Substantial Variation in Peripherally Inserted Central Catheter Use and Outcomes in Patients with Hematologic Malignancies: A Multi-Center Study

Background:

Use of peripherally inserted central catheters (PICCs) has grown rapidly in patients with hematologic malignancies. Studies demonstrating the safety of PICCs in hematologic malignancies, however, are largely single-center, retrospective designs focused on the outpatient setting. Little is known about inpatient PICC use in patients with hematologic malignancies and how such use varies across hospitals.

Methods:

Data was prospectively collected between November 2013 and December 2019 from a cohort of patients admitted at one of 42 Michigan hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Patients had a diagnosis of a hematologic malignancy and had a PICC placed during their hospital stay. Adult medical patients admitted to a general ward or intensive care unit were eligible for data collection and data were collected from the medical record using a standardized template. The indications for PICC placement, catheter characteristics, and associated complications from 17 hospitals with more than 25 discrete patients with hematologic malignancy were included in a comparative analysis. Major complications were defined as central line associated bloodstream infection (CLABSI), catheter occlusion, and venous thromboembolism (VTE). Differences across hospitals were tested using the Kruskal-Wallis test for continuous variables and Pearson chi-square test for categorical variables.

Results:

A total of 2092 PICCs placed in 1798 patients were included in the analysis with a median (IQR) dwell time of 15 (6-30) days. Most patients were male (n=1242, 59.4%), white (n=1720, 82.2%), and 50 to 69 years old (n=950, 45.4%). Patients were primarily admitted to large hospitals (≥375 beds: n=1429, 68.8%) that were teaching centers (n=1600, 76.5%) in metropolitan locations (n=2000, 95.6%). Leukemia (n=752, 36.0%) and non-Hodgkin's lymphoma (n=409, 19.6%) were the most represented malignancies. The most common primary indication for PICC placement was administration of chemotherapy (n=1180, 56.4%). The majority of PICCs were double lumen (n=1457, 69.6%), most often placed by vascular access nurses (n=1520, 72.7%). A concurrent central venous catheter was present at the time of PICC placement in 12.2% (n=264) of patients. A major complication event occurred in over 1 in 4 PICCs placed (n=562, 26.9%). Catheter occlusion occurred in 17.8% (n=372), CLABSI in 8.2% (n=171), and VTE in 3.8% (n=80) of PICCs respectively.

There was wide variation in PICC indications, characteristics, and outcomes across hospitals. Placement of PICCs for chemotherapy varied from 33.3% to 85.3% (p<0.001). Similarly, there was a wide range of placement for antibiotics (2.8% to 32.4%, p<0.001), transfusion of blood products (0.0% to 9.7%, p<0.001), medications requiring central access (0% to 26.7%, p<0.001), difficult access and blood draws (1.8% to 33.3%, p<0.001), and administration of total parenteral nutrition (0.0% to 14.3%, p=0.002). There was significant variation in the number of lumens used: single (5.6% to 37.9%, p<0.001), double (51.9% to 93.0%, p<0.001), or triple (0.0% to 30.8%, p<0.001). The incidence of major complications spanned from 9.7% to 40.8% (p=0.001). Rate of catheter occlusion had the widest range (0.0% to 36.7%, p<0.001). The differences between rates of VTE (0.0% to 8.7%, p=0.29) and CLABSI (1.4% to 15.9%, p< 0.20) were not statistically significant. Patient mortality ranged from 2.8% to 19.4% (p<0.001).

Conclusion:

Appropriate venous access is critical to the care of patients with hematologic malignancy. This study demonstrates wide variation in the practice patterns and outcomes for PICCs in patients with hematologic malignancies across hospitals in Michigan. Further work is necessary to further understand and improve decision making around choosing vascular access in this vulnerable population.

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