PICC Line Insertion and the Development of Venous Thrombosis in an Acute Care Setting

Chapter 1

Introduction

Peripherally inserted central catheters (PICC) are medical devices that are commonly used in critical care settings. It is a form of intravenous access used for prolonged antibiotic therapy or chemotherapy regimens. These devices are an important alternative to central venous catheters, which are associated with higher rates of infections. However, their use is usually associated with numerous medical complications, including upper extremity venous thrombosis, pulmonary embolism and catheter-related infections. Unlike the other central venous catheters, the emergence of these complications is rarer with the peripherally inserted central catheters due to their method of placement (Gamulka, Mendoza & Connolly, 2005).

Peripherally inserted central catheters are ideal for long-term intravenous access as they facilitate easy delivery of extended antibiotic therapy and total parenteral nutrition. It is usually inserted in a peripheral vein and slowly advanced towards the heart till the tip of the catheter only reaches the superior vena cava. Specially trained nurses or physicians are trained to use sterile techniques in placing the PICC (Hamilton, 2006). They often use a measured estimation of the distance from the insertion site to the heart to fix the catheter. In most cases, chest radiographs can be used to confirm that the catheter is properly fixed. Once confirmed, a sterile occlusive dressing helps to cover the site of insertion to reduce the risk of infection.

As a matter of fact, most PICC placements do not develop any complications. However, some may develop due to the small or irregular shape of the veins. Several of the severe complications such as arterial puncture or medium nerve bisection could necessitate the replacement of PICC with a central venous catheter. A PICC can remain intact for months, as it poses little risk of bleeding to the patient. This method is considered much safer as compared to the other central venous catheters. However, recent studies show a high rate of development of complications such as phlebitis, catheter damage and embolization. While substantial efforts have been made to prevent catheter-related infections, studies indicate that deep venous thrombosis has lately become a major adverse event in the acute care setting. Deep venous thrombosis is a painful swelling that requires anticoagulation therapy and could trigger premature removal of the PICC to prevent development of further complications. According to recent studies, the overall incidence of deep venous thrombosis associated with PICC ranges from 2 to 38 percent (Gamulka, Mendoza & Connolly, 2005).

Research Objective

To highlight the epidemiology, pathophysiology and management outcomes of PICC-associated venous thrombosis in acute care setting

Problem Statement

Although PICC has always been considered safe, the occurrence of PICC-related venous thrombosis cases is on the rise.

Operational Definitions

Assumptions

It will be assumed that fixation of PICC does not cause the rise in PICC-related venous thrombosis cases.

Hypothesis

Inadequate training of specialist nurses in phlebotomy could be causing the surge in PICC-related venous thrombosis cases in acute care settings.

Chapter 2

Literature Review

The placement of PICC has become commonplace in the acute care setting. Although there are only a few complications associated with its placement, most healthcare personnel encounter some of these complications on a daily basis. Increased awareness of the complications, especially venous thrombosis will enable clinicians to respond to them appropriately. Peripherally inserted central catheters have been in use since the 1940s. Initially, they were primarily used for hemodynamic measurement and this limited their clinical applications. PICC is generally indicated in situations where the standard peripheral catheters cannot suffice for infusion therapy. They are contraindicated in severe burns, scalding or severe skin infection. The presence of a fistula secondary to dialysis or graft is also a contraindication. Additionally, the device is contraindicated in end-stage renal disease or chronic renal insufficiency.

Intravenous catheters are known to cause endothelial trauma, resulting in inflammation at the point of insertion, which can trigger venous thrombosis. It is estimated that about 75 percent of thrombotic events that occur in the deep and superficial veins are related to the presence of an intravenous catheter. The other 25 percent is shown to be consequence of the mechanical compression that results from anatomical abnormalities such as the venous thoracic outlet syndrome. Superficial thrombophlebitis that results from peripheral catheters is usually self-limiting and resolves once the catheter is removed. However, thrombotic events that involve deep veins often result in pulmonary embolism and cause long-term sequelae despite the adequate medical therapy. It is important to note that pulmonary embolism that occurs from the upper extremities accounts for about 6 percent of the cases.

Chapter 3

Methodology

The study will utilize an information system to filter through patient data for cases of PICC-related venous thrombosis. It will be a regressive study of in-patients as well as a limited number of outpatients who can be easily monitored for thrombotic complications. It is important to note that a computer program will be used to collect and avail the requisite data for analysis and reporting. However, patients who will have had anticoagulation therapy will be excluded from the study, as their complications could be a result of other causes, other than PICC. This will ensure that the research findings are accurate and not compromised.

