User login
Patient Preferences for Physician Attire: A Multicenter Study in Japan
The patient-physician relationship is critical for ensuring the delivery of high-quality healthcare. Successful patient-physician relationships arise from shared trust, knowledge, mutual respect, and effective verbal and nonverbal communication. The ways in which patients experience healthcare and their satisfaction with physicians affect a myriad of important health outcomes, such as adherence to treatment and outcomes for conditions such as hypertension and diabetes mellitus.1-5 One method for potentially enhancing patient satisfaction is through understanding how patients wish their physicians to dress6-8 and tailoring attire to match these expectations. In addition to our systematic review,9 a recent large-scale, multicenter study in the United States revealed that most patients perceive physician attire as important, but that preferences for specific types of attire are contextual.9,10 For example, elderly patients preferred physicians in formal attire and white coat, while scrubs with white coat or scrubs alone were preferred for emergency department (ED) physicians and surgeons, respectively. Moreover, regional variation regarding attire preference was also observed in the US, with preferences for more formal attire in the South and less formal in the Midwest.
Geographic variation, regarding patient preferences for physician dress, is perhaps even more relevant internationally. In particular, Japan is considered to have a highly contextualized culture that relies on nonverbal and implicit communication. However, medical professionals have no specific dress code and, thus, don many different kinds of attire. In part, this may be because it is not clear whether or how physician attire impacts patient satisfaction and perceived healthcare quality in Japan.11-13 Although previous studies in Japan have suggested that physician attire has a considerable influence on patient satisfaction, these studies either involved a single department in one hospital or a small number of respondents.14-17 Therefore, we performed a multicenter, cross-sectional study to understand patients’ preferences for physician attire in different clinical settings and in different geographic regions in Japan.
METHODS
Study Population
We conducted a cross-sectional, questionnaire-based study from 2015 to 2017, in four geographically diverse hospitals in Japan. Two of these hospitals, Tokyo Joto Hospital and Juntendo University Hospital, are located in eastern Japan whereas the others, Kurashiki Central Hospital and Akashi Medical Center, are in western Japan.
Questionnaires were printed and randomly distributed by research staff to outpatients in waiting rooms and inpatients in medical wards who were 20 years of age or older. We placed no restriction on ward site or time of questionnaire distribution. Research staff, including physicians, nurses, and medical clerks, were instructed to avoid guiding or influencing participants’ responses. Informed consent was obtained by the staff; only those who provided informed consent participated in the study. Respondents could request assistance with form completion from persons accompanying them if they had difficulties, such as physical, visual, or hearing impairments. All responses were collected anonymously. The study was approved by the ethics committees of all four hospitals.
Questionnaire
We used a modified version of the survey instrument from a prior study.10 The first section of the survey showed photographs of either a male or female physician with 7 unique forms of attire, including casual, casual with white coat, scrubs, scrubs with white coat, formal, formal with white coat, and business suit (Figure 1). Given the Japanese context of this study, the language was translated to Japanese and photographs of physicians of Japanese descent were used. Photographs were taken with attention paid to achieving constant facial expressions on the physicians as well as in other visual cues (eg, lighting, background, pose). The physician’s gender and attire in the first photograph seen by each respondent were randomized to prevent bias in ordering, priming, and anchoring; all other sections of the survey were identical.
Respondents were first asked to rate the standalone, randomized physician photograph using a 1-10 scale across five domains (ie, how knowledgeable, trustworthy, caring, and approachable the physician appeared and how comfortable the physician’s appearance made the respondent feel), with a score of 10 representing the highest rating. Respondents were subsequently given 7 photographs of the same physician wearing various forms of attire. Questions were asked regarding preference of attire in varied clinical settings (ie, primary care, ED, hospital, surgery, overall preference). To identify the influence of and respondent preferences for physician dress and white coats, a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) was employed. The scale was trichotomized into “disagree” (1, 2), “neither agree nor disagree” (3), and “agree” (4, 5) for analysis. Demographic data, including age, gender, education level, nationality (Japanese or non-Japanese), and number of physicians seen in the past year were collected.
Outcomes and Sample Size Calculation
The primary outcome of attire preference was calculated as the mean composite score of the five individual rating domains (ie, knowledgeable, trustworthy, caring, approachable, and comfortable), with the highest score representing the most preferred form of attire. We also assessed variation in preferences for physician attire by respondent characteristics, such as age and gender.
Sample size estimation was based on previous survey methodology.10 The Likert scale range for identifying influence of and respondent preferences for physician dress and white coats was 1-5 (“strongly disagree” to “strongly agree”). The scale range for measuring preferences for the randomized attire photograph was 1-10. An assumption of normality was made regarding responses on the 1-10 scale. An estimated standard deviation of 2.2 was assumed, based on prior findings.10 Based on these assumptions and the inclusion of at least 816 respondents (assuming a two-sided alpha error of 0.05), we expected to have 90% capacity to detect differences for effect sizes of 0.50 on the 1-10 scale.
Statistical Analyses
Paper-based survey data were entered independently and in duplicate by the study team. Respondents were not required to answer all questions; therefore, the denominator for each question varied. Data were reported as mean and standard deviation (SD) or percentages, where appropriate. Differences in the mean composite rating scores were assessed using one-way ANOVA with the Tukey method for pairwise comparisons. Differences in proportions for categorical data were compared using the Z-test. Chi-squared tests were used for bivariate comparisons between respondent age, gender, and level of education and corresponding respondent preferences. All analyses were performed using Stata 14 MP/SE (Stata Corp., College Station, Texas, USA).
RESULTS
Characteristics of Participants
Between December 1, 2015 and October 30, 2017, a total of 2,020 surveys were completed by patients across four academic hospitals in Japan. Of those, 1,960 patients (97.0%) completed the survey in its entirety. Approximately half of the respondents were 65 years of age or older (49%), of female gender (52%), and reported receiving care in the outpatient setting (53%). Regarding use of healthcare, 91% had seen more than one physician in the year preceding the time of survey completion (Table 1).
Ratings of Physician Attire
Compared with all forms of attire depicted in the survey’s first standalone photograph, respondents rated “casual attire with white coat” the highest (Figure 2). The mean composite score for “casual attire with white coat” was 7.1 (standard deviation [SD] = 1.8), and this attire was set as the referent group. Cronbach’s alpha, for the five items included in the composite score, was 0.95. However, “formal attire with white coat” was rated almost as highly as “casual attire with white coat” with an overall mean composite score of 7.0 (SD = 1.6).
Variation in Preference for Physician Attire by Clinical Setting
Preferences for physician attire varied by clinical care setting. Most respondents preferred “casual attire with white coat” or “formal attire with white coat” in both primary care and hospital settings, with a slight preference for “casual attire with white coat.” In contrast, respondents preferred “scrubs without white coat” in the ED and surgical settings. When asked about their overall preference, respondents reported they felt their physician should wear “formal attire with white coat” (35%) or “casual attire with white coat” (30%; Table 2). When comparing the group of photographs of physicians with white coats to the group without white coats (Figure 1), respondents preferred physicians wearing white coats overall and specifically when providing care in primary care and hospital settings. However, they preferred physicians without white coats when providing care in the ED (P < .001). With respect to surgeons, there was no statistically significant difference between preference for white coats and no white coats. These results were similar for photographs of both male and female physicians.
When asked whether physician dress was important to them and if physician attire influenced their satisfaction with the care received, 61% of participants agreed that physician dress was important, and 47% agreed that physician attire influenced satisfaction (Appendix Table 1). With respect to appropriateness of physicians dressing casually over the weekend in clinical settings, 52% responded that casual wear was inappropriate, while 31% had a neutral opinion.
Participants were asked whether physicians should wear a white coat in different clinical settings. Nearly two-thirds indicated a preference for white coats in the office and hospital (65% and 64%, respectively). Responses regarding whether emergency physicians should wear white coats were nearly equally divided (Agree, 37%; Disagree, 32%; Neither Agree nor Disagree, 31%). However, “scrubs without white coat” was most preferred (56%) when patients were given photographs of various attire and asked, “Which physician would you prefer to see when visiting the ER?” Responses to the question “Physicians should always wear a white coat when seeing patients in any setting” varied equally (Agree, 32%; Disagree, 34%; Neither Agree nor Disagree, 34%).
Variation in Preference for Physician Attire by Respondent Demographics
When comparing respondents by age, those 65 years or older preferred “formal attire with white coat” more so than respondents younger than 65 years (Appendix Table 2). This finding was identified in both primary care (36% vs 31%, P < .001) and hospital settings (37% vs 30%, P < .001). Additionally, physician attire had a greater impact on older respondents’ satisfaction and experience (Appendix Table 3). For example, 67% of respondents 65 years and older agreed that physician attire was important, and 54% agreed that attire influenced satisfaction. Conversely, for respondents younger than 65 years, the proportion agreeing with these statements was lower (56% and 41%, both P < .001). When comparing older and younger respondents, those 65 years and older more often preferred physicians wearing white coats in any setting (39% vs 26%, P < .001) and specifically in their office (68% vs 61%, P = .002), the ED (40% vs 34%, P < .001), and the hospital (69% vs 60%, P < .001).
When comparing male and female respondents, male respondents more often stated that physician dress was important to them (men, 64%; women, 58%; P = .002). When comparing responses to the question “Overall, which clothes do you feel a doctor should wear?”, between the eastern and western Japanese hospitals, preferences for physician attire varied.
Variation in Expectations Between Male and Female Physicians
When comparing the ratings of male and female physicians, female physicians were rated higher in how caring (P = .005) and approachable (P < .001) they appeared. However, there were no significant differences in the ratings of the three remaining domains (ie, knowledgeable, trustworthy, and comfortable) or the composite score.
DISCUSSION
Since we employed the same methodology as previous studies conducted in the US10 and Switzerland,18 a notable strength of our approach is that comparisons among these countries can be drawn. For example, physician attire appears to hold greater importance in Japan than in the US and Switzerland. Among Japanese participants, 61% agreed that physician dress is important (US, 53%; Switzerland, 36%), and 47% agreed that physician dress influenced how satisfied they were with their care (US, 36%; Switzerland, 23%).10 This result supports the notion that nonverbal and implicit communications (such as physician dress) may carry more importance among Japanese people.11-13
Regarding preference ratings for type of dress among respondents in Japan, “casual attire with white coat” received the highest mean composite score rating, with “formal attire with white coat” rated second overall. In contrast, US respondents rated “formal attire with white coat” highest and “scrubs with white coat” second.10 Our result runs counter to our expectation in that we expected Japanese respondents to prefer formal attire, since Japan is one of the most formal cultures in the world. One potential explanation for this difference is that the casual style chosen for this study was close to the smart casual style (slightly casual). Most hospitals and clinics in Japan do not allow physicians to wear jeans or polo shirts, which were chosen as the casual attire in the previous US study.
When examining various care settings and physician types, both Japanese and US respondents were more likely to prefer physicians wearing a white coat in the office or hospital.10 However, Japanese participants preferred both “casual attire with white coat” and “formal attire with white coat” equally in primary care or hospital settings. A smaller proportion of US respondents preferred “casual attire with white coat” in primary care (11%) and hospital settings (9%), but more preferred “formal attire with white coat” for primary care (44%) and hospital physicians (39%). In the ED setting, 32% of participants in Japan and 18% in the US disagreed with the idea that physicians should wear a white coat. Among Japanese participants, “scrubs without white coat” was rated highest for emergency physicians (56%) and surgeons (47%), while US preferences were 40% and 42%, respectively.10 One potential explanation is that scrubs-based attire became popular among Japanese ED and surgical contexts as a result of cultural influence and spread from western countries.19, 20
With respect to perceptions regarding physician attire on weekends, 52% of participants considered it inappropriate for a physician to dress casually over the weekend, compared with only 30% in Switzerland and 21% in the US.11,12 Given Japan’s level of formality and the fact that most Japanese physicians continue to work over the weekend,21-23 Japanese patients tend to expect their physicians to dress in more formal attire during these times.
Previous studies in Japan have demonstrated that older patients gave low ratings to scrubs and high ratings to white coat with any attire,15,17 and this was also the case in our study. Perhaps elderly patients reflect conservative values in their preferences of physician dress. Their perceptions may be less influenced by scenes portraying physicians in popular media when compared with the perceptions of younger patients. Though a 2015 systematic review and studies in other countries revealed white coats were preferred regardless of exact dress,9,24-26 they also showed variation in preferences for physician attire. For example, patients in Saudi Arabia preferred white coat and traditional ethnic dress,25 whereas mothers of pediatric patients in Saudi Arabia preferred scrubs for their pediatricians.27 Therefore, it is recommended for internationally mobile physicians to choose their dress depending on a variety of factors including country, context, and patient age group.
Our study has limitations. First, because some physicians presented the surveys to the patients, participants may have responded differently. Second, participants may have identified photographs of the male physician model as their personal healthcare provider (one author, K.K.). To avoid this possible bias, we randomly distributed 14 different versions of physician photographs in the questionnaire. Third, although physician photographs were strictly controlled, the “formal attire and white coat” and “casual attire and white coat” photographs appeared similar, especially given that the white coats were buttoned. Also, the female physician depicted in the photographs did not have the scrub shirt tucked in, while the male physician did. These nuances may have affected participant ratings between groups. Fourth,
In conclusion, patient preferences for physician attire were examined using a multicenter survey with a large sample size and robust survey methodology, thus overcoming weaknesses of previous studies into Japanese attire. Japanese patients perceive that physician attire is important and influences satisfaction with their care, more so than patients in other countries, like the US and Switzerland. Geography, settings of care, and patient age play a role in preferences. As a result, hospitals and health systems may use these findings to inform dress code policy based on patient population and context, recognizing that the appearance of their providers affects the patient-physician relationship. Future research should focus on better understanding the various cultural and societal customs that lead to patient expectations of physician attire.
Acknowledgments
The authors thank Drs. Fumi Takemoto, Masayuki Ueno, Kazuya Sakai, Saori Kinami, and Toshio Naito for their assistance with data collection at their respective sites. Additionally, the authors thank Dr. Yoko Kanamitsu for serving as a model for photographs.
1. Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med. 2013;368(3):201-203. https://doi.org/ 10.1056/NEJMp1211775.
2. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48.
3. Barbosa CD, Balp MM, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adherence. 2012;6:39-48. https://doi.org/10.2147/PPA.S24752.
4. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921-31. https://doi.org/10.1056/NEJMsa080411.
5. O’Malley AS, Forrest CB, Mandelblatt J. Adherence of low-income women to cancer screening recommendations. J Gen Intern Med. 2002;17(2):144-54. https://doi.org/10.1046/j.1525-1497.2002.10431.x.
6. Chung H, Lee H, Chang DS, Kim HS, Park HJ, Chae Y. Doctor’s attire influences perceived empathy in the patient-doctor relationship. Patient Educ Couns. 2012;89(3):387-391. https://doi.org/10.1016/j.pec.2012.02.017.
7. Bianchi MT. Desiderata or dogma: what the evidence reveals about physician attire. J Gen Intern Med. 2008;23(5):641-643. https://doi.org/10.1007/s11606-008-0546-8.
8. Brandt LJ. On the value of an old dress code in the new millennium. Arch Intern Med. 2003;163(11):1277-1281. https://doi.org/10.1001/archinte.163.11.1277.
9. Petrilli CM, Mack M, Petrilli JJ, Hickner A, Saint S, Chopra V. Understanding the role of physician attire on patient perceptions: a systematic review of the literature--targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open. 2015;5(1):e006578. https://doi.org/10.1136/bmjopen-2014-006578.
10. Petrilli CM, Saint S, Jennings JJ, et al. Understanding patient preference for physician attire: a cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open. 2018;8(5):e021239. https://doi.org/10.1136/bmjopen-2017-021239.
11. Rowbury R. The need for more proactive communications. Low trust and changing values mean Japan can no longer fall back on its homogeneity. The Japan Times. 2017, Oct 15;Sect. Opinion. https://www.japantimes.co.jp/opinion/2017/10/15/commentary/japan-commentary/need-proactive-communications/#.Xej7lC3MzUI. Accessed December 5, 2019.
12. Shoji Nishimura ANaST. Communication Style and Cultural Features in High/Low Context Communication Cultures: A Case Study of Finland, Japan and India. Nov 22nd, 2009.
13. Smith RMRSW. The influence of high/low-context culture and power distance on choice of communication media: Students’ media choice to communicate with Professors in Japan and America. Int J Intercultural Relations. 2007;31(4):479-501.
14. Yamada Y, Takahashi O, Ohde S, Deshpande GA, Fukui T. Patients’ preferences for doctors’ attire in Japan. Intern Med. 2010;49(15):1521-1526. https://doi.org/10.2169/internalmedicine.49.3572.
15. Ikusaka M, Kamegai M, Sunaga T, et al. Patients’ attitude toward consultations by a physician without a white coat in Japan. Intern Med. 1999;38(7):533-536. https://doi.org/10.2169/internalmedicine.38.533.
16. Lefor AK, Ohnuma T, Nunomiya S, Yokota S, Makino J, Sanui M. Physician attire in the intensive care unit in Japan influences visitors’ perception of care. J Crit Care. 2018;43:288-293.
17. Kurihara H, Maeno T. Importance of physicians’ attire: factors influencing the impression it makes on patients, a cross-sectional study. Asia Pac Fam Med. 2014;13(1):2. https://doi.org/10.1186/1447-056X-13-2.
18. Zollinger M, Houchens N, Chopra V, et al. Understanding patient preference for physician attire in ambulatory clinics: a cross-sectional observational study. BMJ Open. 2019;9(5):e026009. https://doi.org/10.1136/bmjopen-2018-026009.
19. Chung JE. Medical Dramas and Viewer Perception of Health: Testing Cultivation Effects. Hum Commun Res. 2014;40(3):333-349.
20. Michael Pfau LJM, Kirsten Garrow. The influence of television viewing on public perceptions of physicians. J Broadcast Electron Media. 1995;39(4):441-458.
21. Suzuki S. Exhausting physicians employed in hospitals in Japan assessed by a health questionnaire [in Japanese]. Sangyo Eiseigaku Zasshi. 2017;59(4):107-118. https://doi.org/10.1539/sangyoeisei.
22. Ogawa R, Seo E, Maeno T, Ito M, Sanuki M. The relationship between long working hours and depression among first-year residents in Japan. BMC Med Educ. 2018;18(1):50. https://doi.org/10.1186/s12909-018-1171-9.
23. Saijo Y, Chiba S, Yoshioka E, et al. Effects of work burden, job strain and support on depressive symptoms and burnout among Japanese physicians. Int J Occup Med Environ Health. 2014;27(6):980-992. https://doi.org/10.2478/s13382-014-0324-2.
24. Tiang KW, Razack AH, Ng KL. The ‘auxiliary’ white coat effect in hospitals: perceptions of patients and doctors. Singapore Med J. 2017;58(10):574-575. https://doi.org/10.11622/smedj.2017023.
25. Al Amry KM, Al Farrah M, Ur Rahman S, Abdulmajeed I. Patient perceptions and preferences of physicians’ attire in Saudi primary healthcare setting. J Community Hosp Intern Med Perspect. 2018;8(6):326-330. https://doi.org/10.1080/20009666.2018.1551026.
26. Healy WL. Letter to the editor: editor’s spotlight/take 5: physicians’ attire influences patients’ perceptions in the urban outpatient orthopaedic surgery setting. Clin Orthop Relat Res. 2016;474(11):2545-2546. https://doi.org/10.1007/s11999-016-5049-z.
27. Aldrees T, Alsuhaibani R, Alqaryan S, et al. Physicians’ attire. Parents preferences in a tertiary hospital. Saudi Med J. 2017;38(4):435-439. https://doi.org/10.15537/smj.2017.4.15853.
The patient-physician relationship is critical for ensuring the delivery of high-quality healthcare. Successful patient-physician relationships arise from shared trust, knowledge, mutual respect, and effective verbal and nonverbal communication. The ways in which patients experience healthcare and their satisfaction with physicians affect a myriad of important health outcomes, such as adherence to treatment and outcomes for conditions such as hypertension and diabetes mellitus.1-5 One method for potentially enhancing patient satisfaction is through understanding how patients wish their physicians to dress6-8 and tailoring attire to match these expectations. In addition to our systematic review,9 a recent large-scale, multicenter study in the United States revealed that most patients perceive physician attire as important, but that preferences for specific types of attire are contextual.9,10 For example, elderly patients preferred physicians in formal attire and white coat, while scrubs with white coat or scrubs alone were preferred for emergency department (ED) physicians and surgeons, respectively. Moreover, regional variation regarding attire preference was also observed in the US, with preferences for more formal attire in the South and less formal in the Midwest.
Geographic variation, regarding patient preferences for physician dress, is perhaps even more relevant internationally. In particular, Japan is considered to have a highly contextualized culture that relies on nonverbal and implicit communication. However, medical professionals have no specific dress code and, thus, don many different kinds of attire. In part, this may be because it is not clear whether or how physician attire impacts patient satisfaction and perceived healthcare quality in Japan.11-13 Although previous studies in Japan have suggested that physician attire has a considerable influence on patient satisfaction, these studies either involved a single department in one hospital or a small number of respondents.14-17 Therefore, we performed a multicenter, cross-sectional study to understand patients’ preferences for physician attire in different clinical settings and in different geographic regions in Japan.
METHODS
Study Population
We conducted a cross-sectional, questionnaire-based study from 2015 to 2017, in four geographically diverse hospitals in Japan. Two of these hospitals, Tokyo Joto Hospital and Juntendo University Hospital, are located in eastern Japan whereas the others, Kurashiki Central Hospital and Akashi Medical Center, are in western Japan.
Questionnaires were printed and randomly distributed by research staff to outpatients in waiting rooms and inpatients in medical wards who were 20 years of age or older. We placed no restriction on ward site or time of questionnaire distribution. Research staff, including physicians, nurses, and medical clerks, were instructed to avoid guiding or influencing participants’ responses. Informed consent was obtained by the staff; only those who provided informed consent participated in the study. Respondents could request assistance with form completion from persons accompanying them if they had difficulties, such as physical, visual, or hearing impairments. All responses were collected anonymously. The study was approved by the ethics committees of all four hospitals.
Questionnaire
We used a modified version of the survey instrument from a prior study.10 The first section of the survey showed photographs of either a male or female physician with 7 unique forms of attire, including casual, casual with white coat, scrubs, scrubs with white coat, formal, formal with white coat, and business suit (Figure 1). Given the Japanese context of this study, the language was translated to Japanese and photographs of physicians of Japanese descent were used. Photographs were taken with attention paid to achieving constant facial expressions on the physicians as well as in other visual cues (eg, lighting, background, pose). The physician’s gender and attire in the first photograph seen by each respondent were randomized to prevent bias in ordering, priming, and anchoring; all other sections of the survey were identical.
Respondents were first asked to rate the standalone, randomized physician photograph using a 1-10 scale across five domains (ie, how knowledgeable, trustworthy, caring, and approachable the physician appeared and how comfortable the physician’s appearance made the respondent feel), with a score of 10 representing the highest rating. Respondents were subsequently given 7 photographs of the same physician wearing various forms of attire. Questions were asked regarding preference of attire in varied clinical settings (ie, primary care, ED, hospital, surgery, overall preference). To identify the influence of and respondent preferences for physician dress and white coats, a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) was employed. The scale was trichotomized into “disagree” (1, 2), “neither agree nor disagree” (3), and “agree” (4, 5) for analysis. Demographic data, including age, gender, education level, nationality (Japanese or non-Japanese), and number of physicians seen in the past year were collected.
Outcomes and Sample Size Calculation
The primary outcome of attire preference was calculated as the mean composite score of the five individual rating domains (ie, knowledgeable, trustworthy, caring, approachable, and comfortable), with the highest score representing the most preferred form of attire. We also assessed variation in preferences for physician attire by respondent characteristics, such as age and gender.
Sample size estimation was based on previous survey methodology.10 The Likert scale range for identifying influence of and respondent preferences for physician dress and white coats was 1-5 (“strongly disagree” to “strongly agree”). The scale range for measuring preferences for the randomized attire photograph was 1-10. An assumption of normality was made regarding responses on the 1-10 scale. An estimated standard deviation of 2.2 was assumed, based on prior findings.10 Based on these assumptions and the inclusion of at least 816 respondents (assuming a two-sided alpha error of 0.05), we expected to have 90% capacity to detect differences for effect sizes of 0.50 on the 1-10 scale.
Statistical Analyses
Paper-based survey data were entered independently and in duplicate by the study team. Respondents were not required to answer all questions; therefore, the denominator for each question varied. Data were reported as mean and standard deviation (SD) or percentages, where appropriate. Differences in the mean composite rating scores were assessed using one-way ANOVA with the Tukey method for pairwise comparisons. Differences in proportions for categorical data were compared using the Z-test. Chi-squared tests were used for bivariate comparisons between respondent age, gender, and level of education and corresponding respondent preferences. All analyses were performed using Stata 14 MP/SE (Stata Corp., College Station, Texas, USA).
RESULTS
Characteristics of Participants
Between December 1, 2015 and October 30, 2017, a total of 2,020 surveys were completed by patients across four academic hospitals in Japan. Of those, 1,960 patients (97.0%) completed the survey in its entirety. Approximately half of the respondents were 65 years of age or older (49%), of female gender (52%), and reported receiving care in the outpatient setting (53%). Regarding use of healthcare, 91% had seen more than one physician in the year preceding the time of survey completion (Table 1).
Ratings of Physician Attire
Compared with all forms of attire depicted in the survey’s first standalone photograph, respondents rated “casual attire with white coat” the highest (Figure 2). The mean composite score for “casual attire with white coat” was 7.1 (standard deviation [SD] = 1.8), and this attire was set as the referent group. Cronbach’s alpha, for the five items included in the composite score, was 0.95. However, “formal attire with white coat” was rated almost as highly as “casual attire with white coat” with an overall mean composite score of 7.0 (SD = 1.6).
Variation in Preference for Physician Attire by Clinical Setting
Preferences for physician attire varied by clinical care setting. Most respondents preferred “casual attire with white coat” or “formal attire with white coat” in both primary care and hospital settings, with a slight preference for “casual attire with white coat.” In contrast, respondents preferred “scrubs without white coat” in the ED and surgical settings. When asked about their overall preference, respondents reported they felt their physician should wear “formal attire with white coat” (35%) or “casual attire with white coat” (30%; Table 2). When comparing the group of photographs of physicians with white coats to the group without white coats (Figure 1), respondents preferred physicians wearing white coats overall and specifically when providing care in primary care and hospital settings. However, they preferred physicians without white coats when providing care in the ED (P < .001). With respect to surgeons, there was no statistically significant difference between preference for white coats and no white coats. These results were similar for photographs of both male and female physicians.
When asked whether physician dress was important to them and if physician attire influenced their satisfaction with the care received, 61% of participants agreed that physician dress was important, and 47% agreed that physician attire influenced satisfaction (Appendix Table 1). With respect to appropriateness of physicians dressing casually over the weekend in clinical settings, 52% responded that casual wear was inappropriate, while 31% had a neutral opinion.
Participants were asked whether physicians should wear a white coat in different clinical settings. Nearly two-thirds indicated a preference for white coats in the office and hospital (65% and 64%, respectively). Responses regarding whether emergency physicians should wear white coats were nearly equally divided (Agree, 37%; Disagree, 32%; Neither Agree nor Disagree, 31%). However, “scrubs without white coat” was most preferred (56%) when patients were given photographs of various attire and asked, “Which physician would you prefer to see when visiting the ER?” Responses to the question “Physicians should always wear a white coat when seeing patients in any setting” varied equally (Agree, 32%; Disagree, 34%; Neither Agree nor Disagree, 34%).
