1156 infection control & hospital epidemiology october 2017, vol. 38, no. 10


A recent prospective study of nursing home residents found that CLABSI complicated the course of 4% of PICCs used in this setting.16 Similarly, a recent study of outpatients with PICCs reported that confirmed or suspected infection was a common cause for PICC removal.17 One potential strategy to prevent CLABSI is to avoid the use


of PICCs in patients at high risk for CLABSI. For example, studies have shown that immunosuppression, multilumen PICCs, length of hospital stay, and PICC placement in an ICU setting are associated with greater risk of CLABSI.18,19 How- ever, how best to operationalize or prioritize these factors when making decisions regarding PICC use is not clear. To date, no risk model has been developed to estimate an indivi- dual’s risk of PICC-CLABSI prior to device placement. To bridge this gap, we used data from an ongoing prospective cohort study to develop the Michigan PICC-CLABSI (MPC) score to predict CLABSI in patients with PICCs.


methods Study Setting and Participants


The study was conducted using data from the Michigan Hospital Medicine Safety (HMS) consortium, a 48-hospital collaborative quality initiative supported by Blue Cross Blue Shield of Michigan and Blue Care Network. The design and setting of this consortium have been previously described.20–22 In brief, HMShospitals prospectively collect data regarding PICC use and outcomes in hospitalized medical patients using a protocoled sampling strategy at participating hospitals.20 Adult medical patients admitted to a general ward or ICU of a participating hospital who receive a PICC for any reason during clinical care are eligible for inclusion. Patients who are (1) under the age of 18, (2) pregnant, (3) admitted to a nonmedical service (eg, general surgery), or (4) admitted under observation status are excluded. At each hospital, dedicated, trained, medical-record


abstractors use a standardized template to collect clinical data directly from health records of patients. Patients with PICCs are sampled on a 14-day cycle, and data from the first 17 cases that meet eligibility criteria within each cycle are collected and stored within a patient registry. To ensure adequate repre- sentation of critically ill patients, 7 of the 17 cases include PICC placement in an ICU setting. All patients are followed until PICC removal, death, or 70 days, whichever occurs first. Data collection for the HMS project is ongoing; for this analysis, complete data from patients enrolled in the study between January 2013 and October 2016 were included.


Covariables and Definitions


Detailed medical history including comorbidities, physical find- ings, laboratory data, andmedication data are collected from the medical record at the time of hospital admission. The following data are abstracted directly from the medical records: age (≤64 vs ≥65 years) sex; race; body mass index; tobacco use (never,


former, or current); admitting diagnosis; prior CLABSI within 3 months of PICC placement; parenteral nutrition via PICC; receipt of hemodialysis; chemotherapy or blood admini- stration during hospitalization; presence of active infection and site of infection; past or present hematological malignancy; active cancer (defined as receipt of chemotherapy while PICC was in place); existing central venous catheter when PICC was placed (yes/no); diabetes mellitus (uncomplicated vs complicated by micro- or macrovascular complications); history of cerebro- vascular accident or transient ischemic attack; history of myocardial infarction; venous thromboembolism prophylaxis (ie, receipt of subcutaneous heparin twice or thrice daily regi- mens or use of enoxaparin at prophylactic doses or treatment dose anticoagulation for any reason); aspirin; statin; erythropoi- esis stimulating agents; and antibiotic administration. Laboratory data including white blood cell count, hemoglobin, platelet count and international normalized ratio at the time of PICC place- ment are also collected. PICCs are vascular access devices inserted into the veins of the


upper extremity that terminate at the cavoatrial junction; thus, midlines, conventional CVCs, or catheters placed in lower extremity veins are excluded. However, the presence of a CVC in a limb or neck at the time of PICC insertion is captured in the data collection. Data regarding PICC characteristics (eg, gauge, lumens, tip position verification) and indication for PICC place- ment are obtained directly from vascular nursing or interven- tional radiology insertion notes or the order for PICC placement. PICC-CLABSI was defined using a modified version of the Centers for Disease Control and Prevention/National Healthcare Safety Network (CDC/NHSN) definition.21 The definition was modified as follows: (1) cases for which CLABSI was docu- mented in the medical record by medical providers based on clinical data (eg, cultures) regardless of conformation to the NSHN definition were included; (2) recording of symptoms of CLABSI (eg, fever, hypotension or rigors) was restricted to 3 days before or after the date of a positive blood culture; (3) determi- nation of infection at another site was generalized to the entire PICC dwell time. Thus, if a patient had an infection at another site at any time the PICC was in place, we did not count these cases as CLABSIs. Changes to the definition were necessary because (1) hospital abstractors are not trained infection control preventionists and therefore cannot reliably adjudicate infection at another site; (2) abstractors had limited time assigned to the project and consideration of abstractor burden necessitated limiting data review; and (3) every hospital has a unique practice for blood culture collection, line removal, and reporting, which can only be addressed through a more “operational” study defi- nition. However, we believe the modifications to increase the specificity for CLABSI increase the likelihood that more “true positive” cases are included with our approach.


Ascertainment of Outcomes


The primary outcome was CLABSI defined using modified CDC/NHSN criteria in a patient with a PICC. Additionally,


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