The Setting

Greenview Hospital is a Level One trauma facility with a bed capacity of 500. It is a major teaching and referral center for the University of Utah School of Medicine. The hospital has a properly functional information system that consists of Health Evaluation through Logistic Processing (HELP), a platform that has been in use at the institution for over 30 years (Hamilton, 2006). The information system has an integrated medical record (EMR) that contains most of the clinical data. This data is mostly coded to allow a direct access by applications for quick data analysis. However, patient information is not coded, as it is stored in the form of free-text documents that are easily accessible through the information system (Hornsby, 2005).

Most of the patients at Greenview Hospital who reported with cases of PICC will have these systems inserted. About 10 percent of the PICCs will be inserted by radiological intervention while a few will be inserted before admission. The team of specialists that will insert the devices will comprise of 10 specially trained nurses. The decision to use specially trained nurses will minimize chances of human error that usually cause most of the PICC-related venous thrombosis. The findings from the research should exclusively document data on the PICC-related venous thrombosis cases that are not caused by human error (Hamilton, 2006).

Selection of Subjects

The subjects for this study will be selected random-based on the information contained in the hospital’s information system. The study subjects will include all the patients who will be in the acute care unit as well as those who were discharged during the previous five days before the study began. This is because these patients recently left the hospital and they can still be traced for any complications, as they continue with treatment from their homes. As for the in-patient population, they will be the easiest to deal with as any information sought can be obtained from them with ease. The study does not limit the number of subjects that will be used in the research. However, based on statistics, the number of patients who report to the critical care unit is approximately 700 per month. Thus, the research will target approximately this number, in addition to those who left hospital during the previous five days before the commencement of the study (Gamulka, Mendoza & Connolly, 2005).

Tool for the Study

A computer program named a PICC-DVT monitor will be developed to make a sequential search and look for codes for every active PICC as well as those removed during the previous 5 days. Once found, the program will proceed to look for any vascular study reports that were documented after the insertion of PICC (Hamilton, 2006). In cases where those existed, the reports will be analyzed using keyword-driven procedure that will also be developed to conduct natural language processing. In addition, the information that will be used to differentiate between upper and lower extremity reports will be contained in the free-text form. Thus, the natural language procedure will make an initial scan of the reports to separate the relevant information into the right categories (Safdar, 2005).

Procedure for Data Collection

Once the computer program has identified a case of DVT associated with PICC, it will format an alert and send it to a printer in the research office. The report will be designed by the research team such that it will contain all the information needed to make patient follow-up and case analysis. Each alert will identify the data of the vascular study as well as the patient’s current location, as this will facilitate patient interventions. In addition, patient pharmacy information will also be examined to access the presence of any anticoagulation therapy that was initiated (Gamulka, Mendoza & Connolly, 2005). The file containing all the data of all the cases of DVT alerts will be stored on the information system for analysis and reporting.

Procedure for Analysis of Data

The procedure for the data analysis will be determined by the computer program that will analyze and generate a report.

Chapter 4

Analysis of Data

The data will be analyzed using the computer program that will process and analyze all the patients’ information. Once analyzed, the program will generate a report that then will be printed out from the research office.

Chapter 5

Discussion of Findings

The findings will be discussed with a view to comparing the epidemiological statistic and treatment outcomes of PICC-related venous thrombosis cases from the study with the literature review. It will help understand the complication better and device methods of limiting its occurrence among patients in the acute care setting.

Chapter 6

Conclusion

Most PICC placements do not develop any complications. However, some complications develop due to the small or irregular shape of the veins. Recent studies show a high rate of development of complications such as phlebitis, catheter damage and embolization. While substantial efforts have been made to prevent catheter-related infections, studies indicate that deep venous thrombosis has lately become a major adverse event in the acute care setting. The research will seek to establish the epidemiological statistics as well as treatment outcomes of PICC-related venous thrombosis (Gamulka, Mendoza & Connolly, 2005).

Implications

Based on the literature review, the occurrence of PICC-related venous thrombosis is on the rise. Once the trend is confirmed from this study, it will be imperative to design preventive measures to ensure that such complications do not occur. Additionally, it will be important to establish the cause of the high rates of occurrence of the complication, as this will inform the approach taken to mitigate it.

Recommendations for Further Study

This research will recommend further study into the training of specialist nurses on phlebotomy to ascertain if the increasing cases are related to their training.

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