Vineet Chopra, MD, MSc

Pneumonia is the most common cause of unplanned hospitalization in the United States.[1] Despite its clinical toll, the management of this disease has evolved markedly. Expanding vaccination programs, efforts to improve timeliness of antibiotic therapy, and improved processes of care are but a few developments that have improved outcomes for patients afflicted with this illness.[2, 3]

Use of peripherally inserted central catheters (PICCs) is an example of a modern development in the management of patients with pneumonia.[4, 5, 6, 7] PICCs provide many of the benefits associated with central venous catheters (CVCs) including reliable venous access for delivery of antibiotics, phlebotomy, and invasive hemodynamic monitoring. However, as they are placed in veins of the upper extremity, PICCs bypass insertion risks (eg, injury to the carotid vessels or pneumothorax) associated with placement of traditional CVCs.[8] Because they offer durable venous access, PICCs also facilitate care transitions while continuing intravenous antimicrobial therapy in patients with pneumonia.

However, accumulating evidence also suggests that PICCs are associated with important complications, including central lineassociated bloodstream infectionand venous thromboembolism.[9, 10] Furthermore, knowledge gaps in clinicians regarding indications for appropriate use and management of complications associated with PICCs have been recognized.[10, 11] These elements are problematic because reports of unjustified and inappropriate PICC use are growing in the literature.[12, 13] Such concerns have prompted a number of policy calls to improve PICC use, including Choosing Wisely recommendations by various professional societies.[14, 15]

As little is known about the prevalence or patterns of PICC use in adults hospitalized with pneumonia, we conducted a retrospective cohort study using data from a large network of US hospitals.

METHODS

RESULTS

Between July 2007 and November 2011, 634,285 admissions representing 545,250 unique patients from 495 hospitals met eligibility criteria and were included in the study (Figure 1). Included patients had a median age of 71 years (interquartile range [IQR]: 5782), and 53.0% were female. Most patients were Caucasian (69.2%), unmarried (51.6%), and insured by Medicare (67.9%). Patients were admitted to the hospital by internal medicine providers (43.4%), hospitalists (21.4%), and family practice providers (14.7%); notably, critical care and pulmonary medicine providers admitted 6.5% of patients. The median Gagne comorbidity score was 2 (IQR: 15). Hypertension, chronic obstructive pulmonary disease, diabetes, and congestive heart failure were among the most common comorbidities observed (Table 1).

Figure 1

Among eligible patients, 41,849 (7.7%) received a PICC during hospitalization. Approximately a quarter of all patients who received PICCs did so by hospital day 2; 90% underwent insertion by hospital day 11 (mean = 5.4 days, median = 4 days). Patients who received PICCs were younger (median IQR: 69 years, 5780 years) but otherwise demographically similar to those that did not receive PICCs (median IQR: 72 years, 5782 years). Compared to other specialties, patients admitted by critical care/pulmonary providers were twice as likely to receive PICCs (12.3% vs 6.1%, P < .001). Patients who received PICCs had higher comorbidity scores than those who did not (median Gagne comorbidity score 4 vs 2, P < 0.001) and were more likely to be diagnosed with HCAP (43.1% vs 29.9%, P < 0.001) than CAP (56.9% vs 70.1%, P < 0.001).

PICC recipients were also more likely to receive intensive care unit (ICU) level of care (41.4% vs 16%, P < 0.001) and both noninvasive (17.5% vs 8.1%, P < 0.001) and invasive ventilation (28.6% vs 8.8%, P < 0.001) upon admission. Vasopressor use was also significantly more frequent in patients who received PICCs (24.7% vs 7.6%, P < 0.001) compared to those who did not receive these devices. Patients with PICCs were more often discharged to skilled nursing facilities (34.5% vs 19.3%) than those without PICCs.

Hospital Level Variation in PICC Use

To ensure stable estimates of hospital PICC use, we excluded 152 facilities (31%): 10% had no patients with PICCs and 21% had <5 patients who received a PICC. Therefore, RSPICC was estimated for 343 of 495 facilities (69%) (Figure 2). In these facilities, RSPICC varied from 0.3% to 41.7%. Hospital RSPICC was significantly associated with hospital location (median 11.9% vs 7.8% for urban vs rural hospitals respectively, P = 0.05). RSPICCs were also greater among hospitals in Southern (11.3%), Western (12.7%), and Midwest (12.0%) regions of the nation compared to those in the Northeast (8.4%) (P = 0.02) (Table 3).