Variation in Preference for Physician Attire by Respondent Demographics
When comparing respondents by age, those 65 years or older preferred “formal attire with white coat” more so than respondents younger than 65 years (Appendix Table 2). This finding was identified in both primary care (36% vs 31%, P < .001) and hospital settings (37% vs 30%, P < .001). Additionally, physician attire had a greater impact on older respondents’ satisfaction and experience (Appendix Table 3). For example, 67% of respondents 65 years and older agreed that physician attire was important, and 54% agreed that attire influenced satisfaction. Conversely, for respondents younger than 65 years, the proportion agreeing with these statements was lower (56% and 41%, both P < .001). When comparing older and younger respondents, those 65 years and older more often preferred physicians wearing white coats in any setting (39% vs 26%, P < .001) and specifically in their office (68% vs 61%, P = .002), the ED (40% vs 34%, P < .001), and the hospital (69% vs 60%, P < .001).
When comparing male and female respondents, male respondents more often stated that physician dress was important to them (men, 64%; women, 58%; P = .002). When comparing responses to the question “Overall, which clothes do you feel a doctor should wear?”, between the eastern and western Japanese hospitals, preferences for physician attire varied.
Variation in Expectations Between Male and Female Physicians
When comparing the ratings of male and female physicians, female physicians were rated higher in how caring (P = .005) and approachable (P < .001) they appeared. However, there were no significant differences in the ratings of the three remaining domains (ie, knowledgeable, trustworthy, and comfortable) or the composite score.
DISCUSSION
Since we employed the same methodology as previous studies conducted in the US10 and Switzerland,18 a notable strength of our approach is that comparisons among these countries can be drawn. For example, physician attire appears to hold greater importance in Japan than in the US and Switzerland. Among Japanese participants, 61% agreed that physician dress is important (US, 53%; Switzerland, 36%), and 47% agreed that physician dress influenced how satisfied they were with their care (US, 36%; Switzerland, 23%).10 This result supports the notion that nonverbal and implicit communications (such as physician dress) may carry more importance among Japanese people.11-13
Regarding preference ratings for type of dress among respondents in Japan, “casual attire with white coat” received the highest mean composite score rating, with “formal attire with white coat” rated second overall. In contrast, US respondents rated “formal attire with white coat” highest and “scrubs with white coat” second.10 Our result runs counter to our expectation in that we expected Japanese respondents to prefer formal attire, since Japan is one of the most formal cultures in the world. One potential explanation for this difference is that the casual style chosen for this study was close to the smart casual style (slightly casual). Most hospitals and clinics in Japan do not allow physicians to wear jeans or polo shirts, which were chosen as the casual attire in the previous US study.
When examining various care settings and physician types, both Japanese and US respondents were more likely to prefer physicians wearing a white coat in the office or hospital.10 However, Japanese participants preferred both “casual attire with white coat” and “formal attire with white coat” equally in primary care or hospital settings. A smaller proportion of US respondents preferred “casual attire with white coat” in primary care (11%) and hospital settings (9%), but more preferred “formal attire with white coat” for primary care (44%) and hospital physicians (39%). In the ED setting, 32% of participants in Japan and 18% in the US disagreed with the idea that physicians should wear a white coat. Among Japanese participants, “scrubs without white coat” was rated highest for emergency physicians (56%) and surgeons (47%), while US preferences were 40% and 42%, respectively.10 One potential explanation is that scrubs-based attire became popular among Japanese ED and surgical contexts as a result of cultural influence and spread from western countries.19, 20
With respect to perceptions regarding physician attire on weekends, 52% of participants considered it inappropriate for a physician to dress casually over the weekend, compared with only 30% in Switzerland and 21% in the US.11,12 Given Japan’s level of formality and the fact that most Japanese physicians continue to work over the weekend,21-23 Japanese patients tend to expect their physicians to dress in more formal attire during these times.
Previous studies in Japan have demonstrated that older patients gave low ratings to scrubs and high ratings to white coat with any attire,15,17 and this was also the case in our study. Perhaps elderly patients reflect conservative values in their preferences of physician dress. Their perceptions may be less influenced by scenes portraying physicians in popular media when compared with the perceptions of younger patients. Though a 2015 systematic review and studies in other countries revealed white coats were preferred regardless of exact dress,9,24-26 they also showed variation in preferences for physician attire. For example, patients in Saudi Arabia preferred white coat and traditional ethnic dress,25 whereas mothers of pediatric patients in Saudi Arabia preferred scrubs for their pediatricians.27 Therefore, it is recommended for internationally mobile physicians to choose their dress depending on a variety of factors including country, context, and patient age group.
Our study has limitations. First, because some physicians presented the surveys to the patients, participants may have responded differently. Second, participants may have identified photographs of the male physician model as their personal healthcare provider (one author, K.K.). To avoid this possible bias, we randomly distributed 14 different versions of physician photographs in the questionnaire. Third, although physician photographs were strictly controlled, the “formal attire and white coat” and “casual attire and white coat” photographs appeared similar, especially given that the white coats were buttoned. Also, the female physician depicted in the photographs did not have the scrub shirt tucked in, while the male physician did. These nuances may have affected participant ratings between groups. Fourth,
In conclusion, patient preferences for physician attire were examined using a multicenter survey with a large sample size and robust survey methodology, thus overcoming weaknesses of previous studies into Japanese attire. Japanese patients perceive that physician attire is important and influences satisfaction with their care, more so than patients in other countries, like the US and Switzerland. Geography, settings of care, and patient age play a role in preferences. As a result, hospitals and health systems may use these findings to inform dress code policy based on patient population and context, recognizing that the appearance of their providers affects the patient-physician relationship. Future research should focus on better understanding the various cultural and societal customs that lead to patient expectations of physician attire.
Acknowledgments
The authors thank Drs. Fumi Takemoto, Masayuki Ueno, Kazuya Sakai, Saori Kinami, and Toshio Naito for their assistance with data collection at their respective sites. Additionally, the authors thank Dr. Yoko Kanamitsu for serving as a model for photographs.
The patient-physician relationship is critical for ensuring the delivery of high-quality healthcare. Successful patient-physician relationships arise from shared trust, knowledge, mutual respect, and effective verbal and nonverbal communication. The ways in which patients experience healthcare and their satisfaction with physicians affect a myriad of important health outcomes, such as adherence to treatment and outcomes for conditions such as hypertension and diabetes mellitus.1-5 One method for potentially enhancing patient satisfaction is through understanding how patients wish their physicians to dress6-8 and tailoring attire to match these expectations. In addition to our systematic review,9 a recent large-scale, multicenter study in the United States revealed that most patients perceive physician attire as important, but that preferences for specific types of attire are contextual.9,10 For example, elderly patients preferred physicians in formal attire and white coat, while scrubs with white coat or scrubs alone were preferred for emergency department (ED) physicians and surgeons, respectively. Moreover, regional variation regarding attire preference was also observed in the US, with preferences for more formal attire in the South and less formal in the Midwest.
Geographic variation, regarding patient preferences for physician dress, is perhaps even more relevant internationally. In particular, Japan is considered to have a highly contextualized culture that relies on nonverbal and implicit communication. However, medical professionals have no specific dress code and, thus, don many different kinds of attire. In part, this may be because it is not clear whether or how physician attire impacts patient satisfaction and perceived healthcare quality in Japan.11-13 Although previous studies in Japan have suggested that physician attire has a considerable influence on patient satisfaction, these studies either involved a single department in one hospital or a small number of respondents.14-17 Therefore, we performed a multicenter, cross-sectional study to understand patients’ preferences for physician attire in different clinical settings and in different geographic regions in Japan.
METHODS
Study Population
We conducted a cross-sectional, questionnaire-based study from 2015 to 2017, in four geographically diverse hospitals in Japan. Two of these hospitals, Tokyo Joto Hospital and Juntendo University Hospital, are located in eastern Japan whereas the others, Kurashiki Central Hospital and Akashi Medical Center, are in western Japan.
Questionnaires were printed and randomly distributed by research staff to outpatients in waiting rooms and inpatients in medical wards who were 20 years of age or older. We placed no restriction on ward site or time of questionnaire distribution. Research staff, including physicians, nurses, and medical clerks, were instructed to avoid guiding or influencing participants’ responses. Informed consent was obtained by the staff; only those who provided informed consent participated in the study. Respondents could request assistance with form completion from persons accompanying them if they had difficulties, such as physical, visual, or hearing impairments. All responses were collected anonymously. The study was approved by the ethics committees of all four hospitals.
Questionnaire
We used a modified version of the survey instrument from a prior study.10 The first section of the survey showed photographs of either a male or female physician with 7 unique forms of attire, including casual, casual with white coat, scrubs, scrubs with white coat, formal, formal with white coat, and business suit (Figure 1). Given the Japanese context of this study, the language was translated to Japanese and photographs of physicians of Japanese descent were used. Photographs were taken with attention paid to achieving constant facial expressions on the physicians as well as in other visual cues (eg, lighting, background, pose). The physician’s gender and attire in the first photograph seen by each respondent were randomized to prevent bias in ordering, priming, and anchoring; all other sections of the survey were identical.
Respondents were first asked to rate the standalone, randomized physician photograph using a 1-10 scale across five domains (ie, how knowledgeable, trustworthy, caring, and approachable the physician appeared and how comfortable the physician’s appearance made the respondent feel), with a score of 10 representing the highest rating. Respondents were subsequently given 7 photographs of the same physician wearing various forms of attire. Questions were asked regarding preference of attire in varied clinical settings (ie, primary care, ED, hospital, surgery, overall preference). To identify the influence of and respondent preferences for physician dress and white coats, a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) was employed. The scale was trichotomized into “disagree” (1, 2), “neither agree nor disagree” (3), and “agree” (4, 5) for analysis. Demographic data, including age, gender, education level, nationality (Japanese or non-Japanese), and number of physicians seen in the past year were collected.
Outcomes and Sample Size Calculation
The primary outcome of attire preference was calculated as the mean composite score of the five individual rating domains (ie, knowledgeable, trustworthy, caring, approachable, and comfortable), with the highest score representing the most preferred form of attire. We also assessed variation in preferences for physician attire by respondent characteristics, such as age and gender.
Sample size estimation was based on previous survey methodology.10 The Likert scale range for identifying influence of and respondent preferences for physician dress and white coats was 1-5 (“strongly disagree” to “strongly agree”). The scale range for measuring preferences for the randomized attire photograph was 1-10. An assumption of normality was made regarding responses on the 1-10 scale. An estimated standard deviation of 2.2 was assumed, based on prior findings.10 Based on these assumptions and the inclusion of at least 816 respondents (assuming a two-sided alpha error of 0.05), we expected to have 90% capacity to detect differences for effect sizes of 0.50 on the 1-10 scale.
Statistical Analyses
Paper-based survey data were entered independently and in duplicate by the study team. Respondents were not required to answer all questions; therefore, the denominator for each question varied. Data were reported as mean and standard deviation (SD) or percentages, where appropriate. Differences in the mean composite rating scores were assessed using one-way ANOVA with the Tukey method for pairwise comparisons. Differences in proportions for categorical data were compared using the Z-test. Chi-squared tests were used for bivariate comparisons between respondent age, gender, and level of education and corresponding respondent preferences. All analyses were performed using Stata 14 MP/SE (Stata Corp., College Station, Texas, USA).
RESULTS
Characteristics of Participants
Between December 1, 2015 and October 30, 2017, a total of 2,020 surveys were completed by patients across four academic hospitals in Japan. Of those, 1,960 patients (97.0%) completed the survey in its entirety. Approximately half of the respondents were 65 years of age or older (49%), of female gender (52%), and reported receiving care in the outpatient setting (53%). Regarding use of healthcare, 91% had seen more than one physician in the year preceding the time of survey completion (Table 1).
Ratings of Physician Attire
Compared with all forms of attire depicted in the survey’s first standalone photograph, respondents rated “casual attire with white coat” the highest (Figure 2). The mean composite score for “casual attire with white coat” was 7.1 (standard deviation [SD] = 1.8), and this attire was set as the referent group. Cronbach’s alpha, for the five items included in the composite score, was 0.95. However, “formal attire with white coat” was rated almost as highly as “casual attire with white coat” with an overall mean composite score of 7.0 (SD = 1.6).
Variation in Preference for Physician Attire by Clinical Setting
Preferences for physician attire varied by clinical care setting. Most respondents preferred “casual attire with white coat” or “formal attire with white coat” in both primary care and hospital settings, with a slight preference for “casual attire with white coat.” In contrast, respondents preferred “scrubs without white coat” in the ED and surgical settings. When asked about their overall preference, respondents reported they felt their physician should wear “formal attire with white coat” (35%) or “casual attire with white coat” (30%; Table 2). When comparing the group of photographs of physicians with white coats to the group without white coats (Figure 1), respondents preferred physicians wearing white coats overall and specifically when providing care in primary care and hospital settings. However, they preferred physicians without white coats when providing care in the ED (P < .001). With respect to surgeons, there was no statistically significant difference between preference for white coats and no white coats. These results were similar for photographs of both male and female physicians.
When asked whether physician dress was important to them and if physician attire influenced their satisfaction with the care received, 61% of participants agreed that physician dress was important, and 47% agreed that physician attire influenced satisfaction (Appendix Table 1). With respect to appropriateness of physicians dressing casually over the weekend in clinical settings, 52% responded that casual wear was inappropriate, while 31% had a neutral opinion.
Participants were asked whether physicians should wear a white coat in different clinical settings. Nearly two-thirds indicated a preference for white coats in the office and hospital (65% and 64%, respectively). Responses regarding whether emergency physicians should wear white coats were nearly equally divided (Agree, 37%; Disagree, 32%; Neither Agree nor Disagree, 31%). However, “scrubs without white coat” was most preferred (56%) when patients were given photographs of various attire and asked, “Which physician would you prefer to see when visiting the ER?” Responses to the question “Physicians should always wear a white coat when seeing patients in any setting” varied equally (Agree, 32%; Disagree, 34%; Neither Agree nor Disagree, 34%).
Variation in Preference for Physician Attire by Respondent Demographics
When comparing respondents by age, those 65 years or older preferred “formal attire with white coat” more so than respondents younger than 65 years (Appendix Table 2). This finding was identified in both primary care (36% vs 31%, P < .001) and hospital settings (37% vs 30%, P < .001). Additionally, physician attire had a greater impact on older respondents’ satisfaction and experience (Appendix Table 3). For example, 67% of respondents 65 years and older agreed that physician attire was important, and 54% agreed that attire influenced satisfaction. Conversely, for respondents younger than 65 years, the proportion agreeing with these statements was lower (56% and 41%, both P < .001). When comparing older and younger respondents, those 65 years and older more often preferred physicians wearing white coats in any setting (39% vs 26%, P < .001) and specifically in their office (68% vs 61%, P = .002), the ED (40% vs 34%, P < .001), and the hospital (69% vs 60%, P < .001).
When comparing male and female respondents, male respondents more often stated that physician dress was important to them (men, 64%; women, 58%; P = .002). When comparing responses to the question “Overall, which clothes do you feel a doctor should wear?”, between the eastern and western Japanese hospitals, preferences for physician attire varied.
Variation in Expectations Between Male and Female Physicians
When comparing the ratings of male and female physicians, female physicians were rated higher in how caring (P = .005) and approachable (P < .001) they appeared. However, there were no significant differences in the ratings of the three remaining domains (ie, knowledgeable, trustworthy, and comfortable) or the composite score.
DISCUSSION
Since we employed the same methodology as previous studies conducted in the US10 and Switzerland,18 a notable strength of our approach is that comparisons among these countries can be drawn. For example, physician attire appears to hold greater importance in Japan than in the US and Switzerland. Among Japanese participants, 61% agreed that physician dress is important (US, 53%; Switzerland, 36%), and 47% agreed that physician dress influenced how satisfied they were with their care (US, 36%; Switzerland, 23%).10 This result supports the notion that nonverbal and implicit communications (such as physician dress) may carry more importance among Japanese people.11-13
Regarding preference ratings for type of dress among respondents in Japan, “casual attire with white coat” received the highest mean composite score rating, with “formal attire with white coat” rated second overall. In contrast, US respondents rated “formal attire with white coat” highest and “scrubs with white coat” second.10 Our result runs counter to our expectation in that we expected Japanese respondents to prefer formal attire, since Japan is one of the most formal cultures in the world. One potential explanation for this difference is that the casual style chosen for this study was close to the smart casual style (slightly casual). Most hospitals and clinics in Japan do not allow physicians to wear jeans or polo shirts, which were chosen as the casual attire in the previous US study.
When examining various care settings and physician types, both Japanese and US respondents were more likely to prefer physicians wearing a white coat in the office or hospital.10 However, Japanese participants preferred both “casual attire with white coat” and “formal attire with white coat” equally in primary care or hospital settings. A smaller proportion of US respondents preferred “casual attire with white coat” in primary care (11%) and hospital settings (9%), but more preferred “formal attire with white coat” for primary care (44%) and hospital physicians (39%). In the ED setting, 32% of participants in Japan and 18% in the US disagreed with the idea that physicians should wear a white coat. Among Japanese participants, “scrubs without white coat” was rated highest for emergency physicians (56%) and surgeons (47%), while US preferences were 40% and 42%, respectively.10 One potential explanation is that scrubs-based attire became popular among Japanese ED and surgical contexts as a result of cultural influence and spread from western countries.19, 20
With respect to perceptions regarding physician attire on weekends, 52% of participants considered it inappropriate for a physician to dress casually over the weekend, compared with only 30% in Switzerland and 21% in the US.11,12 Given Japan’s level of formality and the fact that most Japanese physicians continue to work over the weekend,21-23 Japanese patients tend to expect their physicians to dress in more formal attire during these times.
Previous studies in Japan have demonstrated that older patients gave low ratings to scrubs and high ratings to white coat with any attire,15,17 and this was also the case in our study. Perhaps elderly patients reflect conservative values in their preferences of physician dress. Their perceptions may be less influenced by scenes portraying physicians in popular media when compared with the perceptions of younger patients. Though a 2015 systematic review and studies in other countries revealed white coats were preferred regardless of exact dress,9,24-26 they also showed variation in preferences for physician attire. For example, patients in Saudi Arabia preferred white coat and traditional ethnic dress,25 whereas mothers of pediatric patients in Saudi Arabia preferred scrubs for their pediatricians.27 Therefore, it is recommended for internationally mobile physicians to choose their dress depending on a variety of factors including country, context, and patient age group.
Our study has limitations. First, because some physicians presented the surveys to the patients, participants may have responded differently. Second, participants may have identified photographs of the male physician model as their personal healthcare provider (one author, K.K.). To avoid this possible bias, we randomly distributed 14 different versions of physician photographs in the questionnaire. Third, although physician photographs were strictly controlled, the “formal attire and white coat” and “casual attire and white coat” photographs appeared similar, especially given that the white coats were buttoned. Also, the female physician depicted in the photographs did not have the scrub shirt tucked in, while the male physician did. These nuances may have affected participant ratings between groups. Fourth,
In conclusion, patient preferences for physician attire were examined using a multicenter survey with a large sample size and robust survey methodology, thus overcoming weaknesses of previous studies into Japanese attire. Japanese patients perceive that physician attire is important and influences satisfaction with their care, more so than patients in other countries, like the US and Switzerland. Geography, settings of care, and patient age play a role in preferences. As a result, hospitals and health systems may use these findings to inform dress code policy based on patient population and context, recognizing that the appearance of their providers affects the patient-physician relationship. Future research should focus on better understanding the various cultural and societal customs that lead to patient expectations of physician attire.
Acknowledgments
The authors thank Drs. Fumi Takemoto, Masayuki Ueno, Kazuya Sakai, Saori Kinami, and Toshio Naito for their assistance with data collection at their respective sites. Additionally, the authors thank Dr. Yoko Kanamitsu for serving as a model for photographs.
1. Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med. 2013;368(3):201-203. https://doi.org/ 10.1056/NEJMp1211775.
2. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48.
3. Barbosa CD, Balp MM, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adherence. 2012;6:39-48. https://doi.org/10.2147/PPA.S24752.
4. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921-31. https://doi.org/10.1056/NEJMsa080411.
5. O’Malley AS, Forrest CB, Mandelblatt J. Adherence of low-income women to cancer screening recommendations. J Gen Intern Med. 2002;17(2):144-54. https://doi.org/10.1046/j.1525-1497.2002.10431.x.
6. Chung H, Lee H, Chang DS, Kim HS, Park HJ, Chae Y. Doctor’s attire influences perceived empathy in the patient-doctor relationship. Patient Educ Couns. 2012;89(3):387-391. https://doi.org/10.1016/j.pec.2012.02.017.
7. Bianchi MT. Desiderata or dogma: what the evidence reveals about physician attire. J Gen Intern Med. 2008;23(5):641-643. https://doi.org/10.1007/s11606-008-0546-8.
8. Brandt LJ. On the value of an old dress code in the new millennium. Arch Intern Med. 2003;163(11):1277-1281. https://doi.org/10.1001/archinte.163.11.1277.
9. Petrilli CM, Mack M, Petrilli JJ, Hickner A, Saint S, Chopra V. Understanding the role of physician attire on patient perceptions: a systematic review of the literature--targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open. 2015;5(1):e006578. https://doi.org/10.1136/bmjopen-2014-006578.
10. Petrilli CM, Saint S, Jennings JJ, et al. Understanding patient preference for physician attire: a cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open. 2018;8(5):e021239. https://doi.org/10.1136/bmjopen-2017-021239.
11. Rowbury R. The need for more proactive communications. Low trust and changing values mean Japan can no longer fall back on its homogeneity. The Japan Times. 2017, Oct 15;Sect. Opinion. https://www.japantimes.co.jp/opinion/2017/10/15/commentary/japan-commentary/need-proactive-communications/#.Xej7lC3MzUI. Accessed December 5, 2019.
12. Shoji Nishimura ANaST. Communication Style and Cultural Features in High/Low Context Communication Cultures: A Case Study of Finland, Japan and India. Nov 22nd, 2009.
13. Smith RMRSW. The influence of high/low-context culture and power distance on choice of communication media: Students’ media choice to communicate with Professors in Japan and America. Int J Intercultural Relations. 2007;31(4):479-501.
14. Yamada Y, Takahashi O, Ohde S, Deshpande GA, Fukui T. Patients’ preferences for doctors’ attire in Japan. Intern Med. 2010;49(15):1521-1526. https://doi.org/10.2169/internalmedicine.49.3572.
15. Ikusaka M, Kamegai M, Sunaga T, et al. Patients’ attitude toward consultations by a physician without a white coat in Japan. Intern Med. 1999;38(7):533-536. https://doi.org/10.2169/internalmedicine.38.533.
16. Lefor AK, Ohnuma T, Nunomiya S, Yokota S, Makino J, Sanui M. Physician attire in the intensive care unit in Japan influences visitors’ perception of care. J Crit Care. 2018;43:288-293.
17. Kurihara H, Maeno T. Importance of physicians’ attire: factors influencing the impression it makes on patients, a cross-sectional study. Asia Pac Fam Med. 2014;13(1):2. https://doi.org/10.1186/1447-056X-13-2.
18. Zollinger M, Houchens N, Chopra V, et al. Understanding patient preference for physician attire in ambulatory clinics: a cross-sectional observational study. BMJ Open. 2019;9(5):e026009. https://doi.org/10.1136/bmjopen-2018-026009.
19. Chung JE. Medical Dramas and Viewer Perception of Health: Testing Cultivation Effects. Hum Commun Res. 2014;40(3):333-349.
20. Michael Pfau LJM, Kirsten Garrow. The influence of television viewing on public perceptions of physicians. J Broadcast Electron Media. 1995;39(4):441-458.
21. Suzuki S. Exhausting physicians employed in hospitals in Japan assessed by a health questionnaire [in Japanese]. Sangyo Eiseigaku Zasshi. 2017;59(4):107-118. https://doi.org/10.1539/sangyoeisei.
22. Ogawa R, Seo E, Maeno T, Ito M, Sanuki M. The relationship between long working hours and depression among first-year residents in Japan. BMC Med Educ. 2018;18(1):50. https://doi.org/10.1186/s12909-018-1171-9.
23. Saijo Y, Chiba S, Yoshioka E, et al. Effects of work burden, job strain and support on depressive symptoms and burnout among Japanese physicians. Int J Occup Med Environ Health. 2014;27(6):980-992. https://doi.org/10.2478/s13382-014-0324-2.
24. Tiang KW, Razack AH, Ng KL. The ‘auxiliary’ white coat effect in hospitals: perceptions of patients and doctors. Singapore Med J. 2017;58(10):574-575. https://doi.org/10.11622/smedj.2017023.
25. Al Amry KM, Al Farrah M, Ur Rahman S, Abdulmajeed I. Patient perceptions and preferences of physicians’ attire in Saudi primary healthcare setting. J Community Hosp Intern Med Perspect. 2018;8(6):326-330. https://doi.org/10.1080/20009666.2018.1551026.
26. Healy WL. Letter to the editor: editor’s spotlight/take 5: physicians’ attire influences patients’ perceptions in the urban outpatient orthopaedic surgery setting. Clin Orthop Relat Res. 2016;474(11):2545-2546. https://doi.org/10.1007/s11999-016-5049-z.
27. Aldrees T, Alsuhaibani R, Alqaryan S, et al. Physicians’ attire. Parents preferences in a tertiary hospital. Saudi Med J. 2017;38(4):435-439. https://doi.org/10.15537/smj.2017.4.15853.
1. Manary MP, Boulding W, Staelin R, Glickman SW. The patient experience and health outcomes. N Engl J Med. 2013;368(3):201-203. https://doi.org/ 10.1056/NEJMp1211775.
2. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care. 2011;17(1):41-48.
3. Barbosa CD, Balp MM, Kulich K, Germain N, Rofail D. A literature review to explore the link between treatment satisfaction and adherence, compliance, and persistence. Patient Prefer Adherence. 2012;6:39-48. https://doi.org/10.2147/PPA.S24752.
4. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008;359(18):1921-31. https://doi.org/10.1056/NEJMsa080411.
5. O’Malley AS, Forrest CB, Mandelblatt J. Adherence of low-income women to cancer screening recommendations. J Gen Intern Med. 2002;17(2):144-54. https://doi.org/10.1046/j.1525-1497.2002.10431.x.
6. Chung H, Lee H, Chang DS, Kim HS, Park HJ, Chae Y. Doctor’s attire influences perceived empathy in the patient-doctor relationship. Patient Educ Couns. 2012;89(3):387-391. https://doi.org/10.1016/j.pec.2012.02.017.
7. Bianchi MT. Desiderata or dogma: what the evidence reveals about physician attire. J Gen Intern Med. 2008;23(5):641-643. https://doi.org/10.1007/s11606-008-0546-8.
8. Brandt LJ. On the value of an old dress code in the new millennium. Arch Intern Med. 2003;163(11):1277-1281. https://doi.org/10.1001/archinte.163.11.1277.
9. Petrilli CM, Mack M, Petrilli JJ, Hickner A, Saint S, Chopra V. Understanding the role of physician attire on patient perceptions: a systematic review of the literature--targeting attire to improve likelihood of rapport (TAILOR) investigators. BMJ Open. 2015;5(1):e006578. https://doi.org/10.1136/bmjopen-2014-006578.
