly from

1296 Table 1 Patient characteristics

Support Care Cancer (2010) 18:1293–1298 Characteristic

Gender Male Female Age (years) ≤40 41–50 51–60 61–70 >70 Underlying cancer type Gastrointestinal Lung Hepatobiliary Breast Head and neck Gynecological Kidney Lymphoma Melanoma Soft tissue Unknown primary Indication for PICC Intermittent infusional chemotherapy Continuous infusional chemotherapy Bolus chemotherapy Intravenous fluids, medications Site of PICC insertion Right basilic vein Left median cubital vein Left basilic vein

PICC peripherally inserted central catheter

Right median cubital vein Left cephalic vein Right cephalic vein Right brachial vein

13.04% (9/69) to 4.24% (7/165; P=0.015), and the noninfective complication rate has decreased significantly from 17.40% (12/69) to 7.27% (12/165; P=0.0199)

Discussion Although the optimal approach to reducing PICCassociated complications is unclear, several studies indicate the effectiveness of some of these interventions related to the centrally inserted catheters, and it is reasonable to assume that these interventions would be effective in the PICC line setting. Evidence-based infection-preventive

Preintervention group(n=67)

Postintervention group(n=161)

Number

Percentage (%)

Number

41 26

61.19 38.81

84 77

52.17 47.83

16 28 12 6 5

23.88 41.79 17.91 8.96 7.46

46 44 35 23 13

28.57 27.33 21.74 14.29 8.07

27 13

40.30 19.40

38 32

23.60 19.88

11 9 3 1 1 1 1 0 0

16.42 13.43 4.48 1.49 1.49 1.49 1.49 0 0

13 17 8 27 0 17 1 4 4

8.07 10.56 4.97 16.78 0 10.56 0.62 2.48 2.48

46 12 5 2

68.66 17.91 7.46 2.99

118 29 11 3

73.29 18.01 6.83 1.86

20 28 1

29.85 41.79 1.49

47 35 31

29.19 21.74 19.25

16 2 0 0

23.88 2.99 0 0

30 9 5 4

18.63 5.59 3.11 2.48

Percentage (%)

strategies include education and training of healthcare providers who insert and maintain catheters, maintenance of maximum sterile barrier precautions during catheter insertion, and use of a 2% chlorhexidine preparation for skin antisepsis [9–11]. These findings can probably be extrapolated to the setting of PICC lines [23]. In order to reduce the rate of PICC complications, multifaceted interventions were implemented in our department, such as nurse reeducation on PICC-associated knowledge, insertion procedure modification, maintenance of maximum sterile barrier precautions during PICC insertion and aftercare using a 2% chlorhexidine preparation for skin antisepsis, and adoption of PICC patient nurse archive. In

Support Care Cancer (2010) 18:1293–1298 Table 2 Complications requiring early removal of peripherally inserted central catheter (PICC)

CRBSI catheter-related bloodstream infection

Complications

Infective complications Definite CRBSI Probable CRBSI Entry site infection Non-infective complications Phlebitis Occlusion Thrombosis Accidental dislodgement Catheter leakage

this study, we reduced our rate of PICC complications using relatively simple and inexpensive interventions, as opposed to implementing more expensive interventions, such as antibiotic/antiseptic catheters. The most appropriate location for the tip of PICC is the lower one third of the SVC close to the junction of the SVC and the right atrium [12]. Research has shown that 5–32% of all PICC placements result in malposition [13–15]. It has also been shown that a central tip location for PICC is essential to minimize the risk of complications such as infection, thrombosis, catheter occlusion, and phlebitis [13–19]. As described in the instructions for PICC use, PICC tip placement needs to be confirmed by chest radiography after removal of the guidewire and before the securing of the catheter. Because the external measurement can never exactly duplicate the internal venous anatomy, sometimes, the tip of PICC is in the SVC but not

Fig. 1 Comparison of PICC complication rates of preintervention group and postintervention group

1297 Preintervention group (n=69)

Postintervention group (n=165)

Number

Percentage (%)

Number

4 2 3

5.80 2.90 4.35

3 2 2

1.81 1.21 1.21

5 3 2 2 0

7.25 4.35 2.90 2.90 0

5 2 1 3 1

3.03 1.21 0.61 1.81 0.61

Percentage (%)

in the most appropriate location, the lower third of SVC. If the tip of PICC was not at the appropriate location, it will need repositioning. Withdrawing a catheter without guidewire from the vein is easy, but reinsertion is difficult, and most of time, it is impossible. In order to place the catheter tip in the most appropriate location, the insertion practice in our department was modified: take a chest X-ray before removal of the guidewire and cutting of the catheter. This modification offers two advantages. First, the tip of PICC can be seen more clearly on the chest X-ray with the metal guidewire. Because of the high density of sternum and thoracic vertebrae cause marked X-ray attenuation, sometimes the catheter tips cannot be localized clearly on the standard frontal chest radiograph. Michelle et al. reported that 100 chest radiographs taken after a PICC line placement were read by two radiologists; 41% of readings were discrepant, and 4% had the annotation “difficult to identify the position of the tip” although the identification of tip position was similar [20]. Second, the catheter can be withdrawn and reinserted easily like the first insertion with the guidewire in it. When using the external landmarks and approximate measurement technique, nurses have a 65–70% success rate of placing the catheter tip within the lower third of the SVC in the first attempt [2, 21]. Trerotola et al. reported that about 58% of the attempts to correct malposition at bedside were failed and were forced to correct with catheter exchange [2]. There are some devices that can help to locate the tip of PICC, such as Sherlock Tip Location System, Electromagnetic Detection System, and EKG/Doppler PICC Guidance System, but these private devices are expensive and the operator needs special training. In many conditions, the position of the tip of the catheter need to be further confirmed with fluoroscopy or a chest X-ray [22]. Outpatient therapy and repeated therapy are common in oncology patients. Access is often provided by a PICC. Some PICCs can stay in place for years, if cared for