Table 3.Association Between Hospital Characteristics and Risk‐Standardized Rate of PICC Use*

Hospital Characteristic (No.)	Median (IQR), %	P Value
NOTE: Abbreviations: IQR, interquartile range; PICC, peripherally inserted central catheter.*Numbers indicate the percentage of patients with a PICC in each category, accounting for risk associated with PICC receipt. To ensure stable estimates, 152 facilities (31%) were excluded, as 10% had no patients with PICCs and 21% had <5 patients who received a PICC. Kruskal‐Wallis test.
Bed size		0.12
200 beds (106)	9.1 (4.816.3)
201 beds (237)	11.6 (5.817.6)
Rural/urban		0.05
Urban (275)	11.9 (5.517.4)
Rural (68)	7.8 (5.014.0)
Region		0.02
Northeast (50)	8.4 (3.913.0)
Midwest (69)	12.0 (5.817.4)
West (57)	12.7 (7.617.0)
South (167)	11.3 (4.817.8)
Teaching status		0.77
Nonteaching (246)	10.9 (5.017.4)
Teaching (97)	12.0 (5.816.9)

Figure 2

A likelihood ratio test comparing the hierarchical model to a logistic model with patient factors only was highly significant (P < 0.001), indicating that the hospital where the patient was treated had a major impact on receipt of PICC after accounting for patient factors. The MOR was 2.71, which is a larger effect than we found for any of the individual patient characteristics. The proportion of variance explained by hospitals was 25% (95% CI: 22%‐28%), as measured by the ICC.

DISCUSSION

In this study of 545,250 adults hospitalized with pneumonia, we found that approximately 8% of patients received a PICC. Patients who received PICCs had more comorbidities, were more frequently diagnosed with HCAP, and were more often admitted to the ICU, where they experienced greater rates of mechanical ventilation, noninvasive ventilation, and vasopressor use compared to those who did not receive a PICC. Additionally, risk‐adjusted rates of PICC use varied as much as 10‐fold across institutions. In fact, almost 70% of the total variation in rates of PICC use remained unexplained by hospital or patient characteristics. Although use of PICCs is often clinically nuanced in ways that are difficult to capture in large datasets (eg, difficult venous access or inability to tolerate oral medications), the substantial variation of PICC use observed suggests that physician and institutional practice styles are the major determinants of PICC placement during a hospitalization for pneumonia. Because PICCs are associated with serious complications, and evidence regarding discretionary use is accumulating, a research agenda examining reasons for such use and related outcomes appears necessary.

The placement of PICCs has grown substantially in hospitalized patients all over the world.[23, 24] Although originally developed for total parenteral nutrition in surgical patients,[25] contemporary reports of PICC use in critical illness,[26] diseases such as cystic fibrosis,[27] and even pregnancy[28] are now common. Although PICCs are clinically invaluable in many of these conditions, growing use of these devices has led to the realization that benefits may be offset by complications.[9, 10, 29, 30] Additionally, recent data suggest that not all PICCs may be used for appropriate reasons. For instance, in a decade‐long study at a tertiary care center, changes in patterns of PICC use including shortened dwell times, multiple insertions in a single patient, and unclear indications for use were reported.[11] In another study at an academic medical center, a substantial proportion of PICCs were found to be idle or unjustified.[12] It comes as little surprise, then, that a recent multicenter study found that 1 out of every 5 clinicians did not even know that their patient had a PICC.[29] Although calls to improve PICC use in the hospital setting have emerged, strategies to do so are limited by data that emanate from single‐center reports or retrospective designs. No other studies reporting use of PICCs across US hospitals for any clinical condition currently exist.[31]

We found that patients with weight loss, those with greater combined comorbidity scores, and those who were critically ill or diagnosed with sepsis were more likely to receive PICCs than others. These observations suggest that PICC use may reflect underlying severity of illness, as advanced care such as ventilator support was often associated with PICC use. Additionally, discharge to a skilled nursing facility was frequently associated with PICC placement, a finding consistent with a recent study evaluating the use of PICCs in these settings.[32] However, a substantial proportion of PICC use remained unexplained by available patient or hospital factors. Although our study was not specifically designed to examine this question, a possible reason may relate to unmeasured institutional factors that influence the propensity to use a PICC, recently termed as PICC culture.[33] For example, it is plausible that hospitals with nursing‐led PICC teams or interventional radiology (such as teaching hospitals) are more likely to use PICCs than those without such operators. This hypothesis may explain why urban, larger, and teaching hospitals exhibited higher rates of PICC use. Conversely, providers may have an affinity toward PICC use that is predicated not just by operator availability, but also local hospital norms. Understanding why some facilities use PICCs at higher rates than others and implications of such variation with respect to patient safety, cost, and outcomes is important. Study designs that use mixed‐methods approaches or seek to qualitatively understand reasons behind PICC use are likely to be valuable in this enquiry.

