Are Peripherally Inserted Central Venous Catheters Indications Clinically Justified?

Background: Peripherally inserted central venous catheters (PICCs) are increasingly being used as an alternative to short-term central venous catheters (CVCs) for providing intravenous (IV) access in the hospital setting. The cost of PICC insertion is about US$ 3000 (by registered nurse) and US$ 5000 (by radiologist). Although there are specific guidelines, we have observed the use of PICCs without accepted criteria. In our institution the adult-inpatient service is managed by two different groups of physicians; teaching and non-teaching groups. 

Objective: To determine whether criteria for catheter use is met at the time of insertion; to analyze the PICC use between teaching and non-teaching groups, and to quantify the unjustified use of PICCs considering its financial impact.

Methods: A retrospective, observational review of medical records of all PICCs placed during a 4-month period was conducted at our 625-bed community regional hospital. Eligibility criteria were based on subjects above the age of 18 that underwent PICC insertion and included all acute care departments except for the Obstetric Unit.

Results: A total of 228 PICCs inserted in 203 patients were analyzed. The most frequent used criteria for insertion were the prolonged IV administration of therapeutic agents (68%). The second most common criteria used were the need of short term IV access for more than 4 days (18%), and 7% accounted for lack of IV access due to morbid obesity or previous intravenous drug use.  Only 7% failed to meet strict clinical criteria for insertion. The catheter-day unnecessary use was 55 days within 17 cases. Among the non-teaching group no criteria for PICC placement were identified in 9%, compared to the teaching group with a 3%. This was not a statistically significant difference. (P = 0.125) The mean number of days from admission to PICC insertion among the teaching group was 16 days vs. 8 days among the non-teaching group. (P = 0.002). Skin and soft tissue local infection was suspected in 6% of the cases. Of those, only 4% were confirmed with a central line-associated blood stream infection (CLABSI). No other complications were observed associated to the PICCs.

Conclusions: Our study demonstrated that criteria for PICCs placement were not met in 7% of the cases. These were observed predominantly in the non-teaching group of physicians; which also demonstrated a shorter period of time between admission and PICC placement. The number of unjustified PICCs insertions resulted in about US$ 70.000 extra costs. This should encourage careful adherence to guidelines and take into consideration the economic burden associated to the PICCs unnecessary use.