Reducing the risk of PICC-associated DVT in patients with cystic fibrosis

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“We assessed potential risk factors for symptomatic PICC-associated DVT with subsequent implementation of a quality improvement (QI) initiative to reduce PICC-associated DVT in patients with CF.” Mermis et al (2014).

Reference:

Mermis, J.D., Strom, J.C., Greenwood, J.P., Low, D.M., He, J., Stites, S.W. and Simpson, S.Q. (2014) Quality Improvement Initiative to Reduce DVT Associated with Peripherally Inserted Central Catheters in Adults with Cystic Fibrosis. Annals of the American Thoracic Society. October 8th. [epub ahead of print].

Abstract:

Rationale: Peripherally inserted central catheters (PICCs) are common in the treatment of patients with cystic fibrosis (CF). Previous reports suggest that patients with CF are at increased risk for PICC-associated DVT.

Objectives: We assessed potential risk factors for symptomatic PICC-associated DVT with subsequent implementation of a quality improvement (QI) initiative to reduce PICC-associated DVT in patients with CF.

Methods: A 5-year retrospective cohort study with subsequent 21-month prospective observation following implementation of a QI intervention in adults (age 18 or older) with CF. All patients with a PICC inserted from July 2006 to March 2013 at our CF Foundation accredited center were included. Symptomatic DVT was diagnosed by Doppler ultrasound. PICC insertions were analyzed and nine risk factors for DVT were analyzed to formulate a QI initiative to reduce risk of PICC associated DVT. The QI program focused on staff education and included modification to PICC order entry with a 4 French (F) single lumen (SL) catheter as standard for all patients with CF.

Measurements and Main Results: A total of 369 PICCs were analyzed in 117 unique patients for a total of 5437 PICC-days of placement. Symptomatic DVT was diagnosed in 28 (7.6%) of the 369 PICCs analyzed. Using regression analysis, the strongest predictors for DVT occurrence were warfarin use (OR=9.2, p=0.006) and history of PICC-associated DVT (OR=2.97, p=0.08). Insertion of a 4F SL PICC resulted in zero symptomatic DVT. Zero episodes of DVT associated with 4F PICC insertion prevented use of PICC size in regression analysis. However, univariate analysis revealed that insertion of a 4F PICC instead of either 5F or 6F was associated with a reduction in PICC-associated DVT (P=0.001). Following the QI intervention, 4F SL catheter insertion substantially increased to 65.8 % of all PICCs inserted while 6F catheter insertion declined to 6.8% of PICCs inserted. The QI initiative resulted in an absolute risk reduction in DVT per PICC placed of 6.1% (P= 0.055).

Conclusions: To reduce risk of PICC-associated DVT in patients with CF, QI strategies should focus on insertion of smaller diameter 4F PICCs and reduction in PICC use in high-risk patients when possible.

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