Our study has limitations. First, we used an administrative dataset and ICD‐9‐CM codes rather than clinical data from medical records to identify cases of pneumonia or comorbidities. Our estimates of PICC use across hospitals thus may not fully account for differences in severity of illness, and it is possible that patients needed a PICC for reasons that we could not observe. However, the substantial variation observed in rates of PICC use across hospitals is unlikely to be explained by differences in patient severity of illness, documentation, or coding practices. Second, as PICC removal codes were not available, we are unable to comment on how often hospitalized pneumonia patients were discharged with PICCs or received antimicrobial therapy beyond their inpatient stay. Third, although we observed that a number of patient and hospital factors were associated with PICC receipt, our study was not designed to determine the reasons underlying these patterns.

These limitations aside, our study has important strengths. To our knowledge, this is the first study to report utilization and outcomes associated with PICC use among those hospitalized with pneumonia across the United States. The inclusion of a large number of patients receiving care in diverse facilities lends a high degree of external validity to our findings. Second, we used advanced modeling to identify factors associated with PICC use in hospitalized patients with pneumonia, producing innovative and novel findings. Third, our study is the first to show the existence of substantial variation in rates of PICC use across US hospitals within the single disease state of pneumonia. Understanding the drivers of this variability is important as it may inform future studies, policies, and practices to improve PICC use in hospitalized patients.

In conclusion, we found that PICC use in patients hospitalized with pneumonia is common and highly variable. Future studies examining the contextual factors behind PICC use and their association with outcomes are needed to facilitate efforts to standardize PICC use across hospitals.

Disclosures

Dr. Chopra is supported by a career development award (1‐K08‐HS022835‐01) from the Agency of Healthcare Research and Quality. The authors report no conflicts of interest.

Pneumonia is the most common cause of unplanned hospitalization in the United States.[1] Despite its clinical toll, the management of this disease has evolved markedly. Expanding vaccination programs, efforts to improve timeliness of antibiotic therapy, and improved processes of care are but a few developments that have improved outcomes for patients afflicted with this illness.[2, 3]

Use of peripherally inserted central catheters (PICCs) is an example of a modern development in the management of patients with pneumonia.[4, 5, 6, 7] PICCs provide many of the benefits associated with central venous catheters (CVCs) including reliable venous access for delivery of antibiotics, phlebotomy, and invasive hemodynamic monitoring. However, as they are placed in veins of the upper extremity, PICCs bypass insertion risks (eg, injury to the carotid vessels or pneumothorax) associated with placement of traditional CVCs.[8] Because they offer durable venous access, PICCs also facilitate care transitions while continuing intravenous antimicrobial therapy in patients with pneumonia.

However, accumulating evidence also suggests that PICCs are associated with important complications, including central lineassociated bloodstream infectionand venous thromboembolism.[9, 10] Furthermore, knowledge gaps in clinicians regarding indications for appropriate use and management of complications associated with PICCs have been recognized.[10, 11] These elements are problematic because reports of unjustified and inappropriate PICC use are growing in the literature.[12, 13] Such concerns have prompted a number of policy calls to improve PICC use, including Choosing Wisely recommendations by various professional societies.[14, 15]

As little is known about the prevalence or patterns of PICC use in adults hospitalized with pneumonia, we conducted a retrospective cohort study using data from a large network of US hospitals.

METHODS

RESULTS

Between July 2007 and November 2011, 634,285 admissions representing 545,250 unique patients from 495 hospitals met eligibility criteria and were included in the study (Figure 1). Included patients had a median age of 71 years (interquartile range [IQR]: 5782), and 53.0% were female. Most patients were Caucasian (69.2%), unmarried (51.6%), and insured by Medicare (67.9%). Patients were admitted to the hospital by internal medicine providers (43.4%), hospitalists (21.4%), and family practice providers (14.7%); notably, critical care and pulmonary medicine providers admitted 6.5% of patients. The median Gagne comorbidity score was 2 (IQR: 15). Hypertension, chronic obstructive pulmonary disease, diabetes, and congestive heart failure were among the most common comorbidities observed (Table 1).

