title: Quality improvement initiative to reduce deep vein thrombosis associated with peripherally inserted central catheters in adults with cystic fibrosis.
abstract: BACKGROUND
  Peripherally inserted central catheters (PICCs) are common in the treatment of patients with cystic fibrosis (CF). Previous reports suggest that patients with CF are at increased risk for PICC-associated deep vein thrombosis (DVT).
  
  
  OBJECTIVE
  We assessed potential risk factors for symptomatic PICC-associated DVT with subsequent implementation of a quality improvement (QI) initiative to reduce PICC-associated DVT in patients with CF.
  
  
  METHODS
  This was a 5-year retrospective cohort study with subsequent 21-month prospective observation following implementation of a QI intervention in adults (aged 18 yr or older) with CF. All patients with a PICC inserted from July 2006 to March 2013 at our CF Foundation-accredited center were included. Symptomatic DVT was diagnosed by Doppler ultrasound. PICC insertions were analyzed, and nine risk factors for DVT were analyzed to formulate a QI initiative to reduce risk of PICC-associated DVT. The QI program focused on staff education and included modification to PICC order entry with a 4 French (F) single-lumen (SL) catheter as standard for all patients with CF.
  
  
  RESULTS
  A total of 369 PICCs were analyzed in 117 unique patients for a total of 5,437 PICC-days of placement. Symptomatic DVT was diagnosed in 28 (7.6%) of the 369 PICCs analyzed. Using regression analysis, the strongest predictors for DVT occurrence were warfarin use (odds ratio [OR] = 9.2, P = 0.006) and history of PICC-associated DVT (OR = 2.97, P = 0.08). Insertion of a 4F SL PICC resulted in zero symptomatic DVT. Zero episodes of DVT associated with 4F PICC insertion prevented use of PICC size in regression analysis. However, univariate analysis revealed that insertion of a 4F SL PICC instead of either 5F double lumen or 6F triple lumen was associated with a reduction in PICC-associated DVT (P = 0.001). After the QI intervention, 4F SL catheter insertion substantially increased to 65.8% of all PICCs inserted, whereas 6F triple-lumen catheter insertion declined to 6.8% of PICCs inserted. The QI initiative resulted in an absolute risk reduction in DVT per PICC placed of 6.1% (P = 0.055).
  
  
  CONCLUSIONS
  To reduce risk of PICC-associated DVT in patients with CF, QI strategies should focus on insertion of smaller-diameter 4F PICCs and reduction in PICC use in high-risk patients when possible.
authors.affiliation: 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine.
authors.forename: Joel D
authors.initials: JD
authors.lastname: Mermis
authors.forename: Jeremy C
authors.initials: JC
authors.lastname: Strom
authors.forename: John P
authors.initials: JP
authors.lastname: Greenwood
authors.forename: Derek M
authors.initials: DM
authors.lastname: Low
authors.forename: Jianghua
authors.initials: J
authors.lastname: He
authors.forename: Steven W
authors.initials: SW
authors.lastname: Stites
authors.forename: Steven Q
authors.initials: SQ
authors.lastname: Simpson
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D002406:Catheterization, Peripheral / Q000009:adverse effects* / Q000295:instrumentation*; D057785:Catheters; D015331:Cohort Studies; D003550:Cystic Fibrosis / Q000150:complications*; D004867:Equipment Design; D006801:Humans; D008875:Middle Aged; D058996:Quality Improvement; D012044:Regression Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D014463:Ultrasonography; D020246:Venous Thrombosis / Q000000981:diagnostic imaging / Q000517:prevention & control*; D014859:Warfarin / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D000925:Anticoagulants; D014859:Warfarin
keywords: inflammation; lung function tests; thrombosis; venous thromboembolism; warfarin