How to Advocate for the Right Line, in the Right Patient, at the Right Time? | Knowledge is Power

Updated | Published
by RNwrites Health RNwrites Health, ADN, BSN, MSN (New)

Specializes in Critical Care/Vascular Access. Has 16 years experience.

The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) is an evidence-based guide for selecting the most appropriate vascular access for a patient.

Advocating for your patients to have the appropriate venous access

How to Advocate for the Right Line, in the Right Patient, at the Right Time? | Knowledge is Power

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 possible1,3,4,5.

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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.

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  • The INS Infusion Therapy Standards of Practice advises that each facility should develop an internal list of vesicants and expand the INS list as needed7.

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

9Association of Infectious Disease Physician Approval of Peripherally Inserted Central Catheter With Appropriateness and Complications

10MICHIGAN MAGIC - Now Available for Download!

Board-certified in Vascular Access and Nursing Professional Development, Rebecca has 16+ years experience in nursing: ICU, Vascular Access, Patient & Nursing Education. Rebecca is a #nursewriter.

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3 Comment(s)

SethH

SethH

18 Posts

Thanks for the information, consulting a nephrologist regarding upper arm cannulation for ckd3 makes sense and is not something I’ve thought about before.

LovingLife123

LovingLife123

1,556 Posts

I have several disagreements here.  First of all, midlines are terrible and should not be used.  They are a PIV with a much longer catheter.  You cannot tell if they have infiltrated.  
Second, nobody can predict the length of stay.  We have zero idea if it’s 2 weeks or 6 months that a person can be in the hospital.  Even an outpatient surgery can go bad.  
While it’s a good idea to always start with a PIV, anybody going to the ICU at least needs a PICC if not an IJ or subclavian.  It’s cruel to pile somebody multiple times a day for labs.  
I honestly hate the push to only use a PIV in the ICU.  I would hear that sometimes from residents or new attendings in the ICU and I would roll my eyes.  It’s not easy to stick those fluid rescuscitated, now fluid overloaded patients.

Yes, a PICC can cause a DVT.  But patients aren’t picture perfect and neither can your access.  
Sorry, I’m a big fan of PICCS.  If you take care of them properly, by flushing them q8 and changing the dressing q7 days, they should be your best friend.  

JBMmom, MSN, NP

Specializes in New NP Hospitalist, Critical care, Med-surg, LTC. Has 10 years experience. 4 Articles; 2,160 Posts

When the first wave of COVID came through all of our critical patients got a central line and an A line. Then were was an increase in the number of CLABSIs (shocking), and now it practically takes an act of Congress to get our patients in critical care a central line. I remember arguing with my manager whether the percentage of CLABSIs had increased, or just the number, since we had about three times as many central lines, and they were only placing femoral lines in COVID patients, it seems obvious that there would be an associated increase. Again shockingly, there were no data about rates, only total numbers. 

We just got midlines within the last six months. I agree that the infiltration  potential makes me nervous since you're not going to see any signs until it's a disaster. It's in our policy NOT to run extravasants, like pressors, through midlines. However, MDs will just put in a nursing communication order "may use midline for pressor" instead of getting a more appropriate central access. I don't care what that order says, I'm not risking my license, or my patient's arm and running a pressor. I'd rather run it peripheral where I can at least assess a site. 

We also have doctors saying, "well it's only a low dose of pressor so you'll be fine with a peripheral". Yeah, at 3pm it was running at 2 mcg/min, but now it's 10pm and I'm going up to 20 mcg/min of levo through grannie's thumb and trying to consult surgery is a nightmare. 

I understand that central line access comes with some potential risk, but it shouldn't take nurses yelling and screaming to get appropriate access for their patients. Even with a chart like the one above, MDs just aren't willing to put in the orders these days in many cases.