Figure 1

Among eligible patients, 41,849 (7.7%) received a PICC during hospitalization. Approximately a quarter of all patients who received PICCs did so by hospital day 2; 90% underwent insertion by hospital day 11 (mean = 5.4 days, median = 4 days). Patients who received PICCs were younger (median IQR: 69 years, 5780 years) but otherwise demographically similar to those that did not receive PICCs (median IQR: 72 years, 5782 years). Compared to other specialties, patients admitted by critical care/pulmonary providers were twice as likely to receive PICCs (12.3% vs 6.1%, P < .001). Patients who received PICCs had higher comorbidity scores than those who did not (median Gagne comorbidity score 4 vs 2, P < 0.001) and were more likely to be diagnosed with HCAP (43.1% vs 29.9%, P < 0.001) than CAP (56.9% vs 70.1%, P < 0.001).

PICC recipients were also more likely to receive intensive care unit (ICU) level of care (41.4% vs 16%, P < 0.001) and both noninvasive (17.5% vs 8.1%, P < 0.001) and invasive ventilation (28.6% vs 8.8%, P < 0.001) upon admission. Vasopressor use was also significantly more frequent in patients who received PICCs (24.7% vs 7.6%, P < 0.001) compared to those who did not receive these devices. Patients with PICCs were more often discharged to skilled nursing facilities (34.5% vs 19.3%) than those without PICCs.

Hospital Level Variation in PICC Use

To ensure stable estimates of hospital PICC use, we excluded 152 facilities (31%): 10% had no patients with PICCs and 21% had <5 patients who received a PICC. Therefore, RSPICC was estimated for 343 of 495 facilities (69%) (Figure 2). In these facilities, RSPICC varied from 0.3% to 41.7%. Hospital RSPICC was significantly associated with hospital location (median 11.9% vs 7.8% for urban vs rural hospitals respectively, P = 0.05). RSPICCs were also greater among hospitals in Southern (11.3%), Western (12.7%), and Midwest (12.0%) regions of the nation compared to those in the Northeast (8.4%) (P = 0.02) (Table 3).

Table 3.Association Between Hospital Characteristics and Risk‐Standardized Rate of PICC Use*

Hospital Characteristic (No.)	Median (IQR), %	P Value
NOTE: Abbreviations: IQR, interquartile range; PICC, peripherally inserted central catheter.*Numbers indicate the percentage of patients with a PICC in each category, accounting for risk associated with PICC receipt. To ensure stable estimates, 152 facilities (31%) were excluded, as 10% had no patients with PICCs and 21% had <5 patients who received a PICC. Kruskal‐Wallis test.
Bed size		0.12
200 beds (106)	9.1 (4.816.3)
201 beds (237)	11.6 (5.817.6)
Rural/urban		0.05
Urban (275)	11.9 (5.517.4)
Rural (68)	7.8 (5.014.0)
Region		0.02
Northeast (50)	8.4 (3.913.0)
Midwest (69)	12.0 (5.817.4)
West (57)	12.7 (7.617.0)
South (167)	11.3 (4.817.8)
Teaching status		0.77
Nonteaching (246)	10.9 (5.017.4)
Teaching (97)	12.0 (5.816.9)

Figure 2

A likelihood ratio test comparing the hierarchical model to a logistic model with patient factors only was highly significant (P < 0.001), indicating that the hospital where the patient was treated had a major impact on receipt of PICC after accounting for patient factors. The MOR was 2.71, which is a larger effect than we found for any of the individual patient characteristics. The proportion of variance explained by hospitals was 25% (95% CI: 22%‐28%), as measured by the ICC.

DISCUSSION

In this study of 545,250 adults hospitalized with pneumonia, we found that approximately 8% of patients received a PICC. Patients who received PICCs had more comorbidities, were more frequently diagnosed with HCAP, and were more often admitted to the ICU, where they experienced greater rates of mechanical ventilation, noninvasive ventilation, and vasopressor use compared to those who did not receive a PICC. Additionally, risk‐adjusted rates of PICC use varied as much as 10‐fold across institutions. In fact, almost 70% of the total variation in rates of PICC use remained unexplained by hospital or patient characteristics. Although use of PICCs is often clinically nuanced in ways that are difficult to capture in large datasets (eg, difficult venous access or inability to tolerate oral medications), the substantial variation of PICC use observed suggests that physician and institutional practice styles are the major determinants of PICC placement during a hospitalization for pneumonia. Because PICCs are associated with serious complications, and evidence regarding discretionary use is accumulating, a research agenda examining reasons for such use and related outcomes appears necessary.

