The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

Reliable venous access is a cornerstone of safe and effective care of hospitalized patients. Spurred by technological advances, several venous access devices (VADs) for use during and beyond hospitalization are available to meet this need. In recent years, peripherally inserted central catheters (PICCs) have become popular for venous access in hospital settings (1, 2). Compared with traditional central venous catheters (CVCs), PICCs offer several advantages, including safer insertion in the arm, cost-effective and convenient placement via vascular access nursing teams, and self-care compatibility that facilitates use beyond hospitalization (35). It is therefore not surprising that use of PICCs has grown considerably worldwide (68). Despite these advantages, PICCs are central venous catheters that may lead to important complications (9). For instance, problems such as luminal occlusion, malpositioning, and dislodgement occur frequently with these devices (1012). Similarly, superficial thrombophlebitis or infection at the site of PICC insertion may occur despite uneventful and optimal placement (13, 14). In addition, PICCs are associated with morbid complications, including venous thromboembolism and central lineassociated bloodstream infection (1517). Ensuring appropriate use of PICCs is thus vital to preventing these costly and potentially fatal adverse events. A growing number of studies suggest substantial variation and potentially inappropriate use of PICCs in hospitalized patients. For example, in a study from a large academic medical center, many PICCs were not actively used or were inserted in patients who also had peripheral intravenous catheters (18). In a decade-long study conducted in a tertiary hospital, changes in patterns of PICC use, including shorter dwell times and ambiguous indications for insertion, were reported (19). Additional cause for concern comes from a recent study, which found that 1 in 5 inpatient providers did not know that their patients had CVCs, with lack of awareness being greatest for PICCs (20). Surveys of inpatient providers have also demonstrated knowledge gaps related to appropriate indications and care practices for PICCs (21, 22). Collectively, these data have not only led to reviews of PICC use in hospitals (23) but also to calls by the Choosing Wisely initiative to improve PICC practices across the United States (24, 25). The concepts of inappropriate overuse and underuse of medical devices are by no means unique to PICCs. Rather, such issues accompany the diffusion of many novel health technologies. In many such instances, a key barrier to achieving appropriate use is the fact that evidence at a level of detail needed to apply to the range of patients seen in everyday practice is not available. Nevertheless, clinicians must make choices regarding such innovations on a daily basis, potentially fueling inconsistent practice. In the absence of high-quality evidence, an approach that combines available data with the experience and insight of clinical experts is valuable as it would provide guidance where none is otherwise available. Given this background, we organized and conducted a multidisciplinary meeting of national and international experts to develop appropriateness criteria for use, care, and management of PICCs and related VADs in hospitalized patients. Our objectives were to 1) develop a list of appropriate indications for use of PICCs in relation to other VADs, 2) define the appropriateness of practices associated with the insertion and care of PICCs, 3) determine appropriate practices for treatment and prevention of PICC complications, and 4) rate the appropriateness of peripheral intravenous catheter use in situations that prompt PICC placement. Methods Overview of the RAND/UCLA Appropriateness Method We used the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method to create criteria for appropriate use of PICCs and related VADs (10). Introduced in the 1980s, the RAND/UCLA method was developed to enable measurement of overuse of medical and surgical procedures. According to this methodology, a procedure is considered appropriate when the "expected health benefits (e.g., increased life expectancy, relief of pain, reduction of anxiety or pain) exceed the expected negative consequences (e.g., mortality, morbidity, anxiety, pain) by a sufficiently wide margin such that the procedure is worth doing, exclusive of cost. " The approach has thus been applied to an array of procedures, including coronary angiography (26), surgical procedures (27, 28), cataract removal (29), and transplant organ allocation (30). Recently, the method was also used to develop criteria for appropriate use of urinary catheters in hospitalized patients (31). The RAND/UCLA method was particularly valuable for developing PICC appropriateness criteria for several reasons. First, the approach allowed the synthesis of the