10. Petrilli CM, Saint S, Jennings JJ, et al. Understanding patient preference for physician attire: a cross-sectional observational study of 10 academic medical centres in the USA. BMJ Open. 2018;8(5):e021239. https://doi.org/10.1136/bmjopen-2017-021239.
11. Rowbury R. The need for more proactive communications. Low trust and changing values mean Japan can no longer fall back on its homogeneity. The Japan Times. 2017, Oct 15;Sect. Opinion. https://www.japantimes.co.jp/opinion/2017/10/15/commentary/japan-commentary/need-proactive-communications/#.Xej7lC3MzUI. Accessed December 5, 2019.
12. Shoji Nishimura ANaST. Communication Style and Cultural Features in High/Low Context Communication Cultures: A Case Study of Finland, Japan and India. Nov 22nd, 2009.
13. Smith RMRSW. The influence of high/low-context culture and power distance on choice of communication media: Students’ media choice to communicate with Professors in Japan and America. Int J Intercultural Relations. 2007;31(4):479-501.
14. Yamada Y, Takahashi O, Ohde S, Deshpande GA, Fukui T. Patients’ preferences for doctors’ attire in Japan. Intern Med. 2010;49(15):1521-1526. https://doi.org/10.2169/internalmedicine.49.3572.
15. Ikusaka M, Kamegai M, Sunaga T, et al. Patients’ attitude toward consultations by a physician without a white coat in Japan. Intern Med. 1999;38(7):533-536. https://doi.org/10.2169/internalmedicine.38.533.
16. Lefor AK, Ohnuma T, Nunomiya S, Yokota S, Makino J, Sanui M. Physician attire in the intensive care unit in Japan influences visitors’ perception of care. J Crit Care. 2018;43:288-293.
17. Kurihara H, Maeno T. Importance of physicians’ attire: factors influencing the impression it makes on patients, a cross-sectional study. Asia Pac Fam Med. 2014;13(1):2. https://doi.org/10.1186/1447-056X-13-2.
18. Zollinger M, Houchens N, Chopra V, et al. Understanding patient preference for physician attire in ambulatory clinics: a cross-sectional observational study. BMJ Open. 2019;9(5):e026009. https://doi.org/10.1136/bmjopen-2018-026009.
19. Chung JE. Medical Dramas and Viewer Perception of Health: Testing Cultivation Effects. Hum Commun Res. 2014;40(3):333-349.
20. Michael Pfau LJM, Kirsten Garrow. The influence of television viewing on public perceptions of physicians. J Broadcast Electron Media. 1995;39(4):441-458.
21. Suzuki S. Exhausting physicians employed in hospitals in Japan assessed by a health questionnaire [in Japanese]. Sangyo Eiseigaku Zasshi. 2017;59(4):107-118. https://doi.org/10.1539/sangyoeisei.
22. Ogawa R, Seo E, Maeno T, Ito M, Sanuki M. The relationship between long working hours and depression among first-year residents in Japan. BMC Med Educ. 2018;18(1):50. https://doi.org/10.1186/s12909-018-1171-9.
23. Saijo Y, Chiba S, Yoshioka E, et al. Effects of work burden, job strain and support on depressive symptoms and burnout among Japanese physicians. Int J Occup Med Environ Health. 2014;27(6):980-992. https://doi.org/10.2478/s13382-014-0324-2.
24. Tiang KW, Razack AH, Ng KL. The ‘auxiliary’ white coat effect in hospitals: perceptions of patients and doctors. Singapore Med J. 2017;58(10):574-575. https://doi.org/10.11622/smedj.2017023.
25. Al Amry KM, Al Farrah M, Ur Rahman S, Abdulmajeed I. Patient perceptions and preferences of physicians’ attire in Saudi primary healthcare setting. J Community Hosp Intern Med Perspect. 2018;8(6):326-330. https://doi.org/10.1080/20009666.2018.1551026.
26. Healy WL. Letter to the editor: editor’s spotlight/take 5: physicians’ attire influences patients’ perceptions in the urban outpatient orthopaedic surgery setting. Clin Orthop Relat Res. 2016;474(11):2545-2546. https://doi.org/10.1007/s11999-016-5049-z.
27. Aldrees T, Alsuhaibani R, Alqaryan S, et al. Physicians’ attire. Parents preferences in a tertiary hospital. Saudi Med J. 2017;38(4):435-439. https://doi.org/10.15537/smj.2017.4.15853.
© 2020 Society of Hospital Medicine
Assessing Vascular Nursing Experience
Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]
Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.
Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.
METHODS
Study Setting and Participants
To quantify vascular nursing experience, practice, knowledge, and beliefs, we conducted a Web‐based survey of vascular nurses across 47 Michigan hospitals that participate in HMS. A statewide quality‐improvement initiative, HMS aims to prevent adverse events in hospitalized medical patients through the creation of a data registry and sharing of best practices. The setting and design of this multicenter initiative have been previously described.[8, 9] Although participation is voluntary, each hospital receives payment for participating in the consortium and for data collection. Because HMS has an ongoing initiative aimed at identifying and preventing PICC‐related complications, this study was particularly relevant for participating hospitals and nurses.
Each HMS site has a designated quality‐improvement lead, physician champion, and data abstractor. To coordinate distribution and dissemination of the survey, we contacted the quality‐improvement leads at each site and enquired whether their hospital employed vascular access nurses who placed PICCs. Because we were only interested in responses from vascular access nurses, HMS hospitals that did not have these providers or stated PICCs were placed by other specialists (eg, interventional radiology) were excluded. At eligible sites, we obtained the total number of vascular nurses employed so as to determine the number of eligible respondents. In this manner, a purposeful sample of vascular nurses at participating HMS hospitals was constituted.
Participation in the survey was solicited through hospital quality leads that either distributed an electronic survey link to vascular nurses at their facilities or sent us individual email addresses to contact them directly. A cover letter explaining the rationale and the purpose of the survey along with the survey link was then sent to respondents through either of these routes. The survey was administered at all HMS sites contemporaneously and kept open for a period of 5 weeks. During the 5‐week period, 2 e‐mail reminders were sent to encourage participation. As a token of appreciation, a $10 Amazon gift card was offered to those who took the survey.
Development and Validation of the Survey
We developed the survey instrument (which we call PICC1 as we hope to administer longitudinally to track changes over time) by first conducting a literature search to identify relevant evidence‐based guidelines and studies regarding vascular access nursing practices and experiences.[10, 11, 12, 13] In addition, we consulted and involved national and international leaders in vascular access nursing to ensure validity and representativeness of the questions posed. We were specifically interested in nursing background, hospital practices, types of PICCs used, use of various technologies, relationships with healthcare providers, and management of complications. To understand participant characteristics and quantify potential variation in responses, we collected basic participant data including demographics, years in practice, number of PICCs placed, leadership roles, and vascular access certification status. Based on clinical reasoning and existing studies,[14, 15] we hypothesized that responses regarding certain practices (ultrasound use, electrocardiography [ECG] guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. We therefore examined these associations as prespecified subgroup analyses.
The initial survey instrument was pilot tested with vascular nurses outside of the sampling frame. Based on feedback from the pilot testers, the instrument was refined and edited to improve clarity of the questions. In addition, specific skip patterns and logic were programmed into the final survey to reduce respondent burden and allow participants to seamlessly bypass questions that were contingent on a prior response (eg, use of ECG to place PICCs would lead to a series of questions about ECG‐assisted placement only for those respondents who used the technology). This final version of the survey was tested by members of the study team (V.C., L.K., S.L.K.) and then posted to SurveyMonkey for dissemination.
Statistical Analysis
Descriptive statistics (percentage, n/N) were used to tabulate results. In accordance with our a priori hypothesis that variation to responses might be associated with respondent characteristics, responses to questions regarding insertion practice (eg, use of ultrasound, measurement of catheter:vein ratio, trimming of catheters) and approach to complications (eg, catheter occlusion, deep vein thrombosis [DVT] notification, and PICC removal in the setting of fever) were compared by respondent years in practice (dichotomized to <5 vs >5 years), volume of PICCs placed (<999 vs 1000), and certification status (yes/no). Bivariate comparisons were made using 2 or Fisher exact tests based on the number of responses in a cell as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All statistical analyses were conducted using SAS version 9.3 (SAS Institute, Cary, NC).
Ethical and Regulatory Oversight
Because our study sought to describe existing practice without collecting any individual or facility level identifiable information, the project received a Not Regulated status by the University of Michigan Medical School Institutional Review Board (HUM00088351).
RESULTS
Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.
Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).
| No.* | % | |
|---|---|---|
| ||
| Participant characteristics | ||
| For how many years have you been inserting PICCs? | ||
| <5 years | 40 | 28.6% |
| 5 years | 81 | 57.9% |
| Missing | ||
| In which of the following populations do you insert PICCs? | ||
| Adult patients | 121 | 86.4% |
| Pediatric patients | 24 | 17.1% |
| Neonatal patients | 1 | 0.7% |
| In which of the following locations do you place PICCs? (Select all that apply.) | ||
| Adult medical ward | 115 | 82.1% |
| General adult surgical ward | 110 | 78.6% |
| General pediatric medical ward | 34 | 24.3% |
| General pediatric surgical ward | 24 | 17.1% |
| Adult intensive care unit | 114 | 81.4% |
| Pediatric intensive care unit | 19 | 13.6% |
| Neonatal intensive care unit | 3 | 2.1% |
| Other intensive care unit | 59 | 42.1% |
| Outpatient clinic or emergency department | 17 | 12.1% |
| Other | 10 | 7.1% |
| Approximately how many PICCs may you have placed in your career? | ||
| 099 | 15 | 10.7% |
| 100499 | 36 | 25.7% |
| 500999 | 23 | 16.4% |
| 1,000 | 47 | 33.6% |
| Are you the vascular access lead nurse for your facility or organization? | ||
| Yes | 22 | 15.7% |
| No | 98 | 70.0% |
| Do you currently hold a dedicated vascular access certification (BC‐VA, CRNI, etc.)? | ||
| Yes | 32 | 22.9% |
| No | 89 | 63.6% |
| Facility characteristics | ||
| Which of the following best describes your primary work location? | ||
| Academic medical center | 41 | 29.3% |
| For‐profit community‐based hospital or medical center | 30 | 21.4% |
| Not‐for‐profit community‐based hospital or medical center | 50 | 35.7% |
| Who inserts the most PICCs in your facility? | ||
| Vascular access nurses | 133 | 95.0% |
| Interventional radiology or other providers | 7 | 5.0% |
| In which department is vascular access nursing located? | ||
| Vascular nursing | 76 | 54.3% |
| General nursing | 38 | 27.1% |
| Interventional radiology | 15 | 10.7% |
| Other | 11 | 7.9% |
| Using your best guess, how many PICCs do you think your facility inserts each month? | ||
| <25 | 5 | 3.6% |
| 2549 | 13 | 9.3% |
| 50100 | 39 | 27.9% |
| >100 | 78 | 55.7% |
| Unknown | 2 | 1.4% |
| How many vascular access nurses are employed by your facility? | ||
| <4 | 14 | 10.0% |
| 46 | 33 | 23.6% |
| 79 | 15 | 10.7% |
| 1015 | 25 | 17.9% |
| >15 | 53 | 37.9% |
| Does your facility track the number of PICCs placed? | ||
| Yes | 132 | 94.3% |
| No | 5 | 3.6% |
| Unknown | 3 | 2.1% |
| Does your facility track the duration or dwell time of PICCs? | ||
| Yes | 56 | 40.0% |
| No | 60 | 42.9% |
| Unknown | 24 | 17.1% |
| Does your facility have a written policy regarding standard PICC insertion practices? | ||
| Yes | 122 | 87.1% |
| No | 8 | 5.7% |
| Unknown | 7 | 5.0% |
| Does your facility have a written policy regarding standard PICC care and maintenance? | ||
| Yes | 133 | 95.0% |
| No | 3 | 2.1% |
| Unknown | 1 | 0.7% |
| Does your facility have a written process to review the necessity or appropriateness of a PICC? | ||
| Yes | 42 | 30.0% |
| No | 63 | 45.0% |
| Unknown | 20 | 14.3% |
The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).
| Question | No. | % |
|---|---|---|
| ||
| Do you use ultrasound to find a suitable vein prior to PICC insertion? | ||
| Yes | 128 | 91.4% |
| No | 0 | 0.0% |
| Do you use ultrasound to estimate the catheter‐to‐vein ratio prior to PICC insertion? | ||
| Yes | 110 | 78.6% |
| No | 18 | 12.9% |
| When using ultrasound, do you document the catheter‐to‐vein ratio in the PICC insertion note? | ||
| Yes | 20 | 14.3% |
| No | 89 | 63.6% |
| Do you use ECG guidance‐assisted systems to place PICCs? | ||
| Yes | 106 | 75.7% |
| No | 21 | 15.0% |
| If using ECG guidance, do you still routinely obtain a chest x‐ray to verify PICC tip position after placing the PICC using ECG guidance? | ||
| Yes | 38 | 27.1% |
| No | 68 | 48.6% |
| Who is primarily responsible for administering and adhering to a flushing protocol after PICC insertion at your facility? | ||
| Bedside nurses | 118 | 83.6% |
| Patients | 1 | 0.7% |
| Vascular access nurses | 8 | 5.7% |
| Which of the following agents are most often used to flush PICCs? | ||
| Both heparin and normal saline flushes | 61 | 43.6% |
| Normal saline only | 63 | 45.0% |
| Heparin only | 3 | 2.1% |
| Who is responsible for scheduled weekly dressing changes for PICCs? | ||
| Vascular access nurses | 110 | 78.6% |
| Bedside nurses | 14 | 10.0% |
| Other (eg, IR staff, ICU staff) | 3 | 2.1% |
| In the past few months, have you placed a PICC in a patient who was receiving a form of dialysis (eg, peritoneal or hemodialysis)? | ||
| Yes | 65 | 46.4% |
| No | 64 | 45.7% |
| If you have placed PICCs in patients on dialysis, do you discuss PICC placement or receive approval from nephrology prior to inserting the PICC? | ||
| Yes | 59 | 90.8% |
| No | 6 | 9.2% |
With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.
To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).
| Question | No. | % |
|---|---|---|
| ||
| Which of the following PICC‐related complications have you most frequently encountered in your practice? | ||
| Catheter occlusion | 81 | 57.9% |
| Catheter migration | 27 | 19.3% |
| PICC‐associated DVT | 6 | 4.3% |
| Catheter fracture or embolization | 3 | 2.1% |
| Exit site infection | 3 | 2.1% |
| Coiling or kinking after insertion | 2 | 1.4% |
| If you suspect a patient has catheter occlusion, which of the following best describes your approach to resolving this problem? | ||
| Begin with normal saline but use a tPA product if this fails to restore patency | 70 | 50.0% |
| Use a tPA product (eg, Cathflo, Activase, or Retavase) to restore patency | 44 | 31.4% |
| Begin with heparin‐based flushes but use a tPA product if this fails to restore | 7 | 5.0% |
| Use only normal saline flushes to restore patency | 3 | 2.1% |
| If you find a PICC that has migrated out or has been accidentally dislodged <5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 108 | 77.1% |
| Perform a complete catheter exchange over a guidewire if possible | 5 | 3.6% |
| Notify/discuss next steps with physician | 5 | 3.6% |
| Other | 6 | 4.3% |
| If you find a PICC that has migrated out or has been accidentally dislodged >5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 72 | 51.4% |
| Perform a catheter exchange over a guidewire if possible | 30 | 21.4% |
| Notify/discuss next steps with physician | 10 | 7.1% |
| Other | 12 | 8.6% |
| Which of the following best describes your first approach when you suspect a patient has PICC‐associated phlebitis? | ||
| Discuss best course of action with physician or nurse | 79 | 56.4% |
| Supportive measures (eg, warm compresses, analgesics, monitoring) | 25 | 17.9% |
| Remove the PICC | 15 | 10.7% |
| Other | 5 | 3.6% |
| Which of the following best describes your first approach when you suspect a patient has a PICC‐related DVT? | ||
| Notify caregivers to continue using PICC and consider tests such as ultrasound | 82 | 58.6% |
| Notify bedside nurse and physician not to continue use of the PICC and consider tests such as ultrasound | 42 | 30.0% |
| PICCs are often removed when physicians suspect, but have not yet confirmed, CLABSI. Considering your experiences, what percentage of PICCs may have been removed in this manner at your facility? | ||
| <5% | 11 | 7.9% |
| 59% | 16 | 11.4% |
| 1024% | 24 | 17.1% |
| 25% | 71 | 50.7% |
| Based on your experience, what percentage of PICCs do you think are inappropriate or could have been avoided at your facility? | ||
| <5% | 51 | 36.4% |
| 59% | 25 | 17.9% |
| 1024% | 28 | 20.0% |
| 2550% | 13 | 9.3% |
| >50% | 5 | 3.6% |
| Are vascular access nurses empowered to remove PICCs that are idle or clinically unnecessary without physician authorization? | ||
| Yes | 3 | 2.1% |
| No | 122 | 87.1% |
| How would you rank the overall support your vascular access service receives from hospital leadership? | ||
| Excellent | 5 | 3.6% |
| Very good | 32 | 22.9% |
| Good | 40 | 28.6% |
| Fair | 35 | 25.0% |
| Poor | 25 | 17.9% |
| How would you describe your relationship with physicians at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 28 | 20.0% |
| Good | 63 | 45.0% |
| Fair | 35 | 25.0% |
| Poor | 7 | 5.0% |
| Very poor | 4 | 2.9% |
| How would you describe your relationship with bedside nurses at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 32 | 22.9% |
| Good | 58 | 41.4% |
| Fair | 38 | 27.1% |
| Poor | 7 | 5.0% |
| Very poor | 2 | 1.4% |
Variation in Responses Based on Years in Practice or Certification
We initially hypothesized that responses regarding practice (ultrasound use, ECG guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. However, no statistically significant associations with these factors and individual responses were identified.
DISCUSSION
In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.
Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]
Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.
Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.
Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.
In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.
Acknowledgements
The authors thank Claire Rickard, PhD, RN, Britt Meyer, RN, Peter Carr, PhD, and David Dempsey, RN for their assistance in developing the survey instrument used in this study.
Disclosures: This project was funded through an Investigator Initiated Research Grant from the Blue Cross Blue Shield of Michigan (BCBSM) Foundation (grant number 2140.II). The funding source played no role in study design, data acquisition, analysis, or reporting of the data. Support for the Hospital Medicine Safety (HMS) Consortium is provided by BCBSM and the Blue Care Network as part of the BCBSM Value Partnerships program. Although BCBSM and HMS work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. This work was also supported with resources from the Veterans Affairs Ann Arbor Healthcare System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
- , , , et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high‐risk short‐term central venous catheters. Am J Infect Control. 2010;38(2):149–153.
- , , , , . Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters. J Hosp Med. 2009;4(7):417–422.
- , , , , , . Central venous catheter placement by advanced practice nurses demonstrates low procedural complication and infection rates‐‐a report from 13 years of service. Crit Care Med. 2014;42(3):536–543.
- . Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs. 2012;34(1):34–42.
- , . Facility wide benefits of radiology vascular access teams. Radiol Manage. 2010;32(1):28–32; quiz 33–34.
- , . Moving the needle forward: the imperative for collaboration in vascular access. J Infus Nurs. 2015;38(2):100–102.
- , , , . Use of designated PICC teams by U.S. hospitals: a survey‐based study [published online November 10, 2015]. J Patient Saf. doi: 10.1097/PTS.0000000000000246
- , , , , . The association between PICC use and venous thromboembolism in upper and lower extremities. American J Med. 2015;128(9):986–993.e1.
- , , , et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med. 2014;174(10):1577–1584.
- , , , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. Lancet. 2013;382(9889):311–325.
- Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006;29(1 suppl):S1–S92.
- , , , et al. Guidelines for the prevention of intravascular catheter‐related infections. Am J Infect Control. 2011;39(4 suppl 1):S1–S34.
- , , , et al. International evidence‐based recommendations on ultrasound‐guided vascular access. Intensive Care Med. 2012;38(7):1105–1117.
- , , . A single institution experience of seven hundred consecutively placed peripherally inserted central venous catheters. J Vasc Access. 2014;15(6):498–502.
- , , . Central venous access devices site care practices: an international survey of 34 countries [published online September 3, 2015]. J Vasc Access. doi: 10.5301/jva.5000450
- American Society of Nephrology. World's Leading Kidney Society Joins Effort to Reduce Unnecessary Medical Tests and Procedures. Available at: https://www.asn‐online.org/policy/choosingwisely/PressReleaseChoosingWisely.pdf. Accessed September 4, 2015.
- , , , . A survey of the current use of peripherally inserted central venous catheter (PICC) in Swedish oncology departments. Acta Oncol. 2013;52(6):1241–1242.
- , . Nurse‐led PICC insertion: is it cost effective? Br J Nurs. 2013;22(19):S9–S15.
- , , , et al. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey. J Hosp Med. 2013;8(6):309–314.
Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]
Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.
Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.
METHODS
Study Setting and Participants
To quantify vascular nursing experience, practice, knowledge, and beliefs, we conducted a Web‐based survey of vascular nurses across 47 Michigan hospitals that participate in HMS. A statewide quality‐improvement initiative, HMS aims to prevent adverse events in hospitalized medical patients through the creation of a data registry and sharing of best practices. The setting and design of this multicenter initiative have been previously described.[8, 9] Although participation is voluntary, each hospital receives payment for participating in the consortium and for data collection. Because HMS has an ongoing initiative aimed at identifying and preventing PICC‐related complications, this study was particularly relevant for participating hospitals and nurses.
Each HMS site has a designated quality‐improvement lead, physician champion, and data abstractor. To coordinate distribution and dissemination of the survey, we contacted the quality‐improvement leads at each site and enquired whether their hospital employed vascular access nurses who placed PICCs. Because we were only interested in responses from vascular access nurses, HMS hospitals that did not have these providers or stated PICCs were placed by other specialists (eg, interventional radiology) were excluded. At eligible sites, we obtained the total number of vascular nurses employed so as to determine the number of eligible respondents. In this manner, a purposeful sample of vascular nurses at participating HMS hospitals was constituted.
Participation in the survey was solicited through hospital quality leads that either distributed an electronic survey link to vascular nurses at their facilities or sent us individual email addresses to contact them directly. A cover letter explaining the rationale and the purpose of the survey along with the survey link was then sent to respondents through either of these routes. The survey was administered at all HMS sites contemporaneously and kept open for a period of 5 weeks. During the 5‐week period, 2 e‐mail reminders were sent to encourage participation. As a token of appreciation, a $10 Amazon gift card was offered to those who took the survey.
Development and Validation of the Survey
We developed the survey instrument (which we call PICC1 as we hope to administer longitudinally to track changes over time) by first conducting a literature search to identify relevant evidence‐based guidelines and studies regarding vascular access nursing practices and experiences.[10, 11, 12, 13] In addition, we consulted and involved national and international leaders in vascular access nursing to ensure validity and representativeness of the questions posed. We were specifically interested in nursing background, hospital practices, types of PICCs used, use of various technologies, relationships with healthcare providers, and management of complications. To understand participant characteristics and quantify potential variation in responses, we collected basic participant data including demographics, years in practice, number of PICCs placed, leadership roles, and vascular access certification status. Based on clinical reasoning and existing studies,[14, 15] we hypothesized that responses regarding certain practices (ultrasound use, electrocardiography [ECG] guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. We therefore examined these associations as prespecified subgroup analyses.
The initial survey instrument was pilot tested with vascular nurses outside of the sampling frame. Based on feedback from the pilot testers, the instrument was refined and edited to improve clarity of the questions. In addition, specific skip patterns and logic were programmed into the final survey to reduce respondent burden and allow participants to seamlessly bypass questions that were contingent on a prior response (eg, use of ECG to place PICCs would lead to a series of questions about ECG‐assisted placement only for those respondents who used the technology). This final version of the survey was tested by members of the study team (V.C., L.K., S.L.K.) and then posted to SurveyMonkey for dissemination.
Statistical Analysis
Descriptive statistics (percentage, n/N) were used to tabulate results. In accordance with our a priori hypothesis that variation to responses might be associated with respondent characteristics, responses to questions regarding insertion practice (eg, use of ultrasound, measurement of catheter:vein ratio, trimming of catheters) and approach to complications (eg, catheter occlusion, deep vein thrombosis [DVT] notification, and PICC removal in the setting of fever) were compared by respondent years in practice (dichotomized to <5 vs >5 years), volume of PICCs placed (<999 vs 1000), and certification status (yes/no). Bivariate comparisons were made using 2 or Fisher exact tests based on the number of responses in a cell as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All statistical analyses were conducted using SAS version 9.3 (SAS Institute, Cary, NC).
Ethical and Regulatory Oversight
Because our study sought to describe existing practice without collecting any individual or facility level identifiable information, the project received a Not Regulated status by the University of Michigan Medical School Institutional Review Board (HUM00088351).
RESULTS
Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.
Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).
| No.* | % | |
|---|---|---|
| ||
| Participant characteristics | ||
| For how many years have you been inserting PICCs? | ||
| <5 years | 40 | 28.6% |
| 5 years | 81 | 57.9% |
| Missing | ||
| In which of the following populations do you insert PICCs? | ||
| Adult patients | 121 | 86.4% |
| Pediatric patients | 24 | 17.1% |
| Neonatal patients | 1 | 0.7% |
| In which of the following locations do you place PICCs? (Select all that apply.) | ||
| Adult medical ward | 115 | 82.1% |
| General adult surgical ward | 110 | 78.6% |
| General pediatric medical ward | 34 | 24.3% |
| General pediatric surgical ward | 24 | 17.1% |
| Adult intensive care unit | 114 | 81.4% |
| Pediatric intensive care unit | 19 | 13.6% |
| Neonatal intensive care unit | 3 | 2.1% |
| Other intensive care unit | 59 | 42.1% |
| Outpatient clinic or emergency department | 17 | 12.1% |
| Other | 10 | 7.1% |
| Approximately how many PICCs may you have placed in your career? | ||
| 099 | 15 | 10.7% |
| 100499 | 36 | 25.7% |
| 500999 | 23 | 16.4% |
| 1,000 | 47 | 33.6% |
| Are you the vascular access lead nurse for your facility or organization? | ||
| Yes | 22 | 15.7% |
| No | 98 | 70.0% |
| Do you currently hold a dedicated vascular access certification (BC‐VA, CRNI, etc.)? | ||
| Yes | 32 | 22.9% |
| No | 89 | 63.6% |
| Facility characteristics | ||
| Which of the following best describes your primary work location? | ||
| Academic medical center | 41 | 29.3% |
| For‐profit community‐based hospital or medical center | 30 | 21.4% |
| Not‐for‐profit community‐based hospital or medical center | 50 | 35.7% |
| Who inserts the most PICCs in your facility? | ||
| Vascular access nurses | 133 | 95.0% |
| Interventional radiology or other providers | 7 | 5.0% |
| In which department is vascular access nursing located? | ||
| Vascular nursing | 76 | 54.3% |
| General nursing | 38 | 27.1% |
| Interventional radiology | 15 | 10.7% |
| Other | 11 | 7.9% |
| Using your best guess, how many PICCs do you think your facility inserts each month? | ||
| <25 | 5 | 3.6% |
| 2549 | 13 | 9.3% |
| 50100 | 39 | 27.9% |
| >100 | 78 | 55.7% |
| Unknown | 2 | 1.4% |
| How many vascular access nurses are employed by your facility? | ||
| <4 | 14 | 10.0% |
| 46 | 33 | 23.6% |
| 79 | 15 | 10.7% |
| 1015 | 25 | 17.9% |
| >15 | 53 | 37.9% |
| Does your facility track the number of PICCs placed? | ||
| Yes | 132 | 94.3% |
| No | 5 | 3.6% |
| Unknown | 3 | 2.1% |
| Does your facility track the duration or dwell time of PICCs? | ||
| Yes | 56 | 40.0% |
| No | 60 | 42.9% |
| Unknown | 24 | 17.1% |
| Does your facility have a written policy regarding standard PICC insertion practices? | ||
| Yes | 122 | 87.1% |
| No | 8 | 5.7% |
| Unknown | 7 | 5.0% |
| Does your facility have a written policy regarding standard PICC care and maintenance? | ||
| Yes | 133 | 95.0% |
| No | 3 | 2.1% |
| Unknown | 1 | 0.7% |
| Does your facility have a written process to review the necessity or appropriateness of a PICC? | ||
| Yes | 42 | 30.0% |
| No | 63 | 45.0% |
| Unknown | 20 | 14.3% |
The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).
| Question | No. | % |
|---|---|---|
| ||
| Do you use ultrasound to find a suitable vein prior to PICC insertion? | ||
| Yes | 128 | 91.4% |
| No | 0 | 0.0% |
| Do you use ultrasound to estimate the catheter‐to‐vein ratio prior to PICC insertion? | ||
| Yes | 110 | 78.6% |
| No | 18 | 12.9% |
| When using ultrasound, do you document the catheter‐to‐vein ratio in the PICC insertion note? | ||
| Yes | 20 | 14.3% |
| No | 89 | 63.6% |
| Do you use ECG guidance‐assisted systems to place PICCs? | ||
| Yes | 106 | 75.7% |
| No | 21 | 15.0% |
| If using ECG guidance, do you still routinely obtain a chest x‐ray to verify PICC tip position after placing the PICC using ECG guidance? | ||
| Yes | 38 | 27.1% |
| No | 68 | 48.6% |
| Who is primarily responsible for administering and adhering to a flushing protocol after PICC insertion at your facility? | ||
| Bedside nurses | 118 | 83.6% |
| Patients | 1 | 0.7% |
| Vascular access nurses | 8 | 5.7% |
| Which of the following agents are most often used to flush PICCs? | ||
| Both heparin and normal saline flushes | 61 | 43.6% |
| Normal saline only | 63 | 45.0% |
| Heparin only | 3 | 2.1% |
| Who is responsible for scheduled weekly dressing changes for PICCs? | ||
| Vascular access nurses | 110 | 78.6% |
| Bedside nurses | 14 | 10.0% |
| Other (eg, IR staff, ICU staff) | 3 | 2.1% |
| In the past few months, have you placed a PICC in a patient who was receiving a form of dialysis (eg, peritoneal or hemodialysis)? | ||
| Yes | 65 | 46.4% |
| No | 64 | 45.7% |
| If you have placed PICCs in patients on dialysis, do you discuss PICC placement or receive approval from nephrology prior to inserting the PICC? | ||
| Yes | 59 | 90.8% |
| No | 6 | 9.2% |
With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.
To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).
| Question | No. | % |
|---|---|---|
| ||
| Which of the following PICC‐related complications have you most frequently encountered in your practice? | ||
| Catheter occlusion | 81 | 57.9% |
| Catheter migration | 27 | 19.3% |
| PICC‐associated DVT | 6 | 4.3% |
| Catheter fracture or embolization | 3 | 2.1% |
| Exit site infection | 3 | 2.1% |
| Coiling or kinking after insertion | 2 | 1.4% |
| If you suspect a patient has catheter occlusion, which of the following best describes your approach to resolving this problem? | ||
| Begin with normal saline but use a tPA product if this fails to restore patency | 70 | 50.0% |
| Use a tPA product (eg, Cathflo, Activase, or Retavase) to restore patency | 44 | 31.4% |
| Begin with heparin‐based flushes but use a tPA product if this fails to restore | 7 | 5.0% |
| Use only normal saline flushes to restore patency | 3 | 2.1% |
| If you find a PICC that has migrated out or has been accidentally dislodged <5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 108 | 77.1% |
| Perform a complete catheter exchange over a guidewire if possible | 5 | 3.6% |
| Notify/discuss next steps with physician | 5 | 3.6% |
| Other | 6 | 4.3% |
| If you find a PICC that has migrated out or has been accidentally dislodged >5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 72 | 51.4% |
| Perform a catheter exchange over a guidewire if possible | 30 | 21.4% |
| Notify/discuss next steps with physician | 10 | 7.1% |
| Other | 12 | 8.6% |
| Which of the following best describes your first approach when you suspect a patient has PICC‐associated phlebitis? | ||
| Discuss best course of action with physician or nurse | 79 | 56.4% |
| Supportive measures (eg, warm compresses, analgesics, monitoring) | 25 | 17.9% |
| Remove the PICC | 15 | 10.7% |
| Other | 5 | 3.6% |
| Which of the following best describes your first approach when you suspect a patient has a PICC‐related DVT? | ||
| Notify caregivers to continue using PICC and consider tests such as ultrasound | 82 | 58.6% |
| Notify bedside nurse and physician not to continue use of the PICC and consider tests such as ultrasound | 42 | 30.0% |
| PICCs are often removed when physicians suspect, but have not yet confirmed, CLABSI. Considering your experiences, what percentage of PICCs may have been removed in this manner at your facility? | ||
| <5% | 11 | 7.9% |
| 59% | 16 | 11.4% |
| 1024% | 24 | 17.1% |
| 25% | 71 | 50.7% |
| Based on your experience, what percentage of PICCs do you think are inappropriate or could have been avoided at your facility? | ||
| <5% | 51 | 36.4% |
| 59% | 25 | 17.9% |
| 1024% | 28 | 20.0% |
| 2550% | 13 | 9.3% |
| >50% | 5 | 3.6% |
| Are vascular access nurses empowered to remove PICCs that are idle or clinically unnecessary without physician authorization? | ||
| Yes | 3 | 2.1% |
| No | 122 | 87.1% |
| How would you rank the overall support your vascular access service receives from hospital leadership? | ||
| Excellent | 5 | 3.6% |
| Very good | 32 | 22.9% |
| Good | 40 | 28.6% |
| Fair | 35 | 25.0% |
| Poor | 25 | 17.9% |
| How would you describe your relationship with physicians at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 28 | 20.0% |
| Good | 63 | 45.0% |
| Fair | 35 | 25.0% |
| Poor | 7 | 5.0% |
| Very poor | 4 | 2.9% |
| How would you describe your relationship with bedside nurses at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 32 | 22.9% |
| Good | 58 | 41.4% |
| Fair | 38 | 27.1% |
| Poor | 7 | 5.0% |
| Very poor | 2 | 1.4% |
Variation in Responses Based on Years in Practice or Certification
We initially hypothesized that responses regarding practice (ultrasound use, ECG guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. However, no statistically significant associations with these factors and individual responses were identified.
DISCUSSION
In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.
Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]
Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.
Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.
Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.
In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.
Acknowledgements
The authors thank Claire Rickard, PhD, RN, Britt Meyer, RN, Peter Carr, PhD, and David Dempsey, RN for their assistance in developing the survey instrument used in this study.
Disclosures: This project was funded through an Investigator Initiated Research Grant from the Blue Cross Blue Shield of Michigan (BCBSM) Foundation (grant number 2140.II). The funding source played no role in study design, data acquisition, analysis, or reporting of the data. Support for the Hospital Medicine Safety (HMS) Consortium is provided by BCBSM and the Blue Care Network as part of the BCBSM Value Partnerships program. Although BCBSM and HMS work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. This work was also supported with resources from the Veterans Affairs Ann Arbor Healthcare System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]
Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.
Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.
METHODS
Study Setting and Participants
To quantify vascular nursing experience, practice, knowledge, and beliefs, we conducted a Web‐based survey of vascular nurses across 47 Michigan hospitals that participate in HMS. A statewide quality‐improvement initiative, HMS aims to prevent adverse events in hospitalized medical patients through the creation of a data registry and sharing of best practices. The setting and design of this multicenter initiative have been previously described.[8, 9] Although participation is voluntary, each hospital receives payment for participating in the consortium and for data collection. Because HMS has an ongoing initiative aimed at identifying and preventing PICC‐related complications, this study was particularly relevant for participating hospitals and nurses.
Each HMS site has a designated quality‐improvement lead, physician champion, and data abstractor. To coordinate distribution and dissemination of the survey, we contacted the quality‐improvement leads at each site and enquired whether their hospital employed vascular access nurses who placed PICCs. Because we were only interested in responses from vascular access nurses, HMS hospitals that did not have these providers or stated PICCs were placed by other specialists (eg, interventional radiology) were excluded. At eligible sites, we obtained the total number of vascular nurses employed so as to determine the number of eligible respondents. In this manner, a purposeful sample of vascular nurses at participating HMS hospitals was constituted.
Participation in the survey was solicited through hospital quality leads that either distributed an electronic survey link to vascular nurses at their facilities or sent us individual email addresses to contact them directly. A cover letter explaining the rationale and the purpose of the survey along with the survey link was then sent to respondents through either of these routes. The survey was administered at all HMS sites contemporaneously and kept open for a period of 5 weeks. During the 5‐week period, 2 e‐mail reminders were sent to encourage participation. As a token of appreciation, a $10 Amazon gift card was offered to those who took the survey.
Development and Validation of the Survey
We developed the survey instrument (which we call PICC1 as we hope to administer longitudinally to track changes over time) by first conducting a literature search to identify relevant evidence‐based guidelines and studies regarding vascular access nursing practices and experiences.[10, 11, 12, 13] In addition, we consulted and involved national and international leaders in vascular access nursing to ensure validity and representativeness of the questions posed. We were specifically interested in nursing background, hospital practices, types of PICCs used, use of various technologies, relationships with healthcare providers, and management of complications. To understand participant characteristics and quantify potential variation in responses, we collected basic participant data including demographics, years in practice, number of PICCs placed, leadership roles, and vascular access certification status. Based on clinical reasoning and existing studies,[14, 15] we hypothesized that responses regarding certain practices (ultrasound use, electrocardiography [ECG] guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. We therefore examined these associations as prespecified subgroup analyses.
The initial survey instrument was pilot tested with vascular nurses outside of the sampling frame. Based on feedback from the pilot testers, the instrument was refined and edited to improve clarity of the questions. In addition, specific skip patterns and logic were programmed into the final survey to reduce respondent burden and allow participants to seamlessly bypass questions that were contingent on a prior response (eg, use of ECG to place PICCs would lead to a series of questions about ECG‐assisted placement only for those respondents who used the technology). This final version of the survey was tested by members of the study team (V.C., L.K., S.L.K.) and then posted to SurveyMonkey for dissemination.
Statistical Analysis
Descriptive statistics (percentage, n/N) were used to tabulate results. In accordance with our a priori hypothesis that variation to responses might be associated with respondent characteristics, responses to questions regarding insertion practice (eg, use of ultrasound, measurement of catheter:vein ratio, trimming of catheters) and approach to complications (eg, catheter occlusion, deep vein thrombosis [DVT] notification, and PICC removal in the setting of fever) were compared by respondent years in practice (dichotomized to <5 vs >5 years), volume of PICCs placed (<999 vs 1000), and certification status (yes/no). Bivariate comparisons were made using 2 or Fisher exact tests based on the number of responses in a cell as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All statistical analyses were conducted using SAS version 9.3 (SAS Institute, Cary, NC).
Ethical and Regulatory Oversight
Because our study sought to describe existing practice without collecting any individual or facility level identifiable information, the project received a Not Regulated status by the University of Michigan Medical School Institutional Review Board (HUM00088351).
RESULTS
Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.
Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).
| No.* | % | |
|---|---|---|
| ||
| Participant characteristics | ||
| For how many years have you been inserting PICCs? | ||
| <5 years | 40 | 28.6% |
| 5 years | 81 | 57.9% |
| Missing | ||
| In which of the following populations do you insert PICCs? | ||
| Adult patients | 121 | 86.4% |
| Pediatric patients | 24 | 17.1% |
| Neonatal patients | 1 | 0.7% |
| In which of the following locations do you place PICCs? (Select all that apply.) | ||
| Adult medical ward | 115 | 82.1% |
| General adult surgical ward | 110 | 78.6% |
| General pediatric medical ward | 34 | 24.3% |
| General pediatric surgical ward | 24 | 17.1% |
| Adult intensive care unit | 114 | 81.4% |
| Pediatric intensive care unit | 19 | 13.6% |
| Neonatal intensive care unit | 3 | 2.1% |
| Other intensive care unit | 59 | 42.1% |
| Outpatient clinic or emergency department | 17 | 12.1% |
| Other | 10 | 7.1% |
| Approximately how many PICCs may you have placed in your career? | ||
| 099 | 15 | 10.7% |
| 100499 | 36 | 25.7% |
| 500999 | 23 | 16.4% |
| 1,000 | 47 | 33.6% |
| Are you the vascular access lead nurse for your facility or organization? | ||
| Yes | 22 | 15.7% |
| No | 98 | 70.0% |
| Do you currently hold a dedicated vascular access certification (BC‐VA, CRNI, etc.)? | ||
| Yes | 32 | 22.9% |
| No | 89 | 63.6% |
| Facility characteristics | ||
| Which of the following best describes your primary work location? | ||
| Academic medical center | 41 | 29.3% |
| For‐profit community‐based hospital or medical center | 30 | 21.4% |
| Not‐for‐profit community‐based hospital or medical center | 50 | 35.7% |
| Who inserts the most PICCs in your facility? | ||
| Vascular access nurses | 133 | 95.0% |
| Interventional radiology or other providers | 7 | 5.0% |
| In which department is vascular access nursing located? | ||
| Vascular nursing | 76 | 54.3% |
| General nursing | 38 | 27.1% |
| Interventional radiology | 15 | 10.7% |
| Other | 11 | 7.9% |
| Using your best guess, how many PICCs do you think your facility inserts each month? | ||
| <25 | 5 | 3.6% |
| 2549 | 13 | 9.3% |
| 50100 | 39 | 27.9% |
| >100 | 78 | 55.7% |
| Unknown | 2 | 1.4% |
| How many vascular access nurses are employed by your facility? | ||
| <4 | 14 | 10.0% |
| 46 | 33 | 23.6% |
| 79 | 15 | 10.7% |
| 1015 | 25 | 17.9% |
| >15 | 53 | 37.9% |
| Does your facility track the number of PICCs placed? | ||
| Yes | 132 | 94.3% |
| No | 5 | 3.6% |
| Unknown | 3 | 2.1% |
| Does your facility track the duration or dwell time of PICCs? | ||
| Yes | 56 | 40.0% |
| No | 60 | 42.9% |
| Unknown | 24 | 17.1% |
| Does your facility have a written policy regarding standard PICC insertion practices? | ||
| Yes | 122 | 87.1% |
| No | 8 | 5.7% |
| Unknown | 7 | 5.0% |
| Does your facility have a written policy regarding standard PICC care and maintenance? | ||
| Yes | 133 | 95.0% |
| No | 3 | 2.1% |
| Unknown | 1 | 0.7% |
| Does your facility have a written process to review the necessity or appropriateness of a PICC? | ||
| Yes | 42 | 30.0% |
| No | 63 | 45.0% |
| Unknown | 20 | 14.3% |
The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).
| Question | No. | % |
|---|---|---|
| ||
| Do you use ultrasound to find a suitable vein prior to PICC insertion? | ||
| Yes | 128 | 91.4% |
| No | 0 | 0.0% |
| Do you use ultrasound to estimate the catheter‐to‐vein ratio prior to PICC insertion? | ||
| Yes | 110 | 78.6% |
| No | 18 | 12.9% |
| When using ultrasound, do you document the catheter‐to‐vein ratio in the PICC insertion note? | ||
| Yes | 20 | 14.3% |
| No | 89 | 63.6% |
| Do you use ECG guidance‐assisted systems to place PICCs? | ||
| Yes | 106 | 75.7% |
| No | 21 | 15.0% |
| If using ECG guidance, do you still routinely obtain a chest x‐ray to verify PICC tip position after placing the PICC using ECG guidance? | ||
| Yes | 38 | 27.1% |
| No | 68 | 48.6% |
| Who is primarily responsible for administering and adhering to a flushing protocol after PICC insertion at your facility? | ||
| Bedside nurses | 118 | 83.6% |
| Patients | 1 | 0.7% |
| Vascular access nurses | 8 | 5.7% |
| Which of the following agents are most often used to flush PICCs? | ||
| Both heparin and normal saline flushes | 61 | 43.6% |
| Normal saline only | 63 | 45.0% |
| Heparin only | 3 | 2.1% |
| Who is responsible for scheduled weekly dressing changes for PICCs? | ||
| Vascular access nurses | 110 | 78.6% |
| Bedside nurses | 14 | 10.0% |
| Other (eg, IR staff, ICU staff) | 3 | 2.1% |
| In the past few months, have you placed a PICC in a patient who was receiving a form of dialysis (eg, peritoneal or hemodialysis)? | ||
| Yes | 65 | 46.4% |
| No | 64 | 45.7% |
| If you have placed PICCs in patients on dialysis, do you discuss PICC placement or receive approval from nephrology prior to inserting the PICC? | ||
| Yes | 59 | 90.8% |
| No | 6 | 9.2% |
With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.
To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).
| Question | No. | % |
|---|---|---|
| ||
| Which of the following PICC‐related complications have you most frequently encountered in your practice? | ||
| Catheter occlusion | 81 | 57.9% |
| Catheter migration | 27 | 19.3% |
| PICC‐associated DVT | 6 | 4.3% |
| Catheter fracture or embolization | 3 | 2.1% |
| Exit site infection | 3 | 2.1% |
| Coiling or kinking after insertion | 2 | 1.4% |
| If you suspect a patient has catheter occlusion, which of the following best describes your approach to resolving this problem? | ||
| Begin with normal saline but use a tPA product if this fails to restore patency | 70 | 50.0% |
| Use a tPA product (eg, Cathflo, Activase, or Retavase) to restore patency | 44 | 31.4% |
| Begin with heparin‐based flushes but use a tPA product if this fails to restore | 7 | 5.0% |
| Use only normal saline flushes to restore patency | 3 | 2.1% |
| If you find a PICC that has migrated out or has been accidentally dislodged <5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 108 | 77.1% |
| Perform a complete catheter exchange over a guidewire if possible | 5 | 3.6% |
| Notify/discuss next steps with physician | 5 | 3.6% |
| Other | 6 | 4.3% |
| If you find a PICC that has migrated out or has been accidentally dislodged >5 cm in a patient without symptoms, and the device is still clinically needed, which of the following best describes your practice? | ||
| Obtain a chest x‐ray to verify tip position | 72 | 51.4% |
| Perform a catheter exchange over a guidewire if possible | 30 | 21.4% |
| Notify/discuss next steps with physician | 10 | 7.1% |
| Other | 12 | 8.6% |
| Which of the following best describes your first approach when you suspect a patient has PICC‐associated phlebitis? | ||
| Discuss best course of action with physician or nurse | 79 | 56.4% |
| Supportive measures (eg, warm compresses, analgesics, monitoring) | 25 | 17.9% |
| Remove the PICC | 15 | 10.7% |
| Other | 5 | 3.6% |
| Which of the following best describes your first approach when you suspect a patient has a PICC‐related DVT? | ||
| Notify caregivers to continue using PICC and consider tests such as ultrasound | 82 | 58.6% |
| Notify bedside nurse and physician not to continue use of the PICC and consider tests such as ultrasound | 42 | 30.0% |
| PICCs are often removed when physicians suspect, but have not yet confirmed, CLABSI. Considering your experiences, what percentage of PICCs may have been removed in this manner at your facility? | ||
| <5% | 11 | 7.9% |
| 59% | 16 | 11.4% |
| 1024% | 24 | 17.1% |
| 25% | 71 | 50.7% |
| Based on your experience, what percentage of PICCs do you think are inappropriate or could have been avoided at your facility? | ||
| <5% | 51 | 36.4% |
| 59% | 25 | 17.9% |
| 1024% | 28 | 20.0% |
| 2550% | 13 | 9.3% |
| >50% | 5 | 3.6% |
| Are vascular access nurses empowered to remove PICCs that are idle or clinically unnecessary without physician authorization? | ||
| Yes | 3 | 2.1% |
| No | 122 | 87.1% |
| How would you rank the overall support your vascular access service receives from hospital leadership? | ||
| Excellent | 5 | 3.6% |
| Very good | 32 | 22.9% |
| Good | 40 | 28.6% |
| Fair | 35 | 25.0% |
| Poor | 25 | 17.9% |
| How would you describe your relationship with physicians at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 28 | 20.0% |
| Good | 63 | 45.0% |
| Fair | 35 | 25.0% |
| Poor | 7 | 5.0% |
| Very poor | 4 | 2.9% |
| How would you describe your relationship with bedside nurses at your facility when it comes to communicating recommendations or management of PICCs? | ||
| Very good | 32 | 22.9% |
| Good | 58 | 41.4% |
| Fair | 38 | 27.1% |
| Poor | 7 | 5.0% |
| Very poor | 2 | 1.4% |
Variation in Responses Based on Years in Practice or Certification
We initially hypothesized that responses regarding practice (ultrasound use, ECG guidance system use), management of complications, or perceptions regarding leadership might vary based on years of experience, number of PICCs placed, or certification status. However, no statistically significant associations with these factors and individual responses were identified.
DISCUSSION
In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.
Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]
Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.
Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.
Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.
In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.
Acknowledgements
The authors thank Claire Rickard, PhD, RN, Britt Meyer, RN, Peter Carr, PhD, and David Dempsey, RN for their assistance in developing the survey instrument used in this study.
Disclosures: This project was funded through an Investigator Initiated Research Grant from the Blue Cross Blue Shield of Michigan (BCBSM) Foundation (grant number 2140.II). The funding source played no role in study design, data acquisition, analysis, or reporting of the data. Support for the Hospital Medicine Safety (HMS) Consortium is provided by BCBSM and the Blue Care Network as part of the BCBSM Value Partnerships program. Although BCBSM and HMS work collaboratively, the opinions, beliefs, and viewpoints expressed by the authors do not necessarily reflect the opinions, beliefs, and viewpoints of BCBSM or any of its employees. This work was also supported with resources from the Veterans Affairs Ann Arbor Healthcare System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
- , , , et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high‐risk short‐term central venous catheters. Am J Infect Control. 2010;38(2):149–153.
- , , , , . Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters. J Hosp Med. 2009;4(7):417–422.
- , , , , , . Central venous catheter placement by advanced practice nurses demonstrates low procedural complication and infection rates‐‐a report from 13 years of service. Crit Care Med. 2014;42(3):536–543.
- . Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs. 2012;34(1):34–42.
- , . Facility wide benefits of radiology vascular access teams. Radiol Manage. 2010;32(1):28–32; quiz 33–34.
- , . Moving the needle forward: the imperative for collaboration in vascular access. J Infus Nurs. 2015;38(2):100–102.
- , , , . Use of designated PICC teams by U.S. hospitals: a survey‐based study [published online November 10, 2015]. J Patient Saf. doi: 10.1097/PTS.0000000000000246
- , , , , . The association between PICC use and venous thromboembolism in upper and lower extremities. American J Med. 2015;128(9):986–993.e1.
- , , , et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med. 2014;174(10):1577–1584.
- , , , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. Lancet. 2013;382(9889):311–325.
- Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006;29(1 suppl):S1–S92.
- , , , et al. Guidelines for the prevention of intravascular catheter‐related infections. Am J Infect Control. 2011;39(4 suppl 1):S1–S34.
- , , , et al. International evidence‐based recommendations on ultrasound‐guided vascular access. Intensive Care Med. 2012;38(7):1105–1117.
- , , . A single institution experience of seven hundred consecutively placed peripherally inserted central venous catheters. J Vasc Access. 2014;15(6):498–502.
- , , . Central venous access devices site care practices: an international survey of 34 countries [published online September 3, 2015]. J Vasc Access. doi: 10.5301/jva.5000450
- American Society of Nephrology. World's Leading Kidney Society Joins Effort to Reduce Unnecessary Medical Tests and Procedures. Available at: https://www.asn‐online.org/policy/choosingwisely/PressReleaseChoosingWisely.pdf. Accessed September 4, 2015.
- , , , . A survey of the current use of peripherally inserted central venous catheter (PICC) in Swedish oncology departments. Acta Oncol. 2013;52(6):1241–1242.
- , . Nurse‐led PICC insertion: is it cost effective? Br J Nurs. 2013;22(19):S9–S15.
- , , , et al. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey. J Hosp Med. 2013;8(6):309–314.
- , , , et al. Peripherally inserted central venous catheters in the acute care setting: a safe alternative to high‐risk short‐term central venous catheters. Am J Infect Control. 2010;38(2):149–153.
- , , , , . Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters. J Hosp Med. 2009;4(7):417–422.
- , , , , , . Central venous catheter placement by advanced practice nurses demonstrates low procedural complication and infection rates‐‐a report from 13 years of service. Crit Care Med. 2014;42(3):536–543.
- . Developing an alternative workflow model for peripherally inserted central catheter placement. J Infus Nurs. 2012;34(1):34–42.
- , . Facility wide benefits of radiology vascular access teams. Radiol Manage. 2010;32(1):28–32; quiz 33–34.
- , . Moving the needle forward: the imperative for collaboration in vascular access. J Infus Nurs. 2015;38(2):100–102.
- , , , . Use of designated PICC teams by U.S. hospitals: a survey‐based study [published online November 10, 2015]. J Patient Saf. doi: 10.1097/PTS.0000000000000246
- , , , , . The association between PICC use and venous thromboembolism in upper and lower extremities. American J Med. 2015;128(9):986–993.e1.
- , , , et al. Hospital performance for pharmacologic venous thromboembolism prophylaxis and rate of venous thromboembolism: a cohort study. JAMA Intern Med. 2014;174(10):1577–1584.
- , , , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. Lancet. 2013;382(9889):311–325.
- Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2006;29(1 suppl):S1–S92.
- , , , et al. Guidelines for the prevention of intravascular catheter‐related infections. Am J Infect Control. 2011;39(4 suppl 1):S1–S34.
- , , , et al. International evidence‐based recommendations on ultrasound‐guided vascular access. Intensive Care Med. 2012;38(7):1105–1117.
- , , . A single institution experience of seven hundred consecutively placed peripherally inserted central venous catheters. J Vasc Access. 2014;15(6):498–502.
- , , . Central venous access devices site care practices: an international survey of 34 countries [published online September 3, 2015]. J Vasc Access. doi: 10.5301/jva.5000450
- American Society of Nephrology. World's Leading Kidney Society Joins Effort to Reduce Unnecessary Medical Tests and Procedures. Available at: https://www.asn‐online.org/policy/choosingwisely/PressReleaseChoosingWisely.pdf. Accessed September 4, 2015.
- , , , . A survey of the current use of peripherally inserted central venous catheter (PICC) in Swedish oncology departments. Acta Oncol. 2013;52(6):1241–1242.
- , . Nurse‐led PICC insertion: is it cost effective? Br J Nurs. 2013;22(19):S9–S15.
- , , , et al. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey. J Hosp Med. 2013;8(6):309–314.
© 2015 Society of Hospital Medicine
Hospitalist Experiences With PICCs
Peripherally inserted central catheters (PICCs) are central venous catheters that are inserted through peripheral veins of the upper extremities in adults. Because they are safer to insert than central venous catheters (CVCs) and have become increasingly available at the bedside through the advent of specially trained vascular access nurses,[1] the use of PICCs in hospitalized patients has risen across the United States.[2] As the largest group of inpatient providers, hospitalists play a key role in the decision to insert and subsequently manage PICCs in hospitalized patients. Unfortunately, little is known about national hospitalist experiences, practice patterns, or knowledge when it comes to these commonly used devices. Therefore, we designed a 10‐question survey to investigate PICC‐related practices and knowledge among adult hospitalists practicing throughout the United States.
