How to Advocate for the Right Line, in the Right Patient, at the Right Time?

RNwrites Health, ADN, BSN, MSN

Introduction

When peripherally inserted central catheters (PICCs) became popular in the early 2000s, bedside nurses loved them. It was great for a patient to have a central line to draw blood and give intravenous (IV) meds. It was smaller in diameter and appeared to be less dangerous than the larger jugular or subclavian central lines. This turned out not to be the case.

As PICCs became more popular and usage expanded to almost half of all central venous access devices (CVADs) in the United States, the medical community began to realize that PICCs had serious potential complications, including infection and DVTs (deep vein thrombosis), and many were being placed without a clinical reason. For patient safety, there was a need to define appropriate indications for insertion, maintenance, and care of PICCs¹.

In 2015, an international panel was assembled to use the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was developed out of this multispecialty panel. This breakthrough development provided an evidence-based guide for the selection of the most appropriate vascular access device (VAD)¹. Vineet Chopra, the main author of MAGIC, said it best in 2020, "What is MAGICal about MAGIC is...the fact that it brings available evidence to end users in a pragmatic, easy-to-understand way².”

Using MAGIC to advocate for your patients

Nurses use evidence-based literature to inform their professional practice and advocate for the most appropriate treatment with the fewest risks.

MAGIC provides evidence-based guidance on which venous access is appropriate for each patient. Advocate for your patients to have the appropriate venous access for the whole stay when possible^1,3,4,5.

MAGIC Recommendation Summary (acute care)

For patients with an expected hospital stay of:

5 days or less — a regular peripheral IV (PIV) or ultrasound-guided PIV
6-14 days—an ultrasound-guided PIV OR midline is preferred
6-14 days AND critically ill—central venous catheter (CVC) preferred to PICC line
6-30 days and needs central access—PICC is preferred to tunneled catheter
31 days or more—tunneled CVC or Implanted port

For patients being discharged to home or facility with IV antibiotics:

14 days or less, a midline is preferred
15 days or more, a PICC line or a tunneled CVC, if PICC access is not possible

Other considerations for venous access

These are a few considerations used to help determine what, in your nursing judgment, is the best line for your patient.

What IV medications are ordered?

For vesicant medications, a central line is required. Vesicant medications are proven to cause tissue damage if extravasation occurs⁶. The INS Infusion Therapy Standards of Practice defines extravasation as the inadvertent infiltration of vesicant solution or medication into surrounding tissue⁷. The Infusion Nurses Society (INS) created a task force that produced an evidence-based noncytotoxic list of medications and solutions that may cause tissue damage upon extravasation. This list was directly reproduced from the INS Learning Center document⁶.

vesicantlist.jpg.fe6ddff544dee813e4fcb99183ddb228.jpg

The INS Infusion Therapy Standards of Practice advises that each facility should develop an internal list of vesicants and expand the INS list as needed^7.

Does your patient have Chronic Kidney Disease (CKD)?

Nephrologist approval is required for PICC or Midline placement in patients with CKD stage 3 or higher or eGFR <45 mL/min/1.73 m2). Why? Because PICC lines and Midlines go into the veins of the upper arm (basilic or brachial). These veins should be preserved for future hemodialysis access. Only nephrologists are qualified to determine a patient's future dialysis needs. National guidelines recommend against placing lines in the upper arms of CKD patients. Please take care to preserve your patients' veins and always contact the nephrologist for line approval for CKD Stage3 or higher or eGFR<45⁸.
- The nephrologist may recommend a tunneled catheter for their patient instead of a PICC line in order to preserve veins in the upper arm.

Does your patient have positive blood cultures?

Infectious disease physician approval is recommended for PICCs being placed for antimicrobial therapy (IV antibiotics) and is associated with more appropriate placements and fewer complications⁹.

Does your patient have a history of difficult venous access?

For a difficult access patient, ask for an ultrasound-guided PIV¹.

More recommendations from MAGIC³

Evaluate all orders for CVADs to ensure the best line for your patient has been ordered.
For PICCs, placement confirmation is required with a chest x-ray, fluoroscopy, or EKG guidance where appropriate.
Notify the physician when any CVAD (PICC, CVC, tunneled catheter) has not been used for 48 hours and suggest removal.
Suggest removing any catheter when there is no longer a clinical indication or the original purpose has been met.

Summary

The MAGIC guide makes patients safer. MAGIC is used in nearly every US state as a policy or evidence-based resource for venous access. The resulting literature from the evaluation of MAGIC usage shows a reduction in harm and complications for patients.

The evidence to date is clear. Using MAGIC to guide line selection for your patient reduces their risk of harm.

The nurse can be all that stands between a patient and harm. The nurse is the last check before something comes into contact with patients. Patient safety is enhanced whenever we use evidence-based guidelines and practices. MAGIC is one more tool to help nurses advocate on a patient's behalf.

How do you advocate for the right line, in the right patient, at the right time?

All it takes is a little MAGIC!

And, yes, there's an app¹⁰ for that!

References

¹The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method

²Making MAGIC: how to improve the use of peripherally inserted central catheters

³Indications for peripheral, midline and central catheters: summary of the MAGIC recommendations

⁴Device recommendations for peripherally compatible infusions (The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) Recommendations) (Chopra et al. 2015)

⁵Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals

⁶Noncytotoxic Vesicant Medications and Solutions

⁷Infusion Therapy Standards of Practice 8th edition

⁸Use of Peripherally Inserted Central Catheters in Patients With Advanced Chronic Kidney Disease: A Prospective Cohort Study