The placement of PICCs has grown substantially in hospitalized patients all over the world.[23, 24] Although originally developed for total parenteral nutrition in surgical patients,[25] contemporary reports of PICC use in critical illness,[26] diseases such as cystic fibrosis,[27] and even pregnancy[28] are now common. Although PICCs are clinically invaluable in many of these conditions, growing use of these devices has led to the realization that benefits may be offset by complications.[9, 10, 29, 30] Additionally, recent data suggest that not all PICCs may be used for appropriate reasons. For instance, in a decade‐long study at a tertiary care center, changes in patterns of PICC use including shortened dwell times, multiple insertions in a single patient, and unclear indications for use were reported.[11] In another study at an academic medical center, a substantial proportion of PICCs were found to be idle or unjustified.[12] It comes as little surprise, then, that a recent multicenter study found that 1 out of every 5 clinicians did not even know that their patient had a PICC.[29] Although calls to improve PICC use in the hospital setting have emerged, strategies to do so are limited by data that emanate from single‐center reports or retrospective designs. No other studies reporting use of PICCs across US hospitals for any clinical condition currently exist.[31]

We found that patients with weight loss, those with greater combined comorbidity scores, and those who were critically ill or diagnosed with sepsis were more likely to receive PICCs than others. These observations suggest that PICC use may reflect underlying severity of illness, as advanced care such as ventilator support was often associated with PICC use. Additionally, discharge to a skilled nursing facility was frequently associated with PICC placement, a finding consistent with a recent study evaluating the use of PICCs in these settings.[32] However, a substantial proportion of PICC use remained unexplained by available patient or hospital factors. Although our study was not specifically designed to examine this question, a possible reason may relate to unmeasured institutional factors that influence the propensity to use a PICC, recently termed as PICC culture.[33] For example, it is plausible that hospitals with nursing‐led PICC teams or interventional radiology (such as teaching hospitals) are more likely to use PICCs than those without such operators. This hypothesis may explain why urban, larger, and teaching hospitals exhibited higher rates of PICC use. Conversely, providers may have an affinity toward PICC use that is predicated not just by operator availability, but also local hospital norms. Understanding why some facilities use PICCs at higher rates than others and implications of such variation with respect to patient safety, cost, and outcomes is important. Study designs that use mixed‐methods approaches or seek to qualitatively understand reasons behind PICC use are likely to be valuable in this enquiry.

Our study has limitations. First, we used an administrative dataset and ICD‐9‐CM codes rather than clinical data from medical records to identify cases of pneumonia or comorbidities. Our estimates of PICC use across hospitals thus may not fully account for differences in severity of illness, and it is possible that patients needed a PICC for reasons that we could not observe. However, the substantial variation observed in rates of PICC use across hospitals is unlikely to be explained by differences in patient severity of illness, documentation, or coding practices. Second, as PICC removal codes were not available, we are unable to comment on how often hospitalized pneumonia patients were discharged with PICCs or received antimicrobial therapy beyond their inpatient stay. Third, although we observed that a number of patient and hospital factors were associated with PICC receipt, our study was not designed to determine the reasons underlying these patterns.

These limitations aside, our study has important strengths. To our knowledge, this is the first study to report utilization and outcomes associated with PICC use among those hospitalized with pneumonia across the United States. The inclusion of a large number of patients receiving care in diverse facilities lends a high degree of external validity to our findings. Second, we used advanced modeling to identify factors associated with PICC use in hospitalized patients with pneumonia, producing innovative and novel findings. Third, our study is the first to show the existence of substantial variation in rates of PICC use across US hospitals within the single disease state of pneumonia. Understanding the drivers of this variability is important as it may inform future studies, policies, and practices to improve PICC use in hospitalized patients.

In conclusion, we found that PICC use in patients hospitalized with pneumonia is common and highly variable. Future studies examining the contextual factors behind PICC use and their association with outcomes are needed to facilitate efforts to standardize PICC use across hospitals.

Disclosures

Dr. Chopra is supported by a career development award (1‐K08‐HS022835‐01) from the Agency of Healthcare Research and Quality. The authors report no conflicts of interest.

Pneumonia is the most common cause of unplanned hospitalization in the United States.[1] Despite its clinical toll, the management of this disease has evolved markedly. Expanding vaccination programs, efforts to improve timeliness of antibiotic therapy, and improved processes of care are but a few developments that have improved outcomes for patients afflicted with this illness.[2, 3]

Use of peripherally inserted central catheters (PICCs) is an example of a modern development in the management of patients with pneumonia.[4, 5, 6, 7] PICCs provide many of the benefits associated with central venous catheters (CVCs) including reliable venous access for delivery of antibiotics, phlebotomy, and invasive hemodynamic monitoring. However, as they are placed in veins of the upper extremity, PICCs bypass insertion risks (eg, injury to the carotid vessels or pneumothorax) associated with placement of traditional CVCs.[8] Because they offer durable venous access, PICCs also facilitate care transitions while continuing intravenous antimicrobial therapy in patients with pneumonia.