PATIENTS AND METHODS
Questions for this survey were derived from a previously published study conducted across 10 hospitals in the state of Michigan.[3] To assess external validity and test specific hypotheses formulated from the Michigan study, those questions with the greatest variation in response or those most amenable to interventions were chosen for inclusion in this survey.
To reach a national audience of practicing adult hospitalists, we submitted a survey proposal to the Society of Hospital Medicine's (SHM) Research Committee. The SHM Research Committee reviews such proposals using a peer‐review process to ensure both scientific integrity and validity of the survey instrument. Because the survey was already distributed to many hospitalists in Michigan, we requested that only hospitalists outside of Michigan be invited to participate in the national survey. All responses were collected anonymously, and no identifiable data were collected from respondents. Between February 1, 2013 and March 15, 2013, data were collected via an e‐mail sent directly from the SHM to members that contained a link to the study survey administered using SurveyMonkey. To augment data collection, nonresponders to the original e‐mail invitation were sent a second reminder e‐mail midway through the study. Descriptive statistics (percentages) were used to tabulate responses. The institutional review board at the University of Michigan Health System provided ethical and regulatory approval for this study.
RESULTS
A total of 2112 electronic survey invitations were sent to non‐Michigan adult hospitalists, with 381 completing the online survey (response rate 18%). Among respondents to the national survey, 86% reported having placed a PICC solely to obtain venous access in a hospitalized patient (rather than for specific indications such as long‐term intravenous antibiotics, chemotherapy, or parenteral nutrition), whereas 82% reported having cared for a patient who specifically requested a PICC (Table 1). PICC‐related deep vein thrombosis (DVT) and bloodstream infections were reported as being the most frequent PICC complications encountered by hospitalists, followed by superficial thrombophlebitis and mechanical complications such as coiling, kinking, and migration of the PICC tip.
| Total (N=381) | |
|---|---|
| |
| Hospitalist experiences related to PICCs | |
| Among hospitalized patients you have cared for, have any of your patients ever had a PICC placed solely to obtain venous access (eg, not for an indication such as long‐term IV antibiotics, chemotherapy, or TPN)? | |
| Yes | 328 (86.1%) |
| No | 53 (13.9%) |
| Have you ever cared for a patient who specifically requested a PICC because of prior experience with this device? | |
| Yes | 311 (81.6%) |
| No | 70 (18.4%) |
| Most frequently encountered PICC complications | |
| Upper‐extremity DVT or PE | 48 (12.6%) |
| Bloodstream infection | 41 (10.8%) |
| Superficial thrombophlebitis | 34 (8.9%) |
| Cellulitis/exit site erythema | 26 (6.8%) |
| Coiling, kinking of the PICC | 14 (3.7%) |
| Migration of the PICC tip | 9 (2.4%) |
| Breakage of PICC (anywhere) | 6 (1.6%) |
| Hospitalist practice related to PICCs | |
| During patient rounds, do you routinely examine PICCs for external problems (eg, cracks, breaks, leaks, or redness at the insertion site)? | |
| Yes, daily | 97 (25.5%) |
| Yes, but only if the nurse or patient alerts me to a problem with the PICC | 190 (49.9%) |
| No, I don't routinely examine the PICC for external problems | 94 (24.7%) |
| Have you ever forgotten or been unaware of the presence of a PICC? | |
| Yes | 216 (56.7%) |
| No | 165 (43.3%) |
| Assuming no contraindications exist, do you anticoagulate patients who develop a PICC‐associated DVT? | |
| Yes, for at least 1 month | 41(10.8%) |
| Yes, for at least 3 months* | 198 (52.0%) |
| Yes, for at least 6 months | 11 (2.9%) |
| Yes, I anticoagulate for as long as the line remains in place. Once the line is removed, I stop anticoagulation | 30 (7.9%) |
| Yes, I anticoagulate for as long as the line remains in place followed by another 4 weeks of therapy | 72 (18.9%) |
| I don't usually anticoagulate patients who develop a PICC‐related DVT | 29 (7.6%) |
| When a hospitalized patient develops a PICC‐related DVT, do you routinely remove the PICC? | |
| Yes | 271 (71.1%) |
| No | 110 (28.9%) |
| Hospitalist opinions related to PICCs | |
| Thinking about your hospital and your experiences, what percentage of PICC insertions may represent inappropriate use (eg, PICC placed for short‐term venous access for a presumed infection that could be treated with oral antibiotic or PICCs that were promptly removed as the patient no longer needed it for clinical management)? | |
| <10% | 192 (50.4%) |
| 10%25% | 160 (42.0%) |
| 26%50% | 22 (5.8%) |
| >50% | 7 (1.8%) |
| Do you think hospitalists should be trained to insert PICCs? | |
| Yes | 162 (42.5%) |
| No | 219 (57.5%) |
| Hospitalist knowledge related to PICCs | |
| Why is the position of the PICC‐tip checked following bedside PICC insertion? | |
| To decrease the risk of arrhythmia from tip placement in the right atrial | 267 (70.1%) |
| To ensure it is not accidentally placed into an artery | 44 (11.5%) |
| To minimize the risk of venous thrombosis* | 33 (8.7%) |
| For documentation purposes (to reduce the risk of lawsuits related tocomplications) | 16 (4.2%) |
| I don't know | 21 (5.5%) |
Several potentially important safety concerns regarding hospitalist PICC practices were observed in this survey. For instance, only 25% of hospitalists reported examining PICCs on daily rounds for external problems. When alerted by nurses or patients about problems with the device, this number doubled to 50%. In addition, 57% of respondents admitted to having at least once forgotten about the presence of a PICC in their hospitalized patient.
Participants also reported significant variation in duration of anticoagulation therapy for PICC‐related DVT, with only half of all respondents selecting the guideline‐recommended 3 months of anticoagulation.[4, 5] With respect to knowledge regarding PICCs, only 9% of respondents recognized that tip verification performed after PICC insertion was conducted to lower risk of venous thromboembolism, not that of arrhythmia.[6] Hospitalists were ambivalent about being trained on how to place PICCs, with only 43% indicating this skill was necessary. Finally, as many as 10% to 25% of PICCs inserted in their hospitals were felt to be inappropriately placed and/or avoidable by 42% of those surveyed.
DISCUSSION
As the use of PICCs rises in hospitalized patients, variability in practices associated with the use of these indwelling vascular catheters is being increasingly recognized. For instance, Tejedor and colleagues reported that PICCs placed in hospitalized patients at their academic medical center were often idle or inserted in patients who simultaneously have peripheral intravenous catheters.[7] Recent data from a tertiary care pediatric center found significantly greater PICC utilization rates over the past decade in association with shorter dwell times, suggesting important and dynamic changes in patterns of use of these devices.[2] Our prior survey of hospitalists in 10 Michigan hospitals also found variations in reported hospitalist practices, knowledge, and experiences related to PICCs.[3] However, the extent to which the Michigan experience portrayed a national trend remained unclear and was the impetus behind this survey. Results from this study appear to support findings from Michigan and highlight several potential opportunities to improve hospitalist PICC practices on a national scale.
In particular, 57% of respondents in this study (compared to 51% of Michigan hospitalists) stated they had at least once forgotten that their patient had a PICC. As early removal of PICCs that are clinically no longer necessary is a cornerstone to preventing thrombosis and infection,[4, 5, 6, 8] the potential impact of such forgetfulness on clinical outcomes and patient safety is of concern. Notably, PICC‐related DVT and bloodstream infection remained the 2 most commonly encountered complications in this survey, just as in the Michigan study.
Reported variations in treatment duration for PICC‐related DVT were also common in this study, with only half of all respondents in both surveys selecting the guideline‐recommended minimum of 3 months of anticoagulation. Finally, a substantial proportion (42%) of participants felt that 10% to 25% of PICCs placed in their hospitals might be inappropriately placed and avoidable, again echoing the sentiments of 51% of the participants in the Michigan survey. These findings strengthen the call to develop a research agenda focused on PICC use in hospitalized patients across the United States.
Why may hospitalists across the country demonstrate such variability when it comes to these indwelling vascular devices? PICCs have historically been viewed as safer with respect to complications such as infection and thrombosis than other central venous catheters, a viewpoint that has likely promulgated their use in the inpatient setting. However, as we and others have shown,[8, 9, 10, 11, 12] this notion is rapidly vanishing and being replaced by the recognition that severity of illness and patient comorbidities are more important determinants of complications than the device itself. Additionally, important knowledge gaps exist when it comes to the safe use of PICCs in hospitalized patients, contributing to variation in indications for insertion, removal, and treatment of complications related to these devices.
Our study is notably limited by a low response rate. Because the survey was administered directly by SHM without collection of respondent data (eg, practice location, years in practice), we are unable to adjust or weight these data to represent a national cohort of adult hospitalists. However, as responses to questions are consistent with our findings from Michigan, and the response rates of this survey are comparable to observed response rates from prior SHM‐administered nationwide surveys (10%40%),[13, 14, 15] we do not believe our findings necessarily represent systematic deviations from the truth and assumed that these responses were missing at random. In addition, owing to use of a survey‐based design, our study is inherently limited by a number of biases, including the use of a convenience sample of SHM members, nonresponse bias, and recall bias. Given these limitations, the association between the available responses and real‐world clinical practice is unclear and deserving of further investigation.
These limitations notwithstanding, our study has several strengths. We found important national variations in reported practices and knowledge related to PICCs, affirming the need to develop a research agenda to improve practice. Further, because a significant proportion of hospitalists may forget their patients have PICCs, our study supports the role of technologies such as catheter reminder systems, computerized decision aids, and automatic stop orders to improve PICC use. These technologies, if utilized in a workflow‐sensitive fashion, could improve PICC safety in hospitalized settings and merit exploration. In addition, our study highlights the growing need for criteria to guide the use of PICCs in hospital settings. Although the Infusion Nursing Society of America has published indications and guidelines for use of vascular devices,[6] these do not always incorporate clinical nuances such as necessity of intravenous therapy or duration of treatment in decision making. The development of evidence‐based appropriateness criteria to guide clinical decision making is thus critical to improving use of PICCs in inpatient settings.[16]
With growing recognition of PICC‐related complications in hospitalized patients, an urgent need to improve practice related to these devices exists. This study begins to define the scope of such work across the United States. Until more rigorous evidence becomes available to guide clinical practice, hospitals and hospitalists should begin to carefully monitor PICC use to safeguard and improve patient safety.
Disclosures
The Blue Cross/Blue Shield of Michigan Foundation funded this study through an investigator‐initiated research proposal (1931‐PIRAP to Dr. Chopra). The funding source played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.
- , . Peripherally inserted central catheter: compliance with evidence‐based indications for insertion in an inpatient setting. J Infus Nurs. 2013;36(4):291–296.
- , , , , , . Peripherally inserted central catheters: use at a tertiary care pediatric center. J Vasc Interv Radiol. 2013;24(9):1323–1331.
- , , , et al. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey. J Hosp Med. 2013;8(6):309–314.
- , , , et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence‐based clinical practice guidelines. Chest. 2012;141(2 suppl):7S–47S.
- , , , et al. Quality improvement guidelines for central venous access. J Vasc Interv Radiol. 2010;21(7):976–981.
- , , , et al. Infusion nursing standards of practice. J Infus Nurs. 2011;34(1S):1–115.
- , , , et al. Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the “idle central venous catheter”. Infect Control Hosp Epidemiol. 2012;33(1):50–57.
- , , , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. Lancet. 2013;382(9889):311–325.
- , , , , . Risk factors for peripherally inserted central venous catheter complications in children. JAMA Pediatr. 2013;167(5):429–435.
- , , , et al. Patient‐ and device‐specific risk factors for peripherally inserted central venous catheter‐related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
- , , , , . The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta‐analysis. Infect Control Hosp Epidemiol. 2013;34(9):908–918.
- , . Risk of catheter‐related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–495.
- , , , , ; Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. J Hosp Med. 2012;7(5):402–410.
- , . Clinical hospital medicine fellowships: perspectives of employers, hospitalists, and medicine residents. J Hosp Med. 2008;3(1):28–34.
- , , , . Survey of US academic hospitalist leaders about mentorship and academic activities in hospitalist groups. J Hosp Med. 2011;6(1):5–9.
- , , . The problem with peripherally inserted central catheters. JAMA. 2012;308(15):1527–1528.
Peripherally inserted central catheters (PICCs) are central venous catheters that are inserted through peripheral veins of the upper extremities in adults. Because they are safer to insert than central venous catheters (CVCs) and have become increasingly available at the bedside through the advent of specially trained vascular access nurses,[1] the use of PICCs in hospitalized patients has risen across the United States.[2] As the largest group of inpatient providers, hospitalists play a key role in the decision to insert and subsequently manage PICCs in hospitalized patients. Unfortunately, little is known about national hospitalist experiences, practice patterns, or knowledge when it comes to these commonly used devices. Therefore, we designed a 10‐question survey to investigate PICC‐related practices and knowledge among adult hospitalists practicing throughout the United States.
PATIENTS AND METHODS
Questions for this survey were derived from a previously published study conducted across 10 hospitals in the state of Michigan.[3] To assess external validity and test specific hypotheses formulated from the Michigan study, those questions with the greatest variation in response or those most amenable to interventions were chosen for inclusion in this survey.
To reach a national audience of practicing adult hospitalists, we submitted a survey proposal to the Society of Hospital Medicine's (SHM) Research Committee. The SHM Research Committee reviews such proposals using a peer‐review process to ensure both scientific integrity and validity of the survey instrument. Because the survey was already distributed to many hospitalists in Michigan, we requested that only hospitalists outside of Michigan be invited to participate in the national survey. All responses were collected anonymously, and no identifiable data were collected from respondents. Between February 1, 2013 and March 15, 2013, data were collected via an e‐mail sent directly from the SHM to members that contained a link to the study survey administered using SurveyMonkey. To augment data collection, nonresponders to the original e‐mail invitation were sent a second reminder e‐mail midway through the study. Descriptive statistics (percentages) were used to tabulate responses. The institutional review board at the University of Michigan Health System provided ethical and regulatory approval for this study.
RESULTS
A total of 2112 electronic survey invitations were sent to non‐Michigan adult hospitalists, with 381 completing the online survey (response rate 18%). Among respondents to the national survey, 86% reported having placed a PICC solely to obtain venous access in a hospitalized patient (rather than for specific indications such as long‐term intravenous antibiotics, chemotherapy, or parenteral nutrition), whereas 82% reported having cared for a patient who specifically requested a PICC (Table 1). PICC‐related deep vein thrombosis (DVT) and bloodstream infections were reported as being the most frequent PICC complications encountered by hospitalists, followed by superficial thrombophlebitis and mechanical complications such as coiling, kinking, and migration of the PICC tip.
| Total (N=381) | |
|---|---|
| |
| Hospitalist experiences related to PICCs | |
| Among hospitalized patients you have cared for, have any of your patients ever had a PICC placed solely to obtain venous access (eg, not for an indication such as long‐term IV antibiotics, chemotherapy, or TPN)? | |
| Yes | 328 (86.1%) |
| No | 53 (13.9%) |
| Have you ever cared for a patient who specifically requested a PICC because of prior experience with this device? | |
| Yes | 311 (81.6%) |
| No | 70 (18.4%) |
| Most frequently encountered PICC complications | |
| Upper‐extremity DVT or PE | 48 (12.6%) |
| Bloodstream infection | 41 (10.8%) |
| Superficial thrombophlebitis | 34 (8.9%) |
| Cellulitis/exit site erythema | 26 (6.8%) |
| Coiling, kinking of the PICC | 14 (3.7%) |
| Migration of the PICC tip | 9 (2.4%) |
| Breakage of PICC (anywhere) | 6 (1.6%) |
| Hospitalist practice related to PICCs | |
| During patient rounds, do you routinely examine PICCs for external problems (eg, cracks, breaks, leaks, or redness at the insertion site)? | |
| Yes, daily | 97 (25.5%) |
| Yes, but only if the nurse or patient alerts me to a problem with the PICC | 190 (49.9%) |
| No, I don't routinely examine the PICC for external problems | 94 (24.7%) |
| Have you ever forgotten or been unaware of the presence of a PICC? | |
| Yes | 216 (56.7%) |
| No | 165 (43.3%) |
| Assuming no contraindications exist, do you anticoagulate patients who develop a PICC‐associated DVT? | |
| Yes, for at least 1 month | 41(10.8%) |
| Yes, for at least 3 months* | 198 (52.0%) |
| Yes, for at least 6 months | 11 (2.9%) |
| Yes, I anticoagulate for as long as the line remains in place. Once the line is removed, I stop anticoagulation | 30 (7.9%) |
| Yes, I anticoagulate for as long as the line remains in place followed by another 4 weeks of therapy | 72 (18.9%) |
| I don't usually anticoagulate patients who develop a PICC‐related DVT | 29 (7.6%) |
| When a hospitalized patient develops a PICC‐related DVT, do you routinely remove the PICC? | |
| Yes | 271 (71.1%) |
| No | 110 (28.9%) |
| Hospitalist opinions related to PICCs | |
| Thinking about your hospital and your experiences, what percentage of PICC insertions may represent inappropriate use (eg, PICC placed for short‐term venous access for a presumed infection that could be treated with oral antibiotic or PICCs that were promptly removed as the patient no longer needed it for clinical management)? | |
| <10% | 192 (50.4%) |
| 10%25% | 160 (42.0%) |
| 26%50% | 22 (5.8%) |
| >50% | 7 (1.8%) |
| Do you think hospitalists should be trained to insert PICCs? | |
| Yes | 162 (42.5%) |
| No | 219 (57.5%) |
| Hospitalist knowledge related to PICCs | |
| Why is the position of the PICC‐tip checked following bedside PICC insertion? | |
| To decrease the risk of arrhythmia from tip placement in the right atrial | 267 (70.1%) |
| To ensure it is not accidentally placed into an artery | 44 (11.5%) |
| To minimize the risk of venous thrombosis* | 33 (8.7%) |
| For documentation purposes (to reduce the risk of lawsuits related tocomplications) | 16 (4.2%) |
| I don't know | 21 (5.5%) |
Several potentially important safety concerns regarding hospitalist PICC practices were observed in this survey. For instance, only 25% of hospitalists reported examining PICCs on daily rounds for external problems. When alerted by nurses or patients about problems with the device, this number doubled to 50%. In addition, 57% of respondents admitted to having at least once forgotten about the presence of a PICC in their hospitalized patient.
Participants also reported significant variation in duration of anticoagulation therapy for PICC‐related DVT, with only half of all respondents selecting the guideline‐recommended 3 months of anticoagulation.[4, 5] With respect to knowledge regarding PICCs, only 9% of respondents recognized that tip verification performed after PICC insertion was conducted to lower risk of venous thromboembolism, not that of arrhythmia.[6] Hospitalists were ambivalent about being trained on how to place PICCs, with only 43% indicating this skill was necessary. Finally, as many as 10% to 25% of PICCs inserted in their hospitals were felt to be inappropriately placed and/or avoidable by 42% of those surveyed.
DISCUSSION
As the use of PICCs rises in hospitalized patients, variability in practices associated with the use of these indwelling vascular catheters is being increasingly recognized. For instance, Tejedor and colleagues reported that PICCs placed in hospitalized patients at their academic medical center were often idle or inserted in patients who simultaneously have peripheral intravenous catheters.[7] Recent data from a tertiary care pediatric center found significantly greater PICC utilization rates over the past decade in association with shorter dwell times, suggesting important and dynamic changes in patterns of use of these devices.[2] Our prior survey of hospitalists in 10 Michigan hospitals also found variations in reported hospitalist practices, knowledge, and experiences related to PICCs.[3] However, the extent to which the Michigan experience portrayed a national trend remained unclear and was the impetus behind this survey. Results from this study appear to support findings from Michigan and highlight several potential opportunities to improve hospitalist PICC practices on a national scale.
In particular, 57% of respondents in this study (compared to 51% of Michigan hospitalists) stated they had at least once forgotten that their patient had a PICC. As early removal of PICCs that are clinically no longer necessary is a cornerstone to preventing thrombosis and infection,[4, 5, 6, 8] the potential impact of such forgetfulness on clinical outcomes and patient safety is of concern. Notably, PICC‐related DVT and bloodstream infection remained the 2 most commonly encountered complications in this survey, just as in the Michigan study.
Reported variations in treatment duration for PICC‐related DVT were also common in this study, with only half of all respondents in both surveys selecting the guideline‐recommended minimum of 3 months of anticoagulation. Finally, a substantial proportion (42%) of participants felt that 10% to 25% of PICCs placed in their hospitals might be inappropriately placed and avoidable, again echoing the sentiments of 51% of the participants in the Michigan survey. These findings strengthen the call to develop a research agenda focused on PICC use in hospitalized patients across the United States.
Why may hospitalists across the country demonstrate such variability when it comes to these indwelling vascular devices? PICCs have historically been viewed as safer with respect to complications such as infection and thrombosis than other central venous catheters, a viewpoint that has likely promulgated their use in the inpatient setting. However, as we and others have shown,[8, 9, 10, 11, 12] this notion is rapidly vanishing and being replaced by the recognition that severity of illness and patient comorbidities are more important determinants of complications than the device itself. Additionally, important knowledge gaps exist when it comes to the safe use of PICCs in hospitalized patients, contributing to variation in indications for insertion, removal, and treatment of complications related to these devices.
Our study is notably limited by a low response rate. Because the survey was administered directly by SHM without collection of respondent data (eg, practice location, years in practice), we are unable to adjust or weight these data to represent a national cohort of adult hospitalists. However, as responses to questions are consistent with our findings from Michigan, and the response rates of this survey are comparable to observed response rates from prior SHM‐administered nationwide surveys (10%40%),[13, 14, 15] we do not believe our findings necessarily represent systematic deviations from the truth and assumed that these responses were missing at random. In addition, owing to use of a survey‐based design, our study is inherently limited by a number of biases, including the use of a convenience sample of SHM members, nonresponse bias, and recall bias. Given these limitations, the association between the available responses and real‐world clinical practice is unclear and deserving of further investigation.
These limitations notwithstanding, our study has several strengths. We found important national variations in reported practices and knowledge related to PICCs, affirming the need to develop a research agenda to improve practice. Further, because a significant proportion of hospitalists may forget their patients have PICCs, our study supports the role of technologies such as catheter reminder systems, computerized decision aids, and automatic stop orders to improve PICC use. These technologies, if utilized in a workflow‐sensitive fashion, could improve PICC safety in hospitalized settings and merit exploration. In addition, our study highlights the growing need for criteria to guide the use of PICCs in hospital settings. Although the Infusion Nursing Society of America has published indications and guidelines for use of vascular devices,[6] these do not always incorporate clinical nuances such as necessity of intravenous therapy or duration of treatment in decision making. The development of evidence‐based appropriateness criteria to guide clinical decision making is thus critical to improving use of PICCs in inpatient settings.[16]
With growing recognition of PICC‐related complications in hospitalized patients, an urgent need to improve practice related to these devices exists. This study begins to define the scope of such work across the United States. Until more rigorous evidence becomes available to guide clinical practice, hospitals and hospitalists should begin to carefully monitor PICC use to safeguard and improve patient safety.
Disclosures
The Blue Cross/Blue Shield of Michigan Foundation funded this study through an investigator‐initiated research proposal (1931‐PIRAP to Dr. Chopra). The funding source played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.
Peripherally inserted central catheters (PICCs) are central venous catheters that are inserted through peripheral veins of the upper extremities in adults. Because they are safer to insert than central venous catheters (CVCs) and have become increasingly available at the bedside through the advent of specially trained vascular access nurses,[1] the use of PICCs in hospitalized patients has risen across the United States.[2] As the largest group of inpatient providers, hospitalists play a key role in the decision to insert and subsequently manage PICCs in hospitalized patients. Unfortunately, little is known about national hospitalist experiences, practice patterns, or knowledge when it comes to these commonly used devices. Therefore, we designed a 10‐question survey to investigate PICC‐related practices and knowledge among adult hospitalists practicing throughout the United States.
PATIENTS AND METHODS
Questions for this survey were derived from a previously published study conducted across 10 hospitals in the state of Michigan.[3] To assess external validity and test specific hypotheses formulated from the Michigan study, those questions with the greatest variation in response or those most amenable to interventions were chosen for inclusion in this survey.
To reach a national audience of practicing adult hospitalists, we submitted a survey proposal to the Society of Hospital Medicine's (SHM) Research Committee. The SHM Research Committee reviews such proposals using a peer‐review process to ensure both scientific integrity and validity of the survey instrument. Because the survey was already distributed to many hospitalists in Michigan, we requested that only hospitalists outside of Michigan be invited to participate in the national survey. All responses were collected anonymously, and no identifiable data were collected from respondents. Between February 1, 2013 and March 15, 2013, data were collected via an e‐mail sent directly from the SHM to members that contained a link to the study survey administered using SurveyMonkey. To augment data collection, nonresponders to the original e‐mail invitation were sent a second reminder e‐mail midway through the study. Descriptive statistics (percentages) were used to tabulate responses. The institutional review board at the University of Michigan Health System provided ethical and regulatory approval for this study.