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properly. During such a long time, a PICC nurse archive form with “Notice for Patient with PICC” is important for the nurse and the patient. The information documented in the form can help the nurse and patient avoid problems in the PICC aftercare. The patient will have a copy of the archive form after the insertion so they can consult the announcements conveniently. A number of limitations are present in this study. First, our study design does not allow us to determine which components of the intervention accounted for the significant decrease in the rate of PICC-associated complications. Measuring the relative efficacy of each measure implemented is difficult, but it is possible that collectively they have resulted in the improved outcome. Second, the retrospective review on our previous cohort may have been influenced by reporting bias as the review of PICC line safety was initiated after the occurrence of adverse events. It is possible that the marked improvement in PICC complication rates at our department is related to increasing familiarity with the insertion and the use of PICC. Third, we introduced a modification of PICC insertion practice in this study—taking a chest X-ray before removal of the guidewire and cutting of the catheter. The clinical availability and the potential complications of the modification deserve further investigation in large-scale studies. In conclusion, the results of this study indicate that these interventions may be helpful in reducing the complication rate associated with PICC lines. Acknowledgement This study was supported in part by a grant from the Science and Technology Grants for Medicine and Health Research from the Shenzhen Bureau of Science, Technology and Information. Grant Number: 200703272.

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Conflict of interest statement interests.

All authors declare no conflict of 18.

References 1. Abedin S, Kapoor G (2008) Peripherally inserted central venous catheters are a good option for prolonged venous access in children with cancer. Pediatr Blood Cancer 51(2):251–255. doi:10.1002/pbc.21344 2. Walshe LJ, Malak SF, Eagan J et al (2002) Complication rates among cancer patients with peripherally inserted central catheters. J Clin Oncol 20(15):3276–3281. doi:10.1200/JCO.2002.11.135 3. Cheong K, Perry D, Karapetis C et al (2004) High rate of complications associated with peripherally inserted central venous catheters in patients with solid tumours. Intern Med J 34(5):234– 238. doi:10.1111/j.1444-0903.2004.00447.x 4. Trerotola SO, Thompson S, Chittams J et al (2007) Analysis of tip malposition and correction in peripherally inserted central

19.

20.

21.

22.

23.

catheters placed at bedside by a dedicated nursing team. J Vasc Interv Radiol 18(4):513–518. doi:10.1016/j.jvir.2007.01.020 Yap YS, Karapetis C, Lerose S et al (2006) Reducing the risk of peripherally inserted central catheter line complications in the oncology setting. Eur J Cancer Care 15(4):342–347. doi:10.1111/ j.1365-2354.2006.00664.x Pearson ML (1996) Guideline for prevention of intravascular device-related infections. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol 17(7):438– 473 Pittiruti M, Scoppettuolo G, La GA et al (2008) The EKG method for positioning the tip of PICCs: results from two preliminary studies. J Assoc Vasc Access 13(4):179–186. doi:10.2309/java.134-3 Hoffer EK, Borsa J, Santulli P et al (1999) Prospective randomized comparison of valved versus nonvalved peripherally inserted central vein catheters. AJR Am J Roentgenol 173 (5):1393–1398 Michelle EH, Thanh HN, Allen JC (2004) Optimizing the patient positioning for PICC line tip determination. Emerg Radiol 10 (4):186–189. doi:10.1007/s10140-003-0310-7 Mermel LA, Farr BM, Sherertz RJ et al (2001) Guidelines for the management of intravascular catheter related infections. Clin Infect Dis 32(9):1249–1272. doi:10.1086/320001 Racadio JM, Doellman DA, Johnson ND et al (2001) Pediatric peripherally inserted central catheters: complication rates related to catheter tip location. Pediatrics 107:E28 Infusion Nurses Society (2006) Infusion nursing standards of practice. J Infus Nurs 29(1 Suppl):S1–S92 Frey AM (1995) Pediatric peripherally inserted central catheter program report: a summary of 4,536 catheter days. J Intraven Nurs 18(6):280–291 Maki DG, Ringer M, Alvarado CJ (1991) Prospective randomized trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet 338(8763):339–343. doi:10.1016/0140-6736(91)90479-9 Ryder MA (1993) Peripherally inserted central venous catheters. Nurs Clin North Am 28(4):937–971 Hogan MJ (1999) Neonatal vascular catheters and their complications. Radiol Clin North Am 37(6):1109–1125 James L, Bledsoe L, Hadaway LC (1993) A retrospective look at tip location and complications of peripherally inserted central catheter lines. J Intraven Nurs 16(2):104–109 Kearns PJ, Coleman S, Wehner JH (1996) Complications of long arm-catheters: a randomized trial of central vs, peripheral tip location. JPEN J Parenter Enteral Nutr 20(1):20–24 Smith JR, Friedell ML, Cheatham ML et al (1998) Peripherally inserted central catheters revisited. Am J Surg 176:208–211. doi:10.1016/S0002-9610(98)00121-4 Naylor CL (2007) Reduction of malposition in peripherally inserted central catheters with tip location system. J Assoc Vasc Access 12(1):29–31 O’Grady NP, Alexander M, Dellinger EP et al (2002) Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control 30(8):476–489. doi:10.1067/mic.2002.129427 Pronovost P, Needham D, Berenholtz S et al (2006) An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 355(26):2725–2732 Lawson T (1998) Infusion of IV medication and fluids via PICC and midline catheters: influences of tip position on the success of infusion. J Vasc Access Devices 3:11–17