However, accumulating evidence also suggests that PICCs are associated with important complications, including central lineassociated bloodstream infectionand venous thromboembolism.[9, 10] Furthermore, knowledge gaps in clinicians regarding indications for appropriate use and management of complications associated with PICCs have been recognized.[10, 11] These elements are problematic because reports of unjustified and inappropriate PICC use are growing in the literature.[12, 13] Such concerns have prompted a number of policy calls to improve PICC use, including Choosing Wisely recommendations by various professional societies.[14, 15]

As little is known about the prevalence or patterns of PICC use in adults hospitalized with pneumonia, we conducted a retrospective cohort study using data from a large network of US hospitals.

METHODS

RESULTS

Between July 2007 and November 2011, 634,285 admissions representing 545,250 unique patients from 495 hospitals met eligibility criteria and were included in the study (Figure 1). Included patients had a median age of 71 years (interquartile range [IQR]: 5782), and 53.0% were female. Most patients were Caucasian (69.2%), unmarried (51.6%), and insured by Medicare (67.9%). Patients were admitted to the hospital by internal medicine providers (43.4%), hospitalists (21.4%), and family practice providers (14.7%); notably, critical care and pulmonary medicine providers admitted 6.5% of patients. The median Gagne comorbidity score was 2 (IQR: 15). Hypertension, chronic obstructive pulmonary disease, diabetes, and congestive heart failure were among the most common comorbidities observed (Table 1).

Figure 1

Among eligible patients, 41,849 (7.7%) received a PICC during hospitalization. Approximately a quarter of all patients who received PICCs did so by hospital day 2; 90% underwent insertion by hospital day 11 (mean = 5.4 days, median = 4 days). Patients who received PICCs were younger (median IQR: 69 years, 5780 years) but otherwise demographically similar to those that did not receive PICCs (median IQR: 72 years, 5782 years). Compared to other specialties, patients admitted by critical care/pulmonary providers were twice as likely to receive PICCs (12.3% vs 6.1%, P < .001). Patients who received PICCs had higher comorbidity scores than those who did not (median Gagne comorbidity score 4 vs 2, P < 0.001) and were more likely to be diagnosed with HCAP (43.1% vs 29.9%, P < 0.001) than CAP (56.9% vs 70.1%, P < 0.001).

PICC recipients were also more likely to receive intensive care unit (ICU) level of care (41.4% vs 16%, P < 0.001) and both noninvasive (17.5% vs 8.1%, P < 0.001) and invasive ventilation (28.6% vs 8.8%, P < 0.001) upon admission. Vasopressor use was also significantly more frequent in patients who received PICCs (24.7% vs 7.6%, P < 0.001) compared to those who did not receive these devices. Patients with PICCs were more often discharged to skilled nursing facilities (34.5% vs 19.3%) than those without PICCs.

Hospital Level Variation in PICC Use

To ensure stable estimates of hospital PICC use, we excluded 152 facilities (31%): 10% had no patients with PICCs and 21% had <5 patients who received a PICC. Therefore, RSPICC was estimated for 343 of 495 facilities (69%) (Figure 2). In these facilities, RSPICC varied from 0.3% to 41.7%. Hospital RSPICC was significantly associated with hospital location (median 11.9% vs 7.8% for urban vs rural hospitals respectively, P = 0.05). RSPICCs were also greater among hospitals in Southern (11.3%), Western (12.7%), and Midwest (12.0%) regions of the nation compared to those in the Northeast (8.4%) (P = 0.02) (Table 3).

Table 3.Association Between Hospital Characteristics and Risk‐Standardized Rate of PICC Use*

Hospital Characteristic (No.)	Median (IQR), %	P Value
NOTE: Abbreviations: IQR, interquartile range; PICC, peripherally inserted central catheter.*Numbers indicate the percentage of patients with a PICC in each category, accounting for risk associated with PICC receipt. To ensure stable estimates, 152 facilities (31%) were excluded, as 10% had no patients with PICCs and 21% had <5 patients who received a PICC. Kruskal‐Wallis test.
Bed size		0.12
200 beds (106)	9.1 (4.816.3)
201 beds (237)	11.6 (5.817.6)
Rural/urban		0.05
Urban (275)	11.9 (5.517.4)
Rural (68)	7.8 (5.014.0)
Region		0.02
Northeast (50)	8.4 (3.913.0)
Midwest (69)	12.0 (5.817.4)
West (57)	12.7 (7.617.0)
South (167)	11.3 (4.817.8)
Teaching status		0.77
Nonteaching (246)	10.9 (5.017.4)
Teaching (97)	12.0 (5.816.9)