RESULTS
A total of 2112 electronic survey invitations were sent to non‐Michigan adult hospitalists, with 381 completing the online survey (response rate 18%). Among respondents to the national survey, 86% reported having placed a PICC solely to obtain venous access in a hospitalized patient (rather than for specific indications such as long‐term intravenous antibiotics, chemotherapy, or parenteral nutrition), whereas 82% reported having cared for a patient who specifically requested a PICC (Table 1). PICC‐related deep vein thrombosis (DVT) and bloodstream infections were reported as being the most frequent PICC complications encountered by hospitalists, followed by superficial thrombophlebitis and mechanical complications such as coiling, kinking, and migration of the PICC tip.
| Total (N=381) | |
|---|---|
| |
| Hospitalist experiences related to PICCs | |
| Among hospitalized patients you have cared for, have any of your patients ever had a PICC placed solely to obtain venous access (eg, not for an indication such as long‐term IV antibiotics, chemotherapy, or TPN)? | |
| Yes | 328 (86.1%) |
| No | 53 (13.9%) |
| Have you ever cared for a patient who specifically requested a PICC because of prior experience with this device? | |
| Yes | 311 (81.6%) |
| No | 70 (18.4%) |
| Most frequently encountered PICC complications | |
| Upper‐extremity DVT or PE | 48 (12.6%) |
| Bloodstream infection | 41 (10.8%) |
| Superficial thrombophlebitis | 34 (8.9%) |
| Cellulitis/exit site erythema | 26 (6.8%) |
| Coiling, kinking of the PICC | 14 (3.7%) |
| Migration of the PICC tip | 9 (2.4%) |
| Breakage of PICC (anywhere) | 6 (1.6%) |
| Hospitalist practice related to PICCs | |
| During patient rounds, do you routinely examine PICCs for external problems (eg, cracks, breaks, leaks, or redness at the insertion site)? | |
| Yes, daily | 97 (25.5%) |
| Yes, but only if the nurse or patient alerts me to a problem with the PICC | 190 (49.9%) |
| No, I don't routinely examine the PICC for external problems | 94 (24.7%) |
| Have you ever forgotten or been unaware of the presence of a PICC? | |
| Yes | 216 (56.7%) |
| No | 165 (43.3%) |
| Assuming no contraindications exist, do you anticoagulate patients who develop a PICC‐associated DVT? | |
| Yes, for at least 1 month | 41(10.8%) |
| Yes, for at least 3 months* | 198 (52.0%) |
| Yes, for at least 6 months | 11 (2.9%) |
| Yes, I anticoagulate for as long as the line remains in place. Once the line is removed, I stop anticoagulation | 30 (7.9%) |
| Yes, I anticoagulate for as long as the line remains in place followed by another 4 weeks of therapy | 72 (18.9%) |
| I don't usually anticoagulate patients who develop a PICC‐related DVT | 29 (7.6%) |
| When a hospitalized patient develops a PICC‐related DVT, do you routinely remove the PICC? | |
| Yes | 271 (71.1%) |
| No | 110 (28.9%) |
| Hospitalist opinions related to PICCs | |
| Thinking about your hospital and your experiences, what percentage of PICC insertions may represent inappropriate use (eg, PICC placed for short‐term venous access for a presumed infection that could be treated with oral antibiotic or PICCs that were promptly removed as the patient no longer needed it for clinical management)? | |
| <10% | 192 (50.4%) |
| 10%25% | 160 (42.0%) |
| 26%50% | 22 (5.8%) |
| >50% | 7 (1.8%) |
| Do you think hospitalists should be trained to insert PICCs? | |
| Yes | 162 (42.5%) |
| No | 219 (57.5%) |
| Hospitalist knowledge related to PICCs | |
| Why is the position of the PICC‐tip checked following bedside PICC insertion? | |
| To decrease the risk of arrhythmia from tip placement in the right atrial | 267 (70.1%) |
| To ensure it is not accidentally placed into an artery | 44 (11.5%) |
| To minimize the risk of venous thrombosis* | 33 (8.7%) |
| For documentation purposes (to reduce the risk of lawsuits related tocomplications) | 16 (4.2%) |
| I don't know | 21 (5.5%) |
Several potentially important safety concerns regarding hospitalist PICC practices were observed in this survey. For instance, only 25% of hospitalists reported examining PICCs on daily rounds for external problems. When alerted by nurses or patients about problems with the device, this number doubled to 50%. In addition, 57% of respondents admitted to having at least once forgotten about the presence of a PICC in their hospitalized patient.
Participants also reported significant variation in duration of anticoagulation therapy for PICC‐related DVT, with only half of all respondents selecting the guideline‐recommended 3 months of anticoagulation.[4, 5] With respect to knowledge regarding PICCs, only 9% of respondents recognized that tip verification performed after PICC insertion was conducted to lower risk of venous thromboembolism, not that of arrhythmia.[6] Hospitalists were ambivalent about being trained on how to place PICCs, with only 43% indicating this skill was necessary. Finally, as many as 10% to 25% of PICCs inserted in their hospitals were felt to be inappropriately placed and/or avoidable by 42% of those surveyed.
DISCUSSION
As the use of PICCs rises in hospitalized patients, variability in practices associated with the use of these indwelling vascular catheters is being increasingly recognized. For instance, Tejedor and colleagues reported that PICCs placed in hospitalized patients at their academic medical center were often idle or inserted in patients who simultaneously have peripheral intravenous catheters.[7] Recent data from a tertiary care pediatric center found significantly greater PICC utilization rates over the past decade in association with shorter dwell times, suggesting important and dynamic changes in patterns of use of these devices.[2] Our prior survey of hospitalists in 10 Michigan hospitals also found variations in reported hospitalist practices, knowledge, and experiences related to PICCs.[3] However, the extent to which the Michigan experience portrayed a national trend remained unclear and was the impetus behind this survey. Results from this study appear to support findings from Michigan and highlight several potential opportunities to improve hospitalist PICC practices on a national scale.
In particular, 57% of respondents in this study (compared to 51% of Michigan hospitalists) stated they had at least once forgotten that their patient had a PICC. As early removal of PICCs that are clinically no longer necessary is a cornerstone to preventing thrombosis and infection,[4, 5, 6, 8] the potential impact of such forgetfulness on clinical outcomes and patient safety is of concern. Notably, PICC‐related DVT and bloodstream infection remained the 2 most commonly encountered complications in this survey, just as in the Michigan study.
Reported variations in treatment duration for PICC‐related DVT were also common in this study, with only half of all respondents in both surveys selecting the guideline‐recommended minimum of 3 months of anticoagulation. Finally, a substantial proportion (42%) of participants felt that 10% to 25% of PICCs placed in their hospitals might be inappropriately placed and avoidable, again echoing the sentiments of 51% of the participants in the Michigan survey. These findings strengthen the call to develop a research agenda focused on PICC use in hospitalized patients across the United States.
Why may hospitalists across the country demonstrate such variability when it comes to these indwelling vascular devices? PICCs have historically been viewed as safer with respect to complications such as infection and thrombosis than other central venous catheters, a viewpoint that has likely promulgated their use in the inpatient setting. However, as we and others have shown,[8, 9, 10, 11, 12] this notion is rapidly vanishing and being replaced by the recognition that severity of illness and patient comorbidities are more important determinants of complications than the device itself. Additionally, important knowledge gaps exist when it comes to the safe use of PICCs in hospitalized patients, contributing to variation in indications for insertion, removal, and treatment of complications related to these devices.
Our study is notably limited by a low response rate. Because the survey was administered directly by SHM without collection of respondent data (eg, practice location, years in practice), we are unable to adjust or weight these data to represent a national cohort of adult hospitalists. However, as responses to questions are consistent with our findings from Michigan, and the response rates of this survey are comparable to observed response rates from prior SHM‐administered nationwide surveys (10%40%),[13, 14, 15] we do not believe our findings necessarily represent systematic deviations from the truth and assumed that these responses were missing at random. In addition, owing to use of a survey‐based design, our study is inherently limited by a number of biases, including the use of a convenience sample of SHM members, nonresponse bias, and recall bias. Given these limitations, the association between the available responses and real‐world clinical practice is unclear and deserving of further investigation.
These limitations notwithstanding, our study has several strengths. We found important national variations in reported practices and knowledge related to PICCs, affirming the need to develop a research agenda to improve practice. Further, because a significant proportion of hospitalists may forget their patients have PICCs, our study supports the role of technologies such as catheter reminder systems, computerized decision aids, and automatic stop orders to improve PICC use. These technologies, if utilized in a workflow‐sensitive fashion, could improve PICC safety in hospitalized settings and merit exploration. In addition, our study highlights the growing need for criteria to guide the use of PICCs in hospital settings. Although the Infusion Nursing Society of America has published indications and guidelines for use of vascular devices,[6] these do not always incorporate clinical nuances such as necessity of intravenous therapy or duration of treatment in decision making. The development of evidence‐based appropriateness criteria to guide clinical decision making is thus critical to improving use of PICCs in inpatient settings.[16]
With growing recognition of PICC‐related complications in hospitalized patients, an urgent need to improve practice related to these devices exists. This study begins to define the scope of such work across the United States. Until more rigorous evidence becomes available to guide clinical practice, hospitals and hospitalists should begin to carefully monitor PICC use to safeguard and improve patient safety.
Disclosures
The Blue Cross/Blue Shield of Michigan Foundation funded this study through an investigator‐initiated research proposal (1931‐PIRAP to Dr. Chopra). The funding source played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.
- , . Peripherally inserted central catheter: compliance with evidence‐based indications for insertion in an inpatient setting. J Infus Nurs. 2013;36(4):291–296.
- , , , , , . Peripherally inserted central catheters: use at a tertiary care pediatric center. J Vasc Interv Radiol. 2013;24(9):1323–1331.
- , , , et al. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey. J Hosp Med. 2013;8(6):309–314.
- , , , et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence‐based clinical practice guidelines. Chest. 2012;141(2 suppl):7S–47S.
- , , , et al. Quality improvement guidelines for central venous access. J Vasc Interv Radiol. 2010;21(7):976–981.
- , , , et al. Infusion nursing standards of practice. J Infus Nurs. 2011;34(1S):1–115.
- , , , et al. Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the “idle central venous catheter”. Infect Control Hosp Epidemiol. 2012;33(1):50–57.
- , , , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. Lancet. 2013;382(9889):311–325.
- , , , , . Risk factors for peripherally inserted central venous catheter complications in children. JAMA Pediatr. 2013;167(5):429–435.
- , , , et al. Patient‐ and device‐specific risk factors for peripherally inserted central venous catheter‐related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
- , , , , . The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta‐analysis. Infect Control Hosp Epidemiol. 2013;34(9):908–918.
- , . Risk of catheter‐related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–495.
- , , , , ; Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. J Hosp Med. 2012;7(5):402–410.
- , . Clinical hospital medicine fellowships: perspectives of employers, hospitalists, and medicine residents. J Hosp Med. 2008;3(1):28–34.
- , , , . Survey of US academic hospitalist leaders about mentorship and academic activities in hospitalist groups. J Hosp Med. 2011;6(1):5–9.
- , , . The problem with peripherally inserted central catheters. JAMA. 2012;308(15):1527–1528.
- , . Peripherally inserted central catheter: compliance with evidence‐based indications for insertion in an inpatient setting. J Infus Nurs. 2013;36(4):291–296.
- , , , , , . Peripherally inserted central catheters: use at a tertiary care pediatric center. J Vasc Interv Radiol. 2013;24(9):1323–1331.
- , , , et al. Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey. J Hosp Med. 2013;8(6):309–314.
- , , , et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence‐based clinical practice guidelines. Chest. 2012;141(2 suppl):7S–47S.
- , , , et al. Quality improvement guidelines for central venous access. J Vasc Interv Radiol. 2010;21(7):976–981.
- , , , et al. Infusion nursing standards of practice. J Infus Nurs. 2011;34(1S):1–115.
- , , , et al. Temporary central venous catheter utilization patterns in a large tertiary care center: tracking the “idle central venous catheter”. Infect Control Hosp Epidemiol. 2012;33(1):50–57.
- , , , et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta‐analysis. Lancet. 2013;382(9889):311–325.
- , , , , . Risk factors for peripherally inserted central venous catheter complications in children. JAMA Pediatr. 2013;167(5):429–435.
- , , , et al. Patient‐ and device‐specific risk factors for peripherally inserted central venous catheter‐related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
- , , , , . The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta‐analysis. Infect Control Hosp Epidemiol. 2013;34(9):908–918.
- , . Risk of catheter‐related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–495.
- , , , , ; Society of Hospital Medicine Career Satisfaction Task Force. Job characteristics, satisfaction, and burnout across hospitalist practice models. J Hosp Med. 2012;7(5):402–410.
- , . Clinical hospital medicine fellowships: perspectives of employers, hospitalists, and medicine residents. J Hosp Med. 2008;3(1):28–34.
- , , , . Survey of US academic hospitalist leaders about mentorship and academic activities in hospitalist groups. J Hosp Med. 2011;6(1):5–9.
- , , . The problem with peripherally inserted central catheters. JAMA. 2012;308(15):1527–1528.
Dear Doctor: A Patient‐Centered Tool
In their seminal report Crossing the Quality Chasm, the Institute of Medicine outlined patient‐centered care as 1 of its 6 aims to improve the healthcare delivery system.[1] Patients who are more involved in their diagnosis and treatment plan are more likely to feel respected, be satisfied with their healthcare experience, and ultimately have better outcomes.[2, 3] In a study of hospitalized patients, only 42% were able to state their diagnosis at the time of discharge, suggesting that hospital providers could communicate better with patients about their hospital care.[4] Additionally, only 28% of hospitalized patients were able to list their medications, and only 37% were able to state the purpose of their medications. Although hospitals have taken great strides to improve the quality of patient care, publicly reported patient care surveys, such as the Hospital Consumer Assessment of Hospitals and Health Systems (HCAHPS), suggest that physician communication with patients could be further improved.[1, 5] Furthermore, a recent report by the Institute of Medicine stresses the need to get patients and families involved in their care.[6] Thus, hospital‐based providers should seek to enhance the quality of their communication with patients.
With greater emphasis placed on patient‐ and family‐centered care at many health systems, simple and easy‐to‐implement strategies to improve communication with patients need to be developed and tested.[7, 8] Patients who actively participate in their healthcare by asking questions of their doctor are able to control the focus of their interaction and adjust the amount of information provided.[9] Simply asking questions can have a critical impact, as 1 study found that the frequency with which patients asked questions was significantly related to the amount of information received about general and specific medical matters.[10] The notepad is a common tool for reminders and personal interactions that is used in everyday life, but has not been formalized in the hospital. We introduced Dear Doctor (DD) notes, a bedside notepad designed to prompt patient questions, with the goal of facilitating patient communication with their hospitalist physicians (Figure 1). As hospitalists provide direct and indirect care to a growing number of hospitalized patients, they are likely to be asked questions and opinions about the patients' diagnoses and plans. Furthermore, hospitalists are poised to lead institutional quality, safety, efficiency, and service improvement efforts in the inpatient setting. Becoming familiar with communication‐enhancing tools, such as the DD notes, may help hospitalists in their improvement team roles.
METHODS
Setting
We conducted a study between July 2009 and September 2009 on inpatient medical wards at a large academic medical center with 610 beds and over 44,000 annual discharges.[11] The internal medicine services served by attending physicians and residents comprise a large proportion of hospitalized patients, accounting for over 17,000 discharges per year. Each medical unit includes 32 beds.
Population
Patients over the age of 18 years admitted to a general medicine or cardiology unit and who were able to verbally communicate in English were eligible to be surveyed in the study. Patients with a length of stay <24 hours were excluded. A total of 664 patients were surveyed for inclusion in the study, 440 patients in the intervention group and 224 patients in the control group.
Intervention
The DD notepad included sample questions and informational prompts derived with input from a community focus group. The community focus group consisted of current and formerly hospitalized patients and family members who were asked by members of the study group what they thought would be important to include on a notepad provided to patients. From their answers the study team developed the DD notepad prototype. The DD notepad included 3 general categories of questions: (1) diagnosis and treatment, (2) tests and procedures, and (3) medications. To address other miscellaneous topics such as discharge and posthospital care needs, a section was designated for the patient to check off as I have a few more questions (Use the back of the sheet).
All patients admitted to the study units were intended to receive the DD notepad and pen, which were placed on the bedside table during the room change by our custodial staff. Patients who did not receive DD notepads in the intervention group during their first hospitalization day were provided with 1 by the clinical assistants working with the hospitalists. These patients did not initially receive the notepad due to logistical reasons from temporary rotating staff who were not instructed to provide the notepads. Patients were not formally prompted to use the notepad. Hospitalists, residents, and nurses on the study units were informed about the distribution of DD notes to patients on these units; however, they were not provided with any specific instructions on how they should incorporate the DD notes into their interactions with their patients. The use of the DD notepad was left to each healthcare professional's own discretion.
Members of the study team surveyed patients who had been in the hospital for a minimum of 24 hours in the intervention and control groups twice weekly. All responses were deidentified of any personal or health information. Patients were asked to rate on a scale from 1 to 5 their use of the DD notepads, their perceived value, the circumstances in which the notepads were used, and their level of satisfaction with how their physicians communicated and answered their questions (1 = no improvement, 5 = significant improvement). For control patients, questions pertaining to DD notepads were not applicable and were therefore excluded.
Statistical Analysis
The data were analyzed in an intention‐to‐treat analysis of all 440 patients in the intervention group. Intervention and control groups were compared using 2, rank sum, and Fisher exact statistical tests, with significance assigned as P < 0.05, using SPSS software version 17.0 (SPSS, Inc., Chicago, IL). Our project was approved by the University of Michigan's institutional review board.
RESULTS
Of the 440 patients surveyed in the intervention group (1 general medicine and 1 cardiology unit), 343 (78%) received the notepads in their rooms and 207 (47%) used them (Figure 2). Not every patient in the intervention group received DD notepads due to inconsistent placement of DD notepads upon every room turnover. Of the patients admitted to the control group (1 general medicine and 1 cardiology unit), 224 were surveyed. Fifty‐four percent of the 440 patients in the intervention group reported that they took notes related to their hospital care, compared to only 22% of the 224 patients in the control group (P < 0.001). Of the patients who took notes within the intervention group (n = 207), 91% of them utilized the DD notepads.
Patients in the intervention group who received and used the DD notes (n = 207) compared to patients in the control group (n = 224) were more likely to report that their questions were answered by their physicians (4.63 vs 4.45, P < 0.001). In an intention‐to‐treat analysis of all 440 patients in the intervention group, the overall satisfaction with physician communication was not significantly different between the intervention and control groups as measured on a 5‐point Likert scale (4.55 vs 4.55, P = 0.89). However, 89% of the patients in the intervention group who used the notepads felt that DD notepads either moderately or significantly improved their communication with their providers (Figure 3).
When the 207 patients who received DD notepads were asked how they used this tool, 99% of these patients used DD to write down questions, 82% to keep track of tests and procedures, and 54% indicated that their family and friends also used the notepads during the hospital stay (Table 1). Among these patients who utilized the DD notepads, 93% reported that they would use them again in the future.
| Wrote Notes? (P < 0.001) (%) | Used DD? (%) | Use in Future? (%) | Frequency of Questions Answered (P < 0.001) | DD Improved Communication | Satisfied With Communication? (P = 0.89) | |
|---|---|---|---|---|---|---|
| ||||||
| Intervention (n = 440) | 54 | 91 | 93.2 | 4.63 | 3.76 | 4.55 |
| Control (n = 224) | 22 | 4.45 | 4.55 | |||
Of the 97 patients in the intervention group who did not receive a DD notepad, we asked if they would use the DD notepad if they were made aware of such a tool. Of these patients, 77% agreed that they would use DD notes if they were made available in the future, 100% of them said that they would use DD to write down questions, 97% indicated that they would write notes about tests and procedures, and 88% of them believed that their families and friends would use DD notes.
DISCUSSION
As hospitals place greater emphasis and value on patient‐centered care as part of their clinical mission, it is important to develop tools to help facilitate the doctor‐patient relationship. We found that patients who were provided the Dear Doctor notepad were more satisfied that their doctors answered their questions and felt this tool enhanced their ability to communicate with their physicians. Employing the use of a familiar tool such as the notepad to remind patients about specific issues in their interactions with their providers can be a powerful intervention. Our study demonstrated that the DD notepad was widely accepted by patients, and that almost all of them would use this tool if it were made available to them in the future.
Other tools and methods to enhance the quality of communication between patients and their healthcare providers have included using whiteboards in the patients' rooms to relay the care plan to the patients, implementing bedside rounds by the healthcare team, and multidisciplinary huddling to coordinate information to the patient.[12, 13] Studies of these communication tools have shown potential to improve teamwork, interaction, and patient care. All of these have their own merit and value, and our DD notepad should be considered an adjunct to existing methods to enhance the patient care experience. A bedside tool that is familiar in form to most patients also needs to have the feature of easy access and use. Once this barrier has been removed for the patient and their family members, tools such as the DD notepad can impact the patient‐centeredness by fostering increased and better quality dialogue between the patients, their family members, and healthcare providers.
The DD notepad represents a means of communication that may have the potential to empower patients. It is possible that through question prompts, the DD notepad stimulates the patient to be an active partner with his or her healthcare team. This may enable patients to have some sense of control and accountability of their care in a setting where they would otherwise feel overwhelmed or powerless. The 3 general categories to help patients write down their questions included diagnosis, treatment plan, and medications. In the inpatient setting, where patient‐care activities can be fast paced, and patients are unable to recall some details when speaking to the healthcare team, these notes may remind the patient to write their thoughts down so that they may be remembered for a future time. In situations where patients may not know which questions to ask, the question prompts may be particularly helpful. We did not assess whether our particular question prompts were the key elements that resulted in their perceived value, or whether simply placing a blank notepad at the bedside would also have been successful. However, the specific questions were suggested by the focus groups. Enhanced communication, focusing on the patients' understanding of their condition, and the need to pursue certain diagnostic or therapeutic interventions, may help patients to be better prepared for the next course of plan. These topics of reasons for hospitalization, treatment plan, and medication changes are also important for patients to be active participants in their care, in particular as they transition from 1 site of care to the next, and their healthcare will be delivered by different providers.
There are several limitations to our study. First, this intervention was performed at a single hospital site with only 2 clinical services (general medicine, cardiology) represented in the study groups. Although we do not have any causal reasons to believe this tool would be looked upon differently by patients on other clinical services, it is possible that patients on a different clinical unit or service may view this tool as less or more useful. Second, as the patients were not randomized to intervention, but rather based on the units to which they were admitted, it is possible that other variables, such as the experience of the unit staff, the patient's condition, and housestaff‐based service versus hospitalist‐based service may have played a role in how the patients perceived the use of DD notes. Third, patients were only surveyed if they were able to verbally communicate in English. These notes may not be as useful in hospital settings to populations with language or literacy barriers. Fourth, the logistical implementation of DD notes limited our ability to deliver the DD notepads in every patient's rooms, where only 78% of the intervention group received the DD notepads. This may be the reason that we did not find that overall satisfaction with physician communication differed between intervention and control groups. Nonetheless, we performed an intention‐to‐treat analysis to minimize any biases in our analysis. Last, although our survey of patients asked about their satisfaction in using the DD note pads, we did not compare these results with those of Press‐Ganey or HCAHPS scores of patients on the intervention group versus the control group. Additionally, lack of data about type, quality, and quantity of questions asked by a control group to see if the notepads actually improved quality of questions asked is a limitation; however, we believe our outcomes of interest were most specifically evaluated through our survey questions.
DD notes show that the majority of patients who use this tool feel a modest to significant improvement in communication with their providers. Although the quality of medical care is undoubtedly the first priority, the patients' view of their care, which includes communication, is arguably just as important. An often‐forgotten goal of hospitals and clinics is to provide service excellence along with high‐quality care. Thus, it is imperative for hospitals and their care providers to not only focus on the quality and safety of the clinical care, but also be mindful of the patient's entire experience throughout their hospital stay. Many of the categories of questions asked in the HCAHPS address the patient's experience and perspectives of hospital care. Furthermore, the role of the HCAHPS survey in the Value‐Based Purchasing rules may enhance the importance of these notepads. As the results of HCAHPS are becoming more transparent and available to the public, the impact of such results will have a greater significance to the future of the hospital's clinical mission.
CONCLUSION
DD notepads are a simple, low‐cost, patient‐centered tool that can be an effective reminder for patients to ask their healthcare providers questions related to their hospital care. Utilizing a common tool such as the notepad, redesigned for the healthcare setting, can serve to help healthcare providers interact with their patients. Patient satisfaction may be higher in patients who use the DD notepad.
Disclosures: Aaron S. Farberg, MD, and Andrew M. Lin, MD, contributed equally in every way and should be considered co‐first authors. This work was supported by a University of Michigan Fostering Innovations Grant. The authors have no conflicting financial interests.
- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
- , , , . An evidence base for patient‐centered cancer care: a meta‐analysis of studies of observed communication between cancer specialists and their patients. Patient Educ Couns. 2009;77(3):379–383.
- . Effective physician‐patient communication and health outcomes: a review. Can Med Assoc J. 1995;152:1423–1433.
- , . Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8):991–994.
- , , , . Patients' perception of hospital care in the United States. N Engl J Med. 2008;359:1921–1931.
- Institute of Medicine of the National Academies.Best care at lower cost: the path to continuously learning health care in America. Available at: http://www.iom.edu/Reports/2012/Best‐Care‐at‐Lower‐Cost‐The‐Path‐to‐Continuously‐Learning‐Health‐Care‐in‐America.aspx. Accessed October 5, 2012.
- , . An introduction to technology for patient‐centered collaborative care. J Ambul Care Manage. 2006;29:195–198.
- , , , , , . Effect on health‐related outcome of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med. 2004;2(6):595–608
- , , , , . Characteristics of physicians with participatory decision‐making styles. Ann Intern Med. 1996;124(5):497–504.
- . Information‐giving consultations: the influence of patients' communicative styles and personal characteristics. Soc Sci Med. 1991:32(5):541–548.
- University of Michigan Health System.Patient care and University of Michigan Health System. Available at: http://www.uofmhealth.org/about%2Bumhs/about‐clinical‐care. Accessed August 31, 2012.
- , , , et al. It's the writing on the wall: whiteboards improve inpatient satisfaction with provider communication. Am J Med Qual. 2011;26(2):127–131
- , , , , . Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. J Hosp Med. 2010;5(4):234–239.
In their seminal report Crossing the Quality Chasm, the Institute of Medicine outlined patient‐centered care as 1 of its 6 aims to improve the healthcare delivery system.[1] Patients who are more involved in their diagnosis and treatment plan are more likely to feel respected, be satisfied with their healthcare experience, and ultimately have better outcomes.[2, 3] In a study of hospitalized patients, only 42% were able to state their diagnosis at the time of discharge, suggesting that hospital providers could communicate better with patients about their hospital care.[4] Additionally, only 28% of hospitalized patients were able to list their medications, and only 37% were able to state the purpose of their medications. Although hospitals have taken great strides to improve the quality of patient care, publicly reported patient care surveys, such as the Hospital Consumer Assessment of Hospitals and Health Systems (HCAHPS), suggest that physician communication with patients could be further improved.[1, 5] Furthermore, a recent report by the Institute of Medicine stresses the need to get patients and families involved in their care.[6] Thus, hospital‐based providers should seek to enhance the quality of their communication with patients.
With greater emphasis placed on patient‐ and family‐centered care at many health systems, simple and easy‐to‐implement strategies to improve communication with patients need to be developed and tested.[7, 8] Patients who actively participate in their healthcare by asking questions of their doctor are able to control the focus of their interaction and adjust the amount of information provided.[9] Simply asking questions can have a critical impact, as 1 study found that the frequency with which patients asked questions was significantly related to the amount of information received about general and specific medical matters.[10] The notepad is a common tool for reminders and personal interactions that is used in everyday life, but has not been formalized in the hospital. We introduced Dear Doctor (DD) notes, a bedside notepad designed to prompt patient questions, with the goal of facilitating patient communication with their hospitalist physicians (Figure 1). As hospitalists provide direct and indirect care to a growing number of hospitalized patients, they are likely to be asked questions and opinions about the patients' diagnoses and plans. Furthermore, hospitalists are poised to lead institutional quality, safety, efficiency, and service improvement efforts in the inpatient setting. Becoming familiar with communication‐enhancing tools, such as the DD notes, may help hospitalists in their improvement team roles.
METHODS
Setting
We conducted a study between July 2009 and September 2009 on inpatient medical wards at a large academic medical center with 610 beds and over 44,000 annual discharges.[11] The internal medicine services served by attending physicians and residents comprise a large proportion of hospitalized patients, accounting for over 17,000 discharges per year. Each medical unit includes 32 beds.
Population
Patients over the age of 18 years admitted to a general medicine or cardiology unit and who were able to verbally communicate in English were eligible to be surveyed in the study. Patients with a length of stay <24 hours were excluded. A total of 664 patients were surveyed for inclusion in the study, 440 patients in the intervention group and 224 patients in the control group.
Intervention
The DD notepad included sample questions and informational prompts derived with input from a community focus group. The community focus group consisted of current and formerly hospitalized patients and family members who were asked by members of the study group what they thought would be important to include on a notepad provided to patients. From their answers the study team developed the DD notepad prototype. The DD notepad included 3 general categories of questions: (1) diagnosis and treatment, (2) tests and procedures, and (3) medications. To address other miscellaneous topics such as discharge and posthospital care needs, a section was designated for the patient to check off as I have a few more questions (Use the back of the sheet).