best available evidence with practice-based, domain-specific insights from experts. This unique combination ensured both clinical relevance and evidentiary support for the developed recommendations. Second, unlike other group-rating methods, the focus of the RAND/UCLA approach is not to ensure consensus, but minimize artifactual disagreement that may arise from misunderstanding of scenarios being rated. This nuance is highly relevant in the case of PICCs, because available evidence is derived from heterogeneous study designs (for example, retrospective, casecontrol studies and randomized trials), populations (for example, critically ill, cancer), and clinical specialties (nursing, radiology, medical or surgical disciplines) and is thus prone to misinterpretation. Because the RAND/UCLA method pairs clear instructions and precise clinical definitions with a systematic, reliable, and reproducible rating system (27), the recommendations generated will have high internal validity. Finally, should clinical scenarios lack sufficient detail to make an informed judgment regarding appropriateness, the RAND/UCLA method encourages clarification by panelists so as to make ratings more relevant and precise. In this fashion, generalizability and external validity of the developed appropriateness indications are also ensured. Proper conduct of the RAND/UCLA Appropriateness Method requires the sequential performance of several steps, including information synthesis, panelist selection, creation of scenarios, rating process, and analysis of results. Information Synthesis The first step of the RAND/UCLA Appropriateness Method is to systematically review and synthesize the available literature. With the assistance of 2 research librarians, we searched for English-language articles (between 12 November 2012 and 1 July 2013) by using the following databases: MEDLINE via Ovid (1950 to present), EMBASE (1946 to present), BIOSIS (1926 to present), and the Cochrane Central Register of Controlled Trials via Ovid (1960 to present). The search strategy incorporated Boolean logic, controlled vocabularies (for example, Medical Subject Heading terms) and free-text words. Because the panel was focused on determining the appropriateness of PICC use in hospitalized adults, articles that included only pediatric patients or devices not comparable with PICCs (for example, arterial or hemodialysis catheters) were excluded. We also included relevant guidelines, such as the Infusion Nursing Society Standards of Practice (32), Centers for Disease Control and Prevention/Healthcare Infection Control Practices Advisory Committee central lineassociated bloodstream infection prevention guidelines (33), American Society of Anesthesiology Task Force on Central Venous Access (34), American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Guidelines (35), and International Clinical Practice Guidelines for the Treatment and Prophylaxis of Thrombosis Associated With Central Venous Catheters in Patients With Cancer (36). All retrieved articles were independently scanned for eligibility by 2 of the authors. Disagreements on eligibility were resolved by consensus, and a final list of eligible studies and tables summarizing the evidence were created. The search strategy is provided in Appendix Table 1, and Table 1 summarizes the included articles. Appendix Table 1. Literature Search Strategy Table 1. Summary of Studies Included in the Literature Review Table 1Continued Table 1Continued Table 1Continued Table 1Continued Participant and Panelist Selection Viewpoints related to PICC use are known to vary across specialties; thus, what may be appropriate in one field may not be appropriate in another. To foster discussions about these issues, specialists representing vascular access nursing, hospital-based medicine, internal medicine, infectious disease, critical care, nephrology, hematology/oncology, pharmacy, surgery, and interventional radiology were considered necessary to ensure representativeness of the panel. Leading national and international experts from each of these professions who are eminent scholars or researchers, represent relevant medical societies, or have substantial clinical experience in the field were invited to participate. To ensure that deliberations took into account patient-centered viewpoints, we also invited a patient to participate on our panel. We recognized that the ideal patient had to be able to speak about experiences with PICCs and related VADs. We recruited such a patient from our university practice in Ann Arbor, Michigan. Owing to the scientific nature of the material, however, the patient panelist did not rate scenarios and instead contributed to panelist discussions. Through this process, 15 multispecialty panelists were recruited to develop the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) (Appendix Table 2,). Appendix Table 2. Characteristics of MAGIC Panel Members Creation of Scenarios On the basis of articles