Figure 2

A likelihood ratio test comparing the hierarchical model to a logistic model with patient factors only was highly significant (P < 0.001), indicating that the hospital where the patient was treated had a major impact on receipt of PICC after accounting for patient factors. The MOR was 2.71, which is a larger effect than we found for any of the individual patient characteristics. The proportion of variance explained by hospitals was 25% (95% CI: 22%‐28%), as measured by the ICC.

DISCUSSION

In this study of 545,250 adults hospitalized with pneumonia, we found that approximately 8% of patients received a PICC. Patients who received PICCs had more comorbidities, were more frequently diagnosed with HCAP, and were more often admitted to the ICU, where they experienced greater rates of mechanical ventilation, noninvasive ventilation, and vasopressor use compared to those who did not receive a PICC. Additionally, risk‐adjusted rates of PICC use varied as much as 10‐fold across institutions. In fact, almost 70% of the total variation in rates of PICC use remained unexplained by hospital or patient characteristics. Although use of PICCs is often clinically nuanced in ways that are difficult to capture in large datasets (eg, difficult venous access or inability to tolerate oral medications), the substantial variation of PICC use observed suggests that physician and institutional practice styles are the major determinants of PICC placement during a hospitalization for pneumonia. Because PICCs are associated with serious complications, and evidence regarding discretionary use is accumulating, a research agenda examining reasons for such use and related outcomes appears necessary.

The placement of PICCs has grown substantially in hospitalized patients all over the world.[23, 24] Although originally developed for total parenteral nutrition in surgical patients,[25] contemporary reports of PICC use in critical illness,[26] diseases such as cystic fibrosis,[27] and even pregnancy[28] are now common. Although PICCs are clinically invaluable in many of these conditions, growing use of these devices has led to the realization that benefits may be offset by complications.[9, 10, 29, 30] Additionally, recent data suggest that not all PICCs may be used for appropriate reasons. For instance, in a decade‐long study at a tertiary care center, changes in patterns of PICC use including shortened dwell times, multiple insertions in a single patient, and unclear indications for use were reported.[11] In another study at an academic medical center, a substantial proportion of PICCs were found to be idle or unjustified.[12] It comes as little surprise, then, that a recent multicenter study found that 1 out of every 5 clinicians did not even know that their patient had a PICC.[29] Although calls to improve PICC use in the hospital setting have emerged, strategies to do so are limited by data that emanate from single‐center reports or retrospective designs. No other studies reporting use of PICCs across US hospitals for any clinical condition currently exist.[31]

We found that patients with weight loss, those with greater combined comorbidity scores, and those who were critically ill or diagnosed with sepsis were more likely to receive PICCs than others. These observations suggest that PICC use may reflect underlying severity of illness, as advanced care such as ventilator support was often associated with PICC use. Additionally, discharge to a skilled nursing facility was frequently associated with PICC placement, a finding consistent with a recent study evaluating the use of PICCs in these settings.[32] However, a substantial proportion of PICC use remained unexplained by available patient or hospital factors. Although our study was not specifically designed to examine this question, a possible reason may relate to unmeasured institutional factors that influence the propensity to use a PICC, recently termed as PICC culture.[33] For example, it is plausible that hospitals with nursing‐led PICC teams or interventional radiology (such as teaching hospitals) are more likely to use PICCs than those without such operators. This hypothesis may explain why urban, larger, and teaching hospitals exhibited higher rates of PICC use. Conversely, providers may have an affinity toward PICC use that is predicated not just by operator availability, but also local hospital norms. Understanding why some facilities use PICCs at higher rates than others and implications of such variation with respect to patient safety, cost, and outcomes is important. Study designs that use mixed‐methods approaches or seek to qualitatively understand reasons behind PICC use are likely to be valuable in this enquiry.

Our study has limitations. First, we used an administrative dataset and ICD‐9‐CM codes rather than clinical data from medical records to identify cases of pneumonia or comorbidities. Our estimates of PICC use across hospitals thus may not fully account for differences in severity of illness, and it is possible that patients needed a PICC for reasons that we could not observe. However, the substantial variation observed in rates of PICC use across hospitals is unlikely to be explained by differences in patient severity of illness, documentation, or coding practices. Second, as PICC removal codes were not available, we are unable to comment on how often hospitalized pneumonia patients were discharged with PICCs or received antimicrobial therapy beyond their inpatient stay. Third, although we observed that a number of patient and hospital factors were associated with PICC receipt, our study was not designed to determine the reasons underlying these patterns.