All patients admitted to the study units were intended to receive the DD notepad and pen, which were placed on the bedside table during the room change by our custodial staff. Patients who did not receive DD notepads in the intervention group during their first hospitalization day were provided with 1 by the clinical assistants working with the hospitalists. These patients did not initially receive the notepad due to logistical reasons from temporary rotating staff who were not instructed to provide the notepads. Patients were not formally prompted to use the notepad. Hospitalists, residents, and nurses on the study units were informed about the distribution of DD notes to patients on these units; however, they were not provided with any specific instructions on how they should incorporate the DD notes into their interactions with their patients. The use of the DD notepad was left to each healthcare professional's own discretion.
Members of the study team surveyed patients who had been in the hospital for a minimum of 24 hours in the intervention and control groups twice weekly. All responses were deidentified of any personal or health information. Patients were asked to rate on a scale from 1 to 5 their use of the DD notepads, their perceived value, the circumstances in which the notepads were used, and their level of satisfaction with how their physicians communicated and answered their questions (1 = no improvement, 5 = significant improvement). For control patients, questions pertaining to DD notepads were not applicable and were therefore excluded.
Statistical Analysis
The data were analyzed in an intention‐to‐treat analysis of all 440 patients in the intervention group. Intervention and control groups were compared using 2, rank sum, and Fisher exact statistical tests, with significance assigned as P < 0.05, using SPSS software version 17.0 (SPSS, Inc., Chicago, IL). Our project was approved by the University of Michigan's institutional review board.
RESULTS
Of the 440 patients surveyed in the intervention group (1 general medicine and 1 cardiology unit), 343 (78%) received the notepads in their rooms and 207 (47%) used them (Figure 2). Not every patient in the intervention group received DD notepads due to inconsistent placement of DD notepads upon every room turnover. Of the patients admitted to the control group (1 general medicine and 1 cardiology unit), 224 were surveyed. Fifty‐four percent of the 440 patients in the intervention group reported that they took notes related to their hospital care, compared to only 22% of the 224 patients in the control group (P < 0.001). Of the patients who took notes within the intervention group (n = 207), 91% of them utilized the DD notepads.
Patients in the intervention group who received and used the DD notes (n = 207) compared to patients in the control group (n = 224) were more likely to report that their questions were answered by their physicians (4.63 vs 4.45, P < 0.001). In an intention‐to‐treat analysis of all 440 patients in the intervention group, the overall satisfaction with physician communication was not significantly different between the intervention and control groups as measured on a 5‐point Likert scale (4.55 vs 4.55, P = 0.89). However, 89% of the patients in the intervention group who used the notepads felt that DD notepads either moderately or significantly improved their communication with their providers (Figure 3).
When the 207 patients who received DD notepads were asked how they used this tool, 99% of these patients used DD to write down questions, 82% to keep track of tests and procedures, and 54% indicated that their family and friends also used the notepads during the hospital stay (Table 1). Among these patients who utilized the DD notepads, 93% reported that they would use them again in the future.
| Wrote Notes? (P < 0.001) (%) | Used DD? (%) | Use in Future? (%) | Frequency of Questions Answered (P < 0.001) | DD Improved Communication | Satisfied With Communication? (P = 0.89) | |
|---|---|---|---|---|---|---|
| ||||||
| Intervention (n = 440) | 54 | 91 | 93.2 | 4.63 | 3.76 | 4.55 |
| Control (n = 224) | 22 | 4.45 | 4.55 | |||
Of the 97 patients in the intervention group who did not receive a DD notepad, we asked if they would use the DD notepad if they were made aware of such a tool. Of these patients, 77% agreed that they would use DD notes if they were made available in the future, 100% of them said that they would use DD to write down questions, 97% indicated that they would write notes about tests and procedures, and 88% of them believed that their families and friends would use DD notes.
DISCUSSION
As hospitals place greater emphasis and value on patient‐centered care as part of their clinical mission, it is important to develop tools to help facilitate the doctor‐patient relationship. We found that patients who were provided the Dear Doctor notepad were more satisfied that their doctors answered their questions and felt this tool enhanced their ability to communicate with their physicians. Employing the use of a familiar tool such as the notepad to remind patients about specific issues in their interactions with their providers can be a powerful intervention. Our study demonstrated that the DD notepad was widely accepted by patients, and that almost all of them would use this tool if it were made available to them in the future.
Other tools and methods to enhance the quality of communication between patients and their healthcare providers have included using whiteboards in the patients' rooms to relay the care plan to the patients, implementing bedside rounds by the healthcare team, and multidisciplinary huddling to coordinate information to the patient.[12, 13] Studies of these communication tools have shown potential to improve teamwork, interaction, and patient care. All of these have their own merit and value, and our DD notepad should be considered an adjunct to existing methods to enhance the patient care experience. A bedside tool that is familiar in form to most patients also needs to have the feature of easy access and use. Once this barrier has been removed for the patient and their family members, tools such as the DD notepad can impact the patient‐centeredness by fostering increased and better quality dialogue between the patients, their family members, and healthcare providers.
The DD notepad represents a means of communication that may have the potential to empower patients. It is possible that through question prompts, the DD notepad stimulates the patient to be an active partner with his or her healthcare team. This may enable patients to have some sense of control and accountability of their care in a setting where they would otherwise feel overwhelmed or powerless. The 3 general categories to help patients write down their questions included diagnosis, treatment plan, and medications. In the inpatient setting, where patient‐care activities can be fast paced, and patients are unable to recall some details when speaking to the healthcare team, these notes may remind the patient to write their thoughts down so that they may be remembered for a future time. In situations where patients may not know which questions to ask, the question prompts may be particularly helpful. We did not assess whether our particular question prompts were the key elements that resulted in their perceived value, or whether simply placing a blank notepad at the bedside would also have been successful. However, the specific questions were suggested by the focus groups. Enhanced communication, focusing on the patients' understanding of their condition, and the need to pursue certain diagnostic or therapeutic interventions, may help patients to be better prepared for the next course of plan. These topics of reasons for hospitalization, treatment plan, and medication changes are also important for patients to be active participants in their care, in particular as they transition from 1 site of care to the next, and their healthcare will be delivered by different providers.
There are several limitations to our study. First, this intervention was performed at a single hospital site with only 2 clinical services (general medicine, cardiology) represented in the study groups. Although we do not have any causal reasons to believe this tool would be looked upon differently by patients on other clinical services, it is possible that patients on a different clinical unit or service may view this tool as less or more useful. Second, as the patients were not randomized to intervention, but rather based on the units to which they were admitted, it is possible that other variables, such as the experience of the unit staff, the patient's condition, and housestaff‐based service versus hospitalist‐based service may have played a role in how the patients perceived the use of DD notes. Third, patients were only surveyed if they were able to verbally communicate in English. These notes may not be as useful in hospital settings to populations with language or literacy barriers. Fourth, the logistical implementation of DD notes limited our ability to deliver the DD notepads in every patient's rooms, where only 78% of the intervention group received the DD notepads. This may be the reason that we did not find that overall satisfaction with physician communication differed between intervention and control groups. Nonetheless, we performed an intention‐to‐treat analysis to minimize any biases in our analysis. Last, although our survey of patients asked about their satisfaction in using the DD note pads, we did not compare these results with those of Press‐Ganey or HCAHPS scores of patients on the intervention group versus the control group. Additionally, lack of data about type, quality, and quantity of questions asked by a control group to see if the notepads actually improved quality of questions asked is a limitation; however, we believe our outcomes of interest were most specifically evaluated through our survey questions.
DD notes show that the majority of patients who use this tool feel a modest to significant improvement in communication with their providers. Although the quality of medical care is undoubtedly the first priority, the patients' view of their care, which includes communication, is arguably just as important. An often‐forgotten goal of hospitals and clinics is to provide service excellence along with high‐quality care. Thus, it is imperative for hospitals and their care providers to not only focus on the quality and safety of the clinical care, but also be mindful of the patient's entire experience throughout their hospital stay. Many of the categories of questions asked in the HCAHPS address the patient's experience and perspectives of hospital care. Furthermore, the role of the HCAHPS survey in the Value‐Based Purchasing rules may enhance the importance of these notepads. As the results of HCAHPS are becoming more transparent and available to the public, the impact of such results will have a greater significance to the future of the hospital's clinical mission.
CONCLUSION
DD notepads are a simple, low‐cost, patient‐centered tool that can be an effective reminder for patients to ask their healthcare providers questions related to their hospital care. Utilizing a common tool such as the notepad, redesigned for the healthcare setting, can serve to help healthcare providers interact with their patients. Patient satisfaction may be higher in patients who use the DD notepad.
Disclosures: Aaron S. Farberg, MD, and Andrew M. Lin, MD, contributed equally in every way and should be considered co‐first authors. This work was supported by a University of Michigan Fostering Innovations Grant. The authors have no conflicting financial interests.
In their seminal report Crossing the Quality Chasm, the Institute of Medicine outlined patient‐centered care as 1 of its 6 aims to improve the healthcare delivery system.[1] Patients who are more involved in their diagnosis and treatment plan are more likely to feel respected, be satisfied with their healthcare experience, and ultimately have better outcomes.[2, 3] In a study of hospitalized patients, only 42% were able to state their diagnosis at the time of discharge, suggesting that hospital providers could communicate better with patients about their hospital care.[4] Additionally, only 28% of hospitalized patients were able to list their medications, and only 37% were able to state the purpose of their medications. Although hospitals have taken great strides to improve the quality of patient care, publicly reported patient care surveys, such as the Hospital Consumer Assessment of Hospitals and Health Systems (HCAHPS), suggest that physician communication with patients could be further improved.[1, 5] Furthermore, a recent report by the Institute of Medicine stresses the need to get patients and families involved in their care.[6] Thus, hospital‐based providers should seek to enhance the quality of their communication with patients.
With greater emphasis placed on patient‐ and family‐centered care at many health systems, simple and easy‐to‐implement strategies to improve communication with patients need to be developed and tested.[7, 8] Patients who actively participate in their healthcare by asking questions of their doctor are able to control the focus of their interaction and adjust the amount of information provided.[9] Simply asking questions can have a critical impact, as 1 study found that the frequency with which patients asked questions was significantly related to the amount of information received about general and specific medical matters.[10] The notepad is a common tool for reminders and personal interactions that is used in everyday life, but has not been formalized in the hospital. We introduced Dear Doctor (DD) notes, a bedside notepad designed to prompt patient questions, with the goal of facilitating patient communication with their hospitalist physicians (Figure 1). As hospitalists provide direct and indirect care to a growing number of hospitalized patients, they are likely to be asked questions and opinions about the patients' diagnoses and plans. Furthermore, hospitalists are poised to lead institutional quality, safety, efficiency, and service improvement efforts in the inpatient setting. Becoming familiar with communication‐enhancing tools, such as the DD notes, may help hospitalists in their improvement team roles.
METHODS
Setting
We conducted a study between July 2009 and September 2009 on inpatient medical wards at a large academic medical center with 610 beds and over 44,000 annual discharges.[11] The internal medicine services served by attending physicians and residents comprise a large proportion of hospitalized patients, accounting for over 17,000 discharges per year. Each medical unit includes 32 beds.
Population
Patients over the age of 18 years admitted to a general medicine or cardiology unit and who were able to verbally communicate in English were eligible to be surveyed in the study. Patients with a length of stay <24 hours were excluded. A total of 664 patients were surveyed for inclusion in the study, 440 patients in the intervention group and 224 patients in the control group.
Intervention
The DD notepad included sample questions and informational prompts derived with input from a community focus group. The community focus group consisted of current and formerly hospitalized patients and family members who were asked by members of the study group what they thought would be important to include on a notepad provided to patients. From their answers the study team developed the DD notepad prototype. The DD notepad included 3 general categories of questions: (1) diagnosis and treatment, (2) tests and procedures, and (3) medications. To address other miscellaneous topics such as discharge and posthospital care needs, a section was designated for the patient to check off as I have a few more questions (Use the back of the sheet).
All patients admitted to the study units were intended to receive the DD notepad and pen, which were placed on the bedside table during the room change by our custodial staff. Patients who did not receive DD notepads in the intervention group during their first hospitalization day were provided with 1 by the clinical assistants working with the hospitalists. These patients did not initially receive the notepad due to logistical reasons from temporary rotating staff who were not instructed to provide the notepads. Patients were not formally prompted to use the notepad. Hospitalists, residents, and nurses on the study units were informed about the distribution of DD notes to patients on these units; however, they were not provided with any specific instructions on how they should incorporate the DD notes into their interactions with their patients. The use of the DD notepad was left to each healthcare professional's own discretion.
Members of the study team surveyed patients who had been in the hospital for a minimum of 24 hours in the intervention and control groups twice weekly. All responses were deidentified of any personal or health information. Patients were asked to rate on a scale from 1 to 5 their use of the DD notepads, their perceived value, the circumstances in which the notepads were used, and their level of satisfaction with how their physicians communicated and answered their questions (1 = no improvement, 5 = significant improvement). For control patients, questions pertaining to DD notepads were not applicable and were therefore excluded.
Statistical Analysis
The data were analyzed in an intention‐to‐treat analysis of all 440 patients in the intervention group. Intervention and control groups were compared using 2, rank sum, and Fisher exact statistical tests, with significance assigned as P < 0.05, using SPSS software version 17.0 (SPSS, Inc., Chicago, IL). Our project was approved by the University of Michigan's institutional review board.
RESULTS
Of the 440 patients surveyed in the intervention group (1 general medicine and 1 cardiology unit), 343 (78%) received the notepads in their rooms and 207 (47%) used them (Figure 2). Not every patient in the intervention group received DD notepads due to inconsistent placement of DD notepads upon every room turnover. Of the patients admitted to the control group (1 general medicine and 1 cardiology unit), 224 were surveyed. Fifty‐four percent of the 440 patients in the intervention group reported that they took notes related to their hospital care, compared to only 22% of the 224 patients in the control group (P < 0.001). Of the patients who took notes within the intervention group (n = 207), 91% of them utilized the DD notepads.
Patients in the intervention group who received and used the DD notes (n = 207) compared to patients in the control group (n = 224) were more likely to report that their questions were answered by their physicians (4.63 vs 4.45, P < 0.001). In an intention‐to‐treat analysis of all 440 patients in the intervention group, the overall satisfaction with physician communication was not significantly different between the intervention and control groups as measured on a 5‐point Likert scale (4.55 vs 4.55, P = 0.89). However, 89% of the patients in the intervention group who used the notepads felt that DD notepads either moderately or significantly improved their communication with their providers (Figure 3).
When the 207 patients who received DD notepads were asked how they used this tool, 99% of these patients used DD to write down questions, 82% to keep track of tests and procedures, and 54% indicated that their family and friends also used the notepads during the hospital stay (Table 1). Among these patients who utilized the DD notepads, 93% reported that they would use them again in the future.
| Wrote Notes? (P < 0.001) (%) | Used DD? (%) | Use in Future? (%) | Frequency of Questions Answered (P < 0.001) | DD Improved Communication | Satisfied With Communication? (P = 0.89) | |
|---|---|---|---|---|---|---|
| ||||||
| Intervention (n = 440) | 54 | 91 | 93.2 | 4.63 | 3.76 | 4.55 |
| Control (n = 224) | 22 | 4.45 | 4.55 | |||
Of the 97 patients in the intervention group who did not receive a DD notepad, we asked if they would use the DD notepad if they were made aware of such a tool. Of these patients, 77% agreed that they would use DD notes if they were made available in the future, 100% of them said that they would use DD to write down questions, 97% indicated that they would write notes about tests and procedures, and 88% of them believed that their families and friends would use DD notes.
DISCUSSION
As hospitals place greater emphasis and value on patient‐centered care as part of their clinical mission, it is important to develop tools to help facilitate the doctor‐patient relationship. We found that patients who were provided the Dear Doctor notepad were more satisfied that their doctors answered their questions and felt this tool enhanced their ability to communicate with their physicians. Employing the use of a familiar tool such as the notepad to remind patients about specific issues in their interactions with their providers can be a powerful intervention. Our study demonstrated that the DD notepad was widely accepted by patients, and that almost all of them would use this tool if it were made available to them in the future.
Other tools and methods to enhance the quality of communication between patients and their healthcare providers have included using whiteboards in the patients' rooms to relay the care plan to the patients, implementing bedside rounds by the healthcare team, and multidisciplinary huddling to coordinate information to the patient.[12, 13] Studies of these communication tools have shown potential to improve teamwork, interaction, and patient care. All of these have their own merit and value, and our DD notepad should be considered an adjunct to existing methods to enhance the patient care experience. A bedside tool that is familiar in form to most patients also needs to have the feature of easy access and use. Once this barrier has been removed for the patient and their family members, tools such as the DD notepad can impact the patient‐centeredness by fostering increased and better quality dialogue between the patients, their family members, and healthcare providers.
The DD notepad represents a means of communication that may have the potential to empower patients. It is possible that through question prompts, the DD notepad stimulates the patient to be an active partner with his or her healthcare team. This may enable patients to have some sense of control and accountability of their care in a setting where they would otherwise feel overwhelmed or powerless. The 3 general categories to help patients write down their questions included diagnosis, treatment plan, and medications. In the inpatient setting, where patient‐care activities can be fast paced, and patients are unable to recall some details when speaking to the healthcare team, these notes may remind the patient to write their thoughts down so that they may be remembered for a future time. In situations where patients may not know which questions to ask, the question prompts may be particularly helpful. We did not assess whether our particular question prompts were the key elements that resulted in their perceived value, or whether simply placing a blank notepad at the bedside would also have been successful. However, the specific questions were suggested by the focus groups. Enhanced communication, focusing on the patients' understanding of their condition, and the need to pursue certain diagnostic or therapeutic interventions, may help patients to be better prepared for the next course of plan. These topics of reasons for hospitalization, treatment plan, and medication changes are also important for patients to be active participants in their care, in particular as they transition from 1 site of care to the next, and their healthcare will be delivered by different providers.
There are several limitations to our study. First, this intervention was performed at a single hospital site with only 2 clinical services (general medicine, cardiology) represented in the study groups. Although we do not have any causal reasons to believe this tool would be looked upon differently by patients on other clinical services, it is possible that patients on a different clinical unit or service may view this tool as less or more useful. Second, as the patients were not randomized to intervention, but rather based on the units to which they were admitted, it is possible that other variables, such as the experience of the unit staff, the patient's condition, and housestaff‐based service versus hospitalist‐based service may have played a role in how the patients perceived the use of DD notes. Third, patients were only surveyed if they were able to verbally communicate in English. These notes may not be as useful in hospital settings to populations with language or literacy barriers. Fourth, the logistical implementation of DD notes limited our ability to deliver the DD notepads in every patient's rooms, where only 78% of the intervention group received the DD notepads. This may be the reason that we did not find that overall satisfaction with physician communication differed between intervention and control groups. Nonetheless, we performed an intention‐to‐treat analysis to minimize any biases in our analysis. Last, although our survey of patients asked about their satisfaction in using the DD note pads, we did not compare these results with those of Press‐Ganey or HCAHPS scores of patients on the intervention group versus the control group. Additionally, lack of data about type, quality, and quantity of questions asked by a control group to see if the notepads actually improved quality of questions asked is a limitation; however, we believe our outcomes of interest were most specifically evaluated through our survey questions.
DD notes show that the majority of patients who use this tool feel a modest to significant improvement in communication with their providers. Although the quality of medical care is undoubtedly the first priority, the patients' view of their care, which includes communication, is arguably just as important. An often‐forgotten goal of hospitals and clinics is to provide service excellence along with high‐quality care. Thus, it is imperative for hospitals and their care providers to not only focus on the quality and safety of the clinical care, but also be mindful of the patient's entire experience throughout their hospital stay. Many of the categories of questions asked in the HCAHPS address the patient's experience and perspectives of hospital care. Furthermore, the role of the HCAHPS survey in the Value‐Based Purchasing rules may enhance the importance of these notepads. As the results of HCAHPS are becoming more transparent and available to the public, the impact of such results will have a greater significance to the future of the hospital's clinical mission.
CONCLUSION
DD notepads are a simple, low‐cost, patient‐centered tool that can be an effective reminder for patients to ask their healthcare providers questions related to their hospital care. Utilizing a common tool such as the notepad, redesigned for the healthcare setting, can serve to help healthcare providers interact with their patients. Patient satisfaction may be higher in patients who use the DD notepad.
Disclosures: Aaron S. Farberg, MD, and Andrew M. Lin, MD, contributed equally in every way and should be considered co‐first authors. This work was supported by a University of Michigan Fostering Innovations Grant. The authors have no conflicting financial interests.
- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
- , , , . An evidence base for patient‐centered cancer care: a meta‐analysis of studies of observed communication between cancer specialists and their patients. Patient Educ Couns. 2009;77(3):379–383.
- . Effective physician‐patient communication and health outcomes: a review. Can Med Assoc J. 1995;152:1423–1433.
- , . Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8):991–994.
- , , , . Patients' perception of hospital care in the United States. N Engl J Med. 2008;359:1921–1931.
- Institute of Medicine of the National Academies.Best care at lower cost: the path to continuously learning health care in America. Available at: http://www.iom.edu/Reports/2012/Best‐Care‐at‐Lower‐Cost‐The‐Path‐to‐Continuously‐Learning‐Health‐Care‐in‐America.aspx. Accessed October 5, 2012.
- , . An introduction to technology for patient‐centered collaborative care. J Ambul Care Manage. 2006;29:195–198.
- , , , , , . Effect on health‐related outcome of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med. 2004;2(6):595–608
- , , , , . Characteristics of physicians with participatory decision‐making styles. Ann Intern Med. 1996;124(5):497–504.
- . Information‐giving consultations: the influence of patients' communicative styles and personal characteristics. Soc Sci Med. 1991:32(5):541–548.
- University of Michigan Health System.Patient care and University of Michigan Health System. Available at: http://www.uofmhealth.org/about%2Bumhs/about‐clinical‐care. Accessed August 31, 2012.
- , , , et al. It's the writing on the wall: whiteboards improve inpatient satisfaction with provider communication. Am J Med Qual. 2011;26(2):127–131
- , , , , . Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. J Hosp Med. 2010;5(4):234–239.
- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
- , , , . An evidence base for patient‐centered cancer care: a meta‐analysis of studies of observed communication between cancer specialists and their patients. Patient Educ Couns. 2009;77(3):379–383.
- . Effective physician‐patient communication and health outcomes: a review. Can Med Assoc J. 1995;152:1423–1433.
- , . Patients' understanding of their treatment plans and diagnosis at discharge. Mayo Clin Proc. 2005;80(8):991–994.
- , , , . Patients' perception of hospital care in the United States. N Engl J Med. 2008;359:1921–1931.
- Institute of Medicine of the National Academies.Best care at lower cost: the path to continuously learning health care in America. Available at: http://www.iom.edu/Reports/2012/Best‐Care‐at‐Lower‐Cost‐The‐Path‐to‐Continuously‐Learning‐Health‐Care‐in‐America.aspx. Accessed October 5, 2012.
- , . An introduction to technology for patient‐centered collaborative care. J Ambul Care Manage. 2006;29:195–198.
- , , , , , . Effect on health‐related outcome of interventions to alter the interaction between patients and practitioners: a systematic review of trials. Ann Fam Med. 2004;2(6):595–608
- , , , , . Characteristics of physicians with participatory decision‐making styles. Ann Intern Med. 1996;124(5):497–504.
- . Information‐giving consultations: the influence of patients' communicative styles and personal characteristics. Soc Sci Med. 1991:32(5):541–548.
- University of Michigan Health System.Patient care and University of Michigan Health System. Available at: http://www.uofmhealth.org/about%2Bumhs/about‐clinical‐care. Accessed August 31, 2012.
- , , , et al. It's the writing on the wall: whiteboards improve inpatient satisfaction with provider communication. Am J Med Qual. 2011;26(2):127–131
- , , , , . Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. J Hosp Med. 2010;5(4):234–239.
© 2013 Society of Hospital Medicine
Hospitalist Experiences Regarding PICCs
Peripherally inserted central catheters (PICCs) have become among the most common central venous catheters (CVCs) used in contemporary medical practice.[1] Although they were originally developed for delivery of parenteral nutrition, the use of PICCs has expanded to include chemotherapy administration, long‐term intravenous (IV) antibiotic treatment, and venous access when obtaining peripheral veins is difficult (eg, occluded peripheral veins, unusual venous anatomies).[2] Despite these roles, little is known about PICC use in hospitalized patients. This knowledge gap is important, as PICCs are placed in inpatient settings for a variety of reasons. Some of these reasons may not be appropriate, and inappropriate PICC use may worsen outcomes and increase healthcare costs.[3] In addition, PICCs are not innocuous and are frequently associated with important complications including thrombophlebitis, central‐lineassociated bloodstream infection and venous thromboembolism.[4, 5, 6] Therefore, understanding patterns and knowledge associated with PICC use is also an important patient safety concern.
As the main providers of inpatient care, hospitalists frequently order the insertion of PICCs and treat PICC‐related complications. Unfortunately, to date, no study has surveyed hospitalists regarding management or use of PICCs. Understanding hospitalist experiences, practice, opinions, and knowledge related to PICCs is therefore of significant interest when examining present‐day PICC use. To bridge this important knowledge gap and better understand these practices, we conducted a Web‐based survey of hospitalists in 5 healthcare systems in the state of Michigan.
METHODS
A convenience sample of hospitalists (N=227) was assembled from 5 large healthcare systems (representing 10 hospitals) that participate in the Hospital Medicine Safety (HMS) Consortium, a Blue Cross/Blue Shield of Michiganfunded statewide collaborative quality initiative. Individuals engaged in research, quality improvement, or leadership at HMS sites were invited to serve as site principal investigators (site PIs). Site PIs were responsible for obtaining regulatory approval at their parent facilities and disseminating the survey to providers in their group. Participation in the survey was solicited via e‐mail invitations from site PIs to hospitalists within their provider group. To encourage participation, a $10 electronic gift card was offered to respondents who successfully completed the survey. Reminder e‐mails were also sent each week by site PIs to augment participation. To enhance study recruitment, all responses were collected anonymously. The survey was administered between August 2012 and September 2012; data collection occurred for 5 weeks during this interval.
Survey questions were derived from our published, evidence‐based conceptual framework of PICC‐related complications. Briefly, this model identifies complications related to PICCs as arising from domains related to patient‐, provider‐, and device‐related characteristics based on existing evidence.[2] For our survey, questions were sourced from each of these domains so as to improve understanding of hospitalist experience, practice, opinions, and knowledge regarding PICC use. To ensure clarity of the survey questions, all questions were first pilot‐tested with a group of randomly selected hospitalist respondents at the University of Michigan Health System. Direct feedback obtained from these respondents was then used to iteratively improve each question. In order to generate holistic responses, questions were designed to generate a response reflective of the participants typical PICC use/subenario. We used SurveyMonkey to collect and manage survey data.
Statistical Analyses
Variation in hospitalist experience, reported practice, opinions, and knowledge regarding PICCs was assessed by hospitalist type (full time vs part time), years of practice (<1, 15, >5), and care‐delivery model (direct care vs learner‐based care). Bivariate comparisons were made using the 2 or Fisher exact tests as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All analyses were conducted using Stata version 11 (StataCorp, College Station, TX). Local institutional review board approval was obtained at each site participating in the survey.
