1164 infection control & hospital epidemiology october 2017, vol. 38, no. 10


ICU than non-ICU areas. Despite this knowledge, risk factors that contribute specifically to PICC-CLABSI in individual patients have not been well studied. Available prediction models are derived from single-center studies that feature homogenous populations, limiting their applicability.9,15,18 The MPC score is a departure from the status quo because it addresses many of these issues and allows for quantitative estimation of PICC-CLABSI in new ways. Some predictors of PICC-CLABSI identified in our model


reflect those reported in other studies. For example, we and others have shownthatthenumber ofdevicelumens is strongly asso- ciated with PICC-CLABSI.1,15,19,35 Effortstoplace PICCswiththe fewest lumens have therefore been developed and appear effective in reducing complications.36–38 Similarly, administration of TPN via PICCs is known to be significantly associated with CLABSI.39 Prevention efforts tailored toward TPN such as care bundles that dedicate 1 lumen for TPN or change of TPN infusion sets every 24 hours are valuable in patients with PICCs.40,41 The use of alternative vascular access devices such as ports or tunneled catheters (for which rates of infection are known to be lower than those for PICCs) may be more effective in preventing CLABSI. The Michigan Appropriateness Guide to Intravenous Catheters (orMAGIC)offersanalgorithmic approach to selecting devices other than PICCs in such situations.42 If patients have a highMPC score, what may be done to avert CLABSI? Several strategies are feasible. First, reevaluating the necessity of a PICC is prudent. As illustrated in a study of more than 3,000 patients in 10 Michigan hospitals, a large proportion of PICCs might be avoidable.20 Similarly, when comparing oral versus intravenous antibiotic treatment via a PICC, outcomes might not be dissimilar despite greater risk of PICC-related complications.43,44 Thus, policies that direct high-risk patients to receive early infectious diseases consultation to determine appropriateness versus alternative forms of antibiotic therapy (eg, oral therapy, shorter duration, etc.) might be effective.45,46 Second, patients with scores above a preset threshold might be subject to stricter clinical vigilance, such as limited device access or device care by a single, high-functioning team within models such as “catheter rounds.” Third, a higher risk score may prompt consideration of an antimicrobial-impregnated or -coated PICC, as these have been shown to reduce risk of CLABSI in patients at high risk of this event.47 Our study has several limitations. First, it was derived and


validated within a cohort of hospitalized medical adults; external validation in other patient populations such as pediatric or surgical settings is necessary before widespread use can be recommended. Second, we used a modified CDC/ NHSN definition of CLABSI, a change that was necessary to limit abstractor data collection burden and to ensure that the detection of CLABSI was applied similarly across all hospitals by individuals not necessarily trained for this purpose. How- ever, the definition we used is more specific to CLABSI for the following reasons: (1) In an era of payment reform, healthcare providers may not document CLABSI unless they are clinically treating for the same or are fairly certain about the diagnosis.


(2) The definition is equally applicable to all sites and thus more internally valid regardless of documentation, blood culture practices, laboratory reporting, etc. (3) The predictive performance of our model was similar when restricted to the more inclusive CRBSI definition, suggesting that our inclusion of CLABSI cases was representative of those with true infection. Third, data used to develop this tool were col- lected through review of medical records and, as such, are susceptible to reporting bias. However, because the data were sourced directly from medical records by trained abstractors, we believe that this risk was minimized to the extent possible. Our study also has important strengths. First, we created a


model that allows for calculation of a patient-specific CLABSI risk score. Because PICC use continues to rise and compre- hensive models to predict risk of CLABSI do not exist, the MPC score offers an important scientific contribution to the literature. Second, the MPC score can help inform not only decisions regarding when a PICC might be the optimal choice but also institutional policies related to surveillance and management of high-risk cohorts. Because both ICU and non- ICU patients are included in the model, it will meet the needs of multiple stakeholders and providers in this regard. Third, the MPC risk score can be provided to clinicians in new and convenient ways, such as handheld applications and smart- phone tools. Exploring avenues such as these to bring research to the bedside is a key strength of this scoring method. In conclusion, we derived and validated a tool that predicts


the risk of PICC-CLABSI in a large cohort of hospitalized patients. Future studies that focus on both validating the tool and exploring strategies for implementation in clinical settings are needed.


acknowledgments


Blue Cross/Blue Shield of Michigan and Blue Care Network supported data collection at each participating site and funded the data coordinating center but had no role in study concept, interpretation of findings, or in the pre- paration, final approval or decision to submit the manuscript. Financial support: Support for Michigan Hospital Medicine Safety Con-


sortium (HMS) is provided by Blue Cross and Blue Shield of Michigan and Blue Care Network as part of the Blue Cross Blue Shield of Michigan (BCBSM) Value Partnerships program. Although Blue Cross Blue Shield of Michigan and HMS work collaboratively, the opinions, beliefs and viewpoints expressed by the author do not necessarily reflect the opinions, beliefs and viewpoints of BCBSM or any of its employees. Dr Chopra is supported by an AHRQ career development award (grant no. 1-K08HS022835-01). Potential conflicts of interest: Dr Chopra has received grants from the Agency


for Healthcare Research and Quality, the CDC, and the National Institute of Health as well as honoraria for talks as visiting professor. Dr Flanders has received royalties from Wiley Publishing; honoraria for various talks at hospitals as a visiting professor; grants from the CDC, the AHRQ, and BCBSM; and fees for expert witness testimony. Dr Washer has received grant funding from the National Institute of Health, the Healthcare Research Education Trust, and the AHRQ. Drs Herc, Conlon, and Patel report no conflicts of interest relevant to this article.


Address correspondence to Vineet Chopra, MD, MSc, 2800 Plymouth Road, Building 16, #432W, Ann Arbor, MI 48109 (vineetc@umich.edu).


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