More than a billion times a year, doctors and nurses insert tiny tubes into the veins of American hospital patients, so they can deliver lifesaving medicines, give fluids and nutrition, monitor key vital signs, and help patients with conditions ranging from cancer and pain to kidney failure and serious infections.
But these same devices carry risks as well as benefits - especially those designed to stay in the body for days or weeks, called PICCs, ports and central lines. They tunnel deep into the bloodstream, providing a gateway for microbes and a place for dangerous clots to form.
Yet despite their widespread and rapidly growing use, no clear guide has existed for which kind of device to use, in which patient, for the best and safest result -- and which to avoid at all costs.
In the new issue of Annals of Internal Medicine, a team led by University of Michigan Medical School and VA Ann Arbor Healthcare System experts presents the first comprehensive guide to using intravenous, or vascular access, devices of all kinds1.
They call it MAGIC, or Michigan Appropriateness Guide for Intravenous Catheters. Based on an exhaustive review of evidence, and the expertise of top international experts in a wide range of fields, it gives clinicians an easy-to-use framework to pick the right device for each adult patient.
"PICCs, or peripherally inserted central catheters, have become especially convenient to place, and their use has gone up dramatically - as have the complications from them. The easiest way to prevent these complications is not to place a PICC in the first place. So we set out to determine when the use of a PICC is appropriate, and when other choices are the best," says lead author Vineet Chopra, M.D., M.Sc., who has studied risks from PICCS for years.
He and several of his co-authors are members of the Patient Safety Enhancement Program, a joint U-M/VA effort, and of the U-M Institute for Healthcare Policy and Innovation.
The MAGIC criteria are based on experts' review of more than 600 scenarios of different kinds of patient and treatments, and provide color-coded charts or algorithms to indicate which devices are appropriate or inappropriate in each case.
Taking the MAGIC show on the road
MAGIC is already getting its first test in 47 Michigan hospitals taking part in a patient safety project, the Michigan Hospital Medicine Safety Consortium.
Data from that same consortium recently revealed huge variation between hospitals in the use of IV devices for the same conditions. And evidence from this collaborative effort shows that patients with PICCs frequently face a risk of dangerous blood clots called deep vein thrombosis, or DVT.
The U-M/VA team will also test ways to deploy MAGIC across the Veterans Affairs health system, working with the VA National Center for Patient Safety and the No Preventable Harms Campaign. The Infusion Nursing Society is also modifying its standards to incorporate changes based on MAGIC's recommendations.
Even as they evaluate MAGIC's ability to reduce variation, improve appropriate use of different device types, and reduce complications, the team behind the new guide hopes other clinicians will begin using it.
They're preparing to launch a comprehensive website, improvepicc.com, that will offer one-stop access to the MAGIC recommendations, which include information about how clinicians should care for patients who have a vascular access device in the hospital, nursing home or at home. The site will also provide updates on issues and research related to PICCs, central lines and other vascular access issues.
"IV devices of all kinds are being put into patients without much thought about risks, benefits or alternatives. At the end of the day, we hope MAGIC will give providers the information they need to make a good decision for their patient, one that will render these devices appropriate and safe," says Chopra, an assistant professor of general internal medicine and a hospitalist, as well as a research scientist at PSEP.
How the MAGIC happened
The panel of 15 experts included doctors and nurses from a wide range of fields where PICCs and other such devices are commonly used, from vascular nursing, anesthesiology and radiology, to critical care, hospital medicine, infectious disease and oncology. Also participating: a patient who had suffered complications from various IV devices, and still lives with the consequences.
The panel evaluated the scenarios and supporting medical literature, and made its recommendations, using the RAND/UCLA Appropriateness Method.
While in most of the scenarios the experts came to a consensus on which type of device was most appropriate and which were inappropriate, MAGIC also shows where the evidence was neutral, or where experts disagreed to highlight that more research is needed.
The panel also did not consider pediatric use of PICCs and other vascular access devices, but hope their work could provide a framework for a similar effort in pediatrics.
The work that led to the MAGIC gathering and writing of the criteria was sponsored by the Society of Hospital Medicine, by a grant from the Agency for Healthcare Research and Quality (1-K08-HS022835), and by Blue Cross Blue Shield of Michigan, which funds the Michigan Hospital Medicine Safety Consortium.