These limitations aside, our study has important strengths. To our knowledge, this is the first study to report utilization and outcomes associated with PICC use among those hospitalized with pneumonia across the United States. The inclusion of a large number of patients receiving care in diverse facilities lends a high degree of external validity to our findings. Second, we used advanced modeling to identify factors associated with PICC use in hospitalized patients with pneumonia, producing innovative and novel findings. Third, our study is the first to show the existence of substantial variation in rates of PICC use across US hospitals within the single disease state of pneumonia. Understanding the drivers of this variability is important as it may inform future studies, policies, and practices to improve PICC use in hospitalized patients.

In conclusion, we found that PICC use in patients hospitalized with pneumonia is common and highly variable. Future studies examining the contextual factors behind PICC use and their association with outcomes are needed to facilitate efforts to standardize PICC use across hospitals.

Disclosures

Dr. Chopra is supported by a career development award (1‐K08‐HS022835‐01) from the Agency of Healthcare Research and Quality. The authors report no conflicts of interest.

Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]

Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.

Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.

METHODS

RESULTS

Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.

Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).

The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).

With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.

To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).

DISCUSSION

In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.

Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]

Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.

Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.

Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.

In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.

Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]

Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.

Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.

METHODS

RESULTS

Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.

Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).

The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).

With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.

To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).

DISCUSSION

In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.

Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]

Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.

Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.

Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.

In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.

Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]

Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.

Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.

METHODS

RESULTS

Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.

Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).

The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).

With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.

To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).

DISCUSSION

In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.

Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]

Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.

Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.

Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.

In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.

Reliable venous access is fundamental for the safe and effective care of hospitalized patients. Venous access devices (VADs) are conduits for this purpose, providing delivery of intravenous medications, accurate measurement of central venous pressure, or administration of life‐saving blood products. Despite this important role, VADs are also often the source of hospital‐acquired complications. Although inpatient providers must balance the relative risks of VADs against their benefits, the evidence supporting such decisions is often limited. Advances in technology, scattered research, and growing availability of novel devices has only further fragmented provider knowledge in the field of vascular access.[1]

It is not surprising, then, that survey‐based studies of hospitalists reveal important knowledge gaps with regard to practices associated with VADs.[2] In this narrative review, we seek to bridge this gap by providing a concise and pragmatic overview of the fundamentals of venous access. We focus specifically on parameters that influence decisions regarding VAD placement in hospitalized patients, providing key takeaways for practicing hospitalists.

METHODS

To compile this review, we systematically searched Medline (via Ovid) for several keywords, including: peripheral intravenous catheters, ultrasound‐guided peripheral catheter, intraosseous, midline, peripherally inserted central catheter, central venous catheters, and vascular access device complications. We concentrated on full‐length articles in English only; no date restrictions were placed on the search. We reviewed guidelines and consensus statements (eg, from the Center for Disease Control [CDC] or Choosing Wisely criteria) as appropriate. Additional studies of interest were identified through content experts (M.P., C.M.R.) and bibliographies of included studies.

SCIENTIFIC PRINCIPLES UNDERPINNING VENOUS ACCESS

It is useful to begin by reviewing VAD‐related nomenclature and physiology. In the simplest sense, a VAD consists of a hub (providing access to various connectors), a hollow tube divided into 1 or many sections (lumens), and a tip that may terminate within a central or peripheral blood vessel. VADs are classified as central venous catheters (eg, centrally inserted central catheters [CICCs] or peripherally inserted central catheters [PICCs]) or peripheral intravenous catheters (eg, midlines or peripheral intravenous catheters) based on site of entry and location of the catheter tip. Therefore, VADs entering via proximal or distal veins of the arm are often referred to as peripheral lines, as their site of entry and tip both reside within peripheral veins. Conversely, the term central line is often used when VADs enter or terminate in a central vein (eg, subclavian vein insertion with the catheter tip in the lower superior vena cava).

Attention to a host of clinical and theoretical parameters is important when choosing a device for venous access. Some such parameters are summarized in Table 1.

VENOUS ACCESS DEVICES

We will organize our discussion of VADs based on whether they terminate in peripheral or central vessels. These anatomical considerations are relevant as they determine physical characteristics, compatibility with particular infusates, dwell time, and risk of complications associated with each VAD discussed in Table 2.