RESULTS
A total of 227 surveys were administered and 144 responses collected, for a survey response rate of 63%. Each participating site had unique characteristics including size, number of hospitalists, and modality of PICC insertion (Table 1). Of the hospitalists who completed the survey, 81% held full‐time clinical positions and had been in practice an average of 5.6 years. Surveyed hospitalists reported caring for an average of 40.6 patients per week and ordering a mean of 2.9 (range, 015) PICCs per week of clinical service. Among survey respondents, 36% provided direct patient care, 34% provided care either directly or through mid‐level providers and housestaff, and 9% delivered care exclusively through mid‐level providers or housestaff (Table 2). As our survey was conducted anonymously, potential identifying information such as age, race, and sex of those responding was not collected.
| Survey Site | No. of Hospitals | No. of Inpatient Beds | No. of Annual Inpatient Encounters | No. of Hospitalists | Full‐Time Hospitalists, % | Avg. No. Weeks/Year on Service | Avg. Years of Experience | No. PICCs/Week, 2012 | Modality of PICC Insertion Available |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| University of Michigan Health System | 1 | 900+ | 5,775 | 46 | 100 | 25 | 6 | 42 | Vascular access nurse |
| Ann Arbor VA Medical Center | 1 | 135 | 825 | 16 | 50 | 17.6 | 5.1 | 12 | Vascular access nurse |
| Spectrum Health System | 2 | 800 | 14,000 | 47 | 80 | 34 | 3.75 | 56 | Interventional radiology |
| Trinity Health System | 3 | 634 | 2,300 | 67 | 80 | 24 | 4 | 31 | Interventional radiology and hospitalists |
| Henry Ford Health System | 3 | 1,150 | 1,450 | 51 | 100 | 20.4 | 5.6 | 15 | Vascular access nurse |
| Characteristic | Total (N=144) |
|---|---|
| |
| Hospitalist type, n (%) | |
| Full time | 117 (81) |
| Part time | 19 (13) |
| Unknown | 8 (6) |
| Weeks/year on a clinical service, n (%) | |
| <20 | 24 (17) |
| 20 | 107 (74) |
| Unknown | 13 (9) |
| Mean (SD) | 25.5 (10.7) |
| Median | 26 |
| Type of patients treated, n (%) | |
| Adults only | 129 (90) |
| Adults and children | 7 (5) |
| Unknown | 8 (6) |
| Years in practice as a hospitalist, n (%) | |
| 5 | 81 (56) |
| >5 | 54 (38) |
| Unknown | 9 (6) |
| Model of care delivery, n (%) | |
| Direct | 52 (36) |
| Some midlevel or housestaff providers (<50% of all encounters) | 49 (34) |
| Mostly midlevel or housestaff providers (>50% of all encounters) | 22 (15) |
| Only midlevel or housestaff providers | 13 (9) |
| Unknown | 8 (6) |
| Location of practice | |
| Trinity Health System | 39 (27) |
| University of Michigan Health System | 37 (26) |
| Henry Ford Health System | 28 (19) |
| Spectrum Health System | 21 (15) |
| Ann Arbor VA Medical Center | 11 (8) |
| Unknown | 8 (6) |
Hospitalist Experiences and Practice Related to Peripherally Inserted Central Catheters
According to responding hospitalists, the most common indications for PICC placement were long‐term IV antibiotic treatment (64%), followed by inability to obtain peripheral venous access (24%). Hospitalists reported an average duration of PICC placement of 17 days (range, 342 days). A significant percentage of hospitalists (93%) stated that they had cared for patients where a PICC was placed only for use during hospitalization, with the most common reason for such insertion being difficulty in otherwise securing venous access (67%). Respondents also reported caring for patients who had both PICCs and peripheral IV catheters in place at the same time; 49% stated that they had experienced this <5 times, whereas 33% stated they had experienced this 510 times. Furthermore, 87% of respondents indicated having admitted a patient who specifically requested a PICC due to prior difficulties with venous access. More than half of surveyed hospitalists (63%) admitted to having been contacted by a PICC nurse enquiring as to whether their patient might benefit from PICC insertion.
The majority of hospitalists (66%) reported that they specified the number of lumens when ordering PICCs. Thirty‐eight percent indicated that this decision was based on type of medication, whereas 35% selected the lowest number of lumens possible. A power PICC (specialized PICCs that are designed to withstand high‐pressure contrast injections), was specifically requested for radiographic studies (56%), infusion of large volume of fluids (10%), or was the default PICC type at their facility (34%).
A majority (74%) of survey respondents also reported that once inserted, PICCs were always used to obtain blood for routine laboratory testing. Moreover, 41% indicated that PICCs were also always used to obtain blood for microbiological cultures. The 3 most frequently encountered PICC‐related complications reported by hospitalists in our survey were blockage of a PICC lumen, bloodstream infection, and venous thromboembolism (VTE; Table 3).
| Hospitalist Experiences With PICCs | Total (N=144) |
|---|---|
| |
| Primary indication for PICC placement* | |
| Long‐term IV antibiotics | 64 |
| Venous access in a patient with poor peripheral veins | 24 |
| Parenteral nutrition | 5 |
| Chemotherapy | 4 |
| Patient specifically requested a PICC | 1 |
| Unknown/other | 2 |
| PICC placed only for venous access, n (%) | |
| Yes | 135 (94) |
| No | 9 (6) |
| PICC placed only during hospitalization, n (%) | |
| Yes | 134 (93) |
| No | 10 (7) |
| Notified by a PICC nurse (or other provider) that patient may need or benefit from a PICC, n (%) | |
| Yes | 91 (63) |
| No | 53 (37) |
| How frequently PICCs are used to obtain blood for routine laboratory testing, n (%) | |
| Always | 106 (74) |
| Unknown/other | 38 (26) |
| How frequently PICCs are used to obtain blood for blood cultures, n (%) | |
| Always | 59 (41) |
| Unknown/other | 85 (59) |
| Hospitalist Opinions on PICCs | Total (N=144) |
| In your opinion, is it appropriate to place a vascular in a hospitalized patient if other forms of peripheral access cannot be obtained? n (%) | |
| Yes | 121 (84) |
| No | 21 (15) |
| Unknown | 2 (1) |
| In your opinion, should hospitalists be trained to insert PICCs? n (%) | |
| No | 57 (40) |
| Yes, this is an important skill set for hospitalists | 46 (32) |
| Unsure | 39 (27) |
| Unknown/other | 2 (1) |
| Do you think the increasing number of vascular nurses and PICC nursing teams has influenced the use of PICCs in hospitalized patients? n (%) | |
| Yes | 112 (78) |
| No | 30 (21) |
| Unknown | 2 (1) |
| What % of PICC insertions do you think may represent inappropriate use in your hospital? n (%) | |
| <10 | 53 (37) |
| 1025 | 68 (47) |
| 2550 | 18 (13) |
| >50 | 3 (2) |
| Unknown/other | 2 (1) |
Hospitalist Opinions Regarding Peripherally Inserted Central Catheters
Compared with CVCs, 69% of hospitalists felt that PICCs were safer and more efficient because they could stay in place longer and were less likely to cause infection. Most (65%) also agreed that PICCs were more convenient than CVCs because they were inserted by PICC teams. Additionally, 74% of hospitalists felt that their patients preferred PICCs because they minimize pain from routine peripheral IV changes and phlebotomy. A majority of respondents (84%) indicated that it was appropriate to place a PICC if other forms of peripheral venous access could not be obtained. However, when specifically questioned, 47% of hospitalists indicated that at least 10%25% of PICCs placed in their hospitals might represent inappropriate use. A majority (78%) agreed with the statement that the increase in numbers of vascular nurses had influenced use of PICCs in hospitalized patients, but most (45%) were neutral when asked if PICCs were more cost‐effective than traditional CVCs.
Hospitalist Knowledge Regarding Risk of Peripherally Inserted Central CatheterRelated Venous Thromboembolism and Bloodstream Infection
Although 65% of responding hospitalists disagreed with the statement that PICCs were less likely to lead to VTE, important knowledge gaps regarding PICCs and VTE were identified (Table 4). For instance, only 4% of hospitalists were correctly aware that the PICC‐tip position is checked to reduce risk of PICC‐related VTE, and only 12% knew that the site of PICC insertion has also been associated with VTE risk. Although 85% of respondents stated they would prescribe a therapeutic dose of an anticoagulant in the case of PICC‐associated VTE, deviations from the guideline‐recommended 3‐month treatment period were noted. For example, 6% of hospitalists reported treating with anticoagulation for 6 months, and 19% stated they would treat as long as the PICC remained in place, plus an additional period of time (eg, 24 weeks) after removal. With respect to bloodstream infection, 92% of responding hospitalists correctly identified PICC duration and prompt removal as factors promoting PICC‐related bloodstream infection and 78% accurately identified components of the catheter‐associated bloodstream infection bundle. When specifically asked about factors associated with risk of PICC‐related bloodstream infection, only half of respondents recognized the number of PICC lumens as being associated with this outcome.
| Total (N=144) | |
|---|---|
| |
| Why is the position of the PICC tip checked after bedside PICC insertion? n (%) | |
| To decrease the risk of arrhythmia related to right‐atrial positioning | 108 (75) |
| To minimize the risk of VTEa | 6 (4) |
| To ensure it is not accidentally placed into an artery | 16 (11) |
| For documentation purposes (to reduce the risk of lawsuits related to line‐insertion complications) | 6 (4) |
| Unsure/Unknown | 8 (6) |
| According to the 2012 ACCP Guidelines on VTE prevention, is pharmacologic prophylaxis for DVT recommended in patients who receive long‐term PICCs? n (%) | |
| No; no anticoagulant prophylaxis is recommended for patients who receive long‐term PICCsa | 107 (74) |
| Yes, but the choice and duration of anticoagulant is at the discretion of the provider | 23 (16) |
| Yes; aspirin is recommended for 3 months | 4 (3) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 3 months | 3 (2) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 6 months | 2 (1) |
| Unknown | 5 (4) |
| Assuming no contraindications exist, do you anticoagulate patients who develop a PICC‐associated DVT (with any therapeutic anticoagulant)? n (%) | |
| Yesa | 122 (85) |
| No | 16 (11) |
| Unknown | 6 (4) |
| How long do you usually prescribe anticoagulation for patients who develop PICC‐associated DVT? n (%) | |
| I don't prescribe anticoagulation | 12 (8) |
| 1 month | 4 (3) |
| 3 monthsa | 84 (58) |
| 6 months | 8 (6) |
| As long as the line remains in place; I stop anticoagulation once the PICC comes out | 3 (2) |
| As long as the line remains in place and for an additional specified period of time after line removal, such as 2 or 4 weeks | 27 (19) |
| Unknown | 6 (4) |
| As part of the treatment of PICC‐related DVT, do you routinely remove the PICC?b n (%) | |
| Yes | 102 (71) |
| No | 36 (25) |
| Unknown | 6 (4) |
Variation in Hospitalist Knowledge, Experience, or Opinions
We assessed whether any of our findings varied according to hospitalist type (full time versus part time), years of practice (<1, 15, >5), and model of care delivery (direct care vs learner‐based care). Our analyses suggested that part‐time hospitalists were more likely to select rarely when it came to finding patients with a PICC and a working peripheral IV at the same time (74% vs 45%, P=0.02). Interestingly, a higher percentage of those in practice <5 years indicated that 10%25% of PICCs represented inappropriate placement (58% vs 33%, P<0.01) and that vascular nurses had influenced the use of PICCs in hospitalized patients (88% vs 69%, P=0.01). Lastly, a higher percentage of hospitalists who provided direct patient care reported that PICCs were always used to obtain blood for microbiological culture (54% vs 37%, P=0.05).
DISCUSSION
In this survey of hospitalists practicing at 5 large healthcare systems in Michigan, we observed significant variation in experience, reported practice, opinions, and knowledge related to PICCs. Our findings highlight important concerns related to inpatient PICC use and suggest a need for greater scrutiny related to these devices in these settings.
The use of PICCs in hospitalized patients has risen dramatically over the past decade. Though such growth is multifactorial and relates in part to increasing inpatient volume and complexity, hospitalists have increasingly turned to PICCs as a convenient and reliable tool to obtain venous access.[7] Indeed, in our survey, PICCs that were only used during hospitalization were most likely to be placed for this very reason. Because PICCs are safer to insert than CVCs and the original evidence regarding PICC‐related VTE or bloodstream infection suggested low rates of these events,[8, 9, 10, 11, 12, 13, 14] many hospitalists may not perceive these devices as being associated with significant risks. In fact, some have suggested that hospitalists be specifically trained to insert these devices, given their safety compared with traditional CVCs.[7]
However, accumulating evidence suggests that PICCs are associated with important complications.[5, 15, 16] In studies examining risk of bloodstream infection, PICCs were associated with significant risk of this outcome.[6, 17, 18] Recently, the presence of a PICC was identified as an independent predictor of VTE in hospitalized patients.[19] Several studies and systematic reviews have repeatedly demonstrated these findings.[19, 20, 21, 22] A recent systematic review examining nonpharmacologic methods to prevent catheter‐related thrombosis specifically called for avoidance of PICC insertion to prevent thrombosis in hospitalized patients.[23] Despite this growing evidence base, the use of PICCs in the inpatient setting is likely to rise, and our survey highlights several practices that may contribute to adverse outcomes. For instance, hospitalists in our survey were unlikely to remove a PICC until a patient was discharged, irrespective of the need for this device. As each day with a PICC increases the risk of complications, such practice poses potential patient safety concerns. Similarly, many hospitalists believe that PICCs are safer than CVCs, a viewpoint that does not stand up to increasing scrutiny and highlights important knowledge gaps. The risk of PICC‐related complications appears not to be a stationary target, but rather a dynamic balance that is influenced by patient‐, provider‐, and device‐specific characteristics.[2] Increasing discretionary use (especially for patients with poor peripheral venous access), forgetting at times that a patient has a PICC, and the finding that up to 25% of PICCs placed in their hospitals may be unnecessary underscore concerns regarding the safety of current practice trends. Interestingly, the viewpoints of hospitalists in practice <5 years and those providing direct patient care were more likely to reflect concerns regarding inappropriate placement, influence of vascular nurses, and use of PICCs for blood culture. This finding may reflect that these nuances are more recent phenomena or perhaps most apparent when care is delivered directly.
Our study must be interpreted in the context of several limitations. First, as this was a survey‐based study of a small, convenience sample of hospitalists in a single state, recall, respondent, and systematic biases remain threats to our findings. However, all site PIs encouraged survey participation and (through local dialogue) none were aware of material differences between those who did or did not participate in the study. Similarly, Michigan is a diverse and relatively large state, and our results should be generalizable to other settings; however, national studies are necessary to confirm our findings. Second, our response rate may be perceived as low; however, our rates are in accordance with, and, in fact, superior to those of many existing physician surveys.[24] Finally, only 1 federal facility was included in this study; thus, this care‐delivery model is underrepresented, limiting generalization of findings to other such sites.
However, our study also has important strengths. First, this is the only survey that specifically examines hospitalist viewpoints when it comes to PICCs. As hospitalists frequently order and/or insert these devices, their perspectives are highly pertinent to discussions regarding current PICC use. Second, our survey highlights several instances that may be associated with preventable patient harm and identifies areas where interventions may be valuable. For example, forgetting the presence of a device, keeping PICCs in place throughout hospitalization, and rendering treatment for PICC‐related VTE not in accordance with accepted guidelines are remediable practices that may lead to poor outcomes. Interventions such as device‐reminder alerts, provider education regarding complications from PICCs, and systematic efforts to identify and remove unnecessary PICCs may mitigate these problems. Finally, our findings highlight the need for data repositories that track PICC use and hospitalist practice on a national scale. Given the risk and significance of the complications associated with these devices, understanding the epidemiology, use, and potential misuse of PICCs are important areas for hospitalist research.
In conclusion, our study of hospitalist experience, practice, opinions, and knowledge related to PICCs suggests important gaps between available evidence and current practice. There is growing need for the development of appropriateness criteria to guide vascular access in inpatient settings.[25, 26] Such criteria should consider not only type of venous access device, but granular details including rationale for venous access, nature of the infusate, optimal number of lumens, and safest gauge when recommending devices. Until such criteria and comparative studies become available, hospitals should consider instituting policies to monitor PICC use with specific attention to indication for insertion, duration of placement, and complications. These interventions represent a first and necessary step in improving patient safety when it comes to preventing PICC‐related complications.
Disclosures
The Blue Cross/Blue Shield of Michigan Foundation in Detroit funded this study through an investigator‐initiated research proposal (1931‐PIRAP). The funding source, however, played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.
- , , , et al. Hospital‐wide survey of the use of central venous catheters. J Hosp Infect. 2011;77(4):304–308.
- , , , , . Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med. 2012;125(8):733–741.
- , , . The problem with peripherally inserted central catheters. JAMA. 2012;308(15):1527–1528.
- , , , et al. Reduction of peripherally inserted central catheter associated deep venous thrombosis [published online ahead of print August 1, 2012]. Chest. doi: 10.1378/chest.12–0923.
- , , . Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia. 2012;67(1):65–71.
- , , , et al. Patient‐ and device‐specific risk factors for peripherally inserted central venous catheter‐related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
- , . Peripherally inserted central catheter use in the hospitalized patient: is there a role for the hospitalist? J Hosp Med. 2009;4(6):E1–E4.
- , , , , , . Peripherally inserted central catheter (PICC)‐associated upper‐extremity deep venous thrombosis (UEDVT) in critical‐care setting. Chest. 2005;128(4 suppl S):193S–194S.
- , , , , , . Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally inserted central catheters. Clin Nutr. 2000;19(4):237–243.
- , . Risk of catheter‐related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–495.
- , , , . Long‐term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer. 1979;43(5):1937–1943.
- , , , , . Central vs peripheral venous catheters in critically ill patients. Chest. 1986;90(6):806–809.
- , , , , . Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters. Am J Med. 1991;91(3B):95S–100S.
- , , , , . Upper‐extremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest. 1991;99(2):280–283.
- , , , et al. Risk factors for catheter‐related thrombosis (CRT) in cancer patients: a patient‐level data (IPD) meta‐analysis of clinical trials and prospective studies. J Thromb Haemost. 2011;9(2):312–319.
- , , , et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179–1183.
- , , , et al. Peripherally inserted central venous catheter–associated bloodstream infections in hospitalized adult patients. Infect Control Hosp Epidemiol. 2011;32(2):125–130.
- , , . Peripherally inserted central catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia. Ann Saudi Med. 2012;32(2):169–173.
- , , , et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med. 2011;124(10):947.e942–954.e942.
- , , , et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010;138(4):803–810.
- , , . The clinical significance of peripherally inserted central venous catheter‐related deep vein thrombosis. Neurocrit Care. 2011;15(3):454–460.
- , , , et al. Catheter‐associated bloodstream infection incidence and risk factors in adults with cancer: a prospective cohort study. J Hosp Infect. 2011;78(1):26–30.
- , , , . Nonpharmacologic interventions for prevention of catheter‐related thrombosis: a systematic review [published online ahead of print September 13, 2012]. J Crit Care. doi: 10.1016/j.jcrc.2012.07.007.
- , , . Why are response rates in clinician surveys declining? Can Fam Physician. 2012;58(4):e225–e228.
- , , , , , . Sensitivity and specificity of the RAND/UCLA Appropriateness Method to identify the overuse and underuse of coronary revascularization and hysterectomy. J Clin Epidemiol. 2001;54(10):1004–1010.
- , , , et al. Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures. Med Care. 1996;34(6):512–523.
Peripherally inserted central catheters (PICCs) have become among the most common central venous catheters (CVCs) used in contemporary medical practice.[1] Although they were originally developed for delivery of parenteral nutrition, the use of PICCs has expanded to include chemotherapy administration, long‐term intravenous (IV) antibiotic treatment, and venous access when obtaining peripheral veins is difficult (eg, occluded peripheral veins, unusual venous anatomies).[2] Despite these roles, little is known about PICC use in hospitalized patients. This knowledge gap is important, as PICCs are placed in inpatient settings for a variety of reasons. Some of these reasons may not be appropriate, and inappropriate PICC use may worsen outcomes and increase healthcare costs.[3] In addition, PICCs are not innocuous and are frequently associated with important complications including thrombophlebitis, central‐lineassociated bloodstream infection and venous thromboembolism.[4, 5, 6] Therefore, understanding patterns and knowledge associated with PICC use is also an important patient safety concern.
As the main providers of inpatient care, hospitalists frequently order the insertion of PICCs and treat PICC‐related complications. Unfortunately, to date, no study has surveyed hospitalists regarding management or use of PICCs. Understanding hospitalist experiences, practice, opinions, and knowledge related to PICCs is therefore of significant interest when examining present‐day PICC use. To bridge this important knowledge gap and better understand these practices, we conducted a Web‐based survey of hospitalists in 5 healthcare systems in the state of Michigan.
METHODS
A convenience sample of hospitalists (N=227) was assembled from 5 large healthcare systems (representing 10 hospitals) that participate in the Hospital Medicine Safety (HMS) Consortium, a Blue Cross/Blue Shield of Michiganfunded statewide collaborative quality initiative. Individuals engaged in research, quality improvement, or leadership at HMS sites were invited to serve as site principal investigators (site PIs). Site PIs were responsible for obtaining regulatory approval at their parent facilities and disseminating the survey to providers in their group. Participation in the survey was solicited via e‐mail invitations from site PIs to hospitalists within their provider group. To encourage participation, a $10 electronic gift card was offered to respondents who successfully completed the survey. Reminder e‐mails were also sent each week by site PIs to augment participation. To enhance study recruitment, all responses were collected anonymously. The survey was administered between August 2012 and September 2012; data collection occurred for 5 weeks during this interval.
Survey questions were derived from our published, evidence‐based conceptual framework of PICC‐related complications. Briefly, this model identifies complications related to PICCs as arising from domains related to patient‐, provider‐, and device‐related characteristics based on existing evidence.[2] For our survey, questions were sourced from each of these domains so as to improve understanding of hospitalist experience, practice, opinions, and knowledge regarding PICC use. To ensure clarity of the survey questions, all questions were first pilot‐tested with a group of randomly selected hospitalist respondents at the University of Michigan Health System. Direct feedback obtained from these respondents was then used to iteratively improve each question. In order to generate holistic responses, questions were designed to generate a response reflective of the participants typical PICC use/subenario. We used SurveyMonkey to collect and manage survey data.
Statistical Analyses
Variation in hospitalist experience, reported practice, opinions, and knowledge regarding PICCs was assessed by hospitalist type (full time vs part time), years of practice (<1, 15, >5), and care‐delivery model (direct care vs learner‐based care). Bivariate comparisons were made using the 2 or Fisher exact tests as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All analyses were conducted using Stata version 11 (StataCorp, College Station, TX). Local institutional review board approval was obtained at each site participating in the survey.
RESULTS
A total of 227 surveys were administered and 144 responses collected, for a survey response rate of 63%. Each participating site had unique characteristics including size, number of hospitalists, and modality of PICC insertion (Table 1). Of the hospitalists who completed the survey, 81% held full‐time clinical positions and had been in practice an average of 5.6 years. Surveyed hospitalists reported caring for an average of 40.6 patients per week and ordering a mean of 2.9 (range, 015) PICCs per week of clinical service. Among survey respondents, 36% provided direct patient care, 34% provided care either directly or through mid‐level providers and housestaff, and 9% delivered care exclusively through mid‐level providers or housestaff (Table 2). As our survey was conducted anonymously, potential identifying information such as age, race, and sex of those responding was not collected.
| Survey Site | No. of Hospitals | No. of Inpatient Beds | No. of Annual Inpatient Encounters | No. of Hospitalists | Full‐Time Hospitalists, % | Avg. No. Weeks/Year on Service | Avg. Years of Experience | No. PICCs/Week, 2012 | Modality of PICC Insertion Available |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| University of Michigan Health System | 1 | 900+ | 5,775 | 46 | 100 | 25 | 6 | 42 | Vascular access nurse |
| Ann Arbor VA Medical Center | 1 | 135 | 825 | 16 | 50 | 17.6 | 5.1 | 12 | Vascular access nurse |
| Spectrum Health System | 2 | 800 | 14,000 | 47 | 80 | 34 | 3.75 | 56 | Interventional radiology |
| Trinity Health System | 3 | 634 | 2,300 | 67 | 80 | 24 | 4 | 31 | Interventional radiology and hospitalists |
| Henry Ford Health System | 3 | 1,150 | 1,450 | 51 | 100 | 20.4 | 5.6 | 15 | Vascular access nurse |
| Characteristic | Total (N=144) |
|---|---|
| |
| Hospitalist type, n (%) | |
| Full time | 117 (81) |
| Part time | 19 (13) |
| Unknown | 8 (6) |
| Weeks/year on a clinical service, n (%) | |
| <20 | 24 (17) |
| 20 | 107 (74) |
| Unknown | 13 (9) |
| Mean (SD) | 25.5 (10.7) |
| Median | 26 |
| Type of patients treated, n (%) | |
| Adults only | 129 (90) |
| Adults and children | 7 (5) |
| Unknown | 8 (6) |
| Years in practice as a hospitalist, n (%) | |
| 5 | 81 (56) |
| >5 | 54 (38) |
| Unknown | 9 (6) |
| Model of care delivery, n (%) | |
| Direct | 52 (36) |
| Some midlevel or housestaff providers (<50% of all encounters) | 49 (34) |
| Mostly midlevel or housestaff providers (>50% of all encounters) | 22 (15) |
| Only midlevel or housestaff providers | 13 (9) |
| Unknown | 8 (6) |
| Location of practice | |
| Trinity Health System | 39 (27) |
| University of Michigan Health System | 37 (26) |
| Henry Ford Health System | 28 (19) |
| Spectrum Health System | 21 (15) |
| Ann Arbor VA Medical Center | 11 (8) |
| Unknown | 8 (6) |
Hospitalist Experiences and Practice Related to Peripherally Inserted Central Catheters
According to responding hospitalists, the most common indications for PICC placement were long‐term IV antibiotic treatment (64%), followed by inability to obtain peripheral venous access (24%). Hospitalists reported an average duration of PICC placement of 17 days (range, 342 days). A significant percentage of hospitalists (93%) stated that they had cared for patients where a PICC was placed only for use during hospitalization, with the most common reason for such insertion being difficulty in otherwise securing venous access (67%). Respondents also reported caring for patients who had both PICCs and peripheral IV catheters in place at the same time; 49% stated that they had experienced this <5 times, whereas 33% stated they had experienced this 510 times. Furthermore, 87% of respondents indicated having admitted a patient who specifically requested a PICC due to prior difficulties with venous access. More than half of surveyed hospitalists (63%) admitted to having been contacted by a PICC nurse enquiring as to whether their patient might benefit from PICC insertion.
The majority of hospitalists (66%) reported that they specified the number of lumens when ordering PICCs. Thirty‐eight percent indicated that this decision was based on type of medication, whereas 35% selected the lowest number of lumens possible. A power PICC (specialized PICCs that are designed to withstand high‐pressure contrast injections), was specifically requested for radiographic studies (56%), infusion of large volume of fluids (10%), or was the default PICC type at their facility (34%).
A majority (74%) of survey respondents also reported that once inserted, PICCs were always used to obtain blood for routine laboratory testing. Moreover, 41% indicated that PICCs were also always used to obtain blood for microbiological cultures. The 3 most frequently encountered PICC‐related complications reported by hospitalists in our survey were blockage of a PICC lumen, bloodstream infection, and venous thromboembolism (VTE; Table 3).
| Hospitalist Experiences With PICCs | Total (N=144) |
|---|---|
| |
| Primary indication for PICC placement* | |
| Long‐term IV antibiotics | 64 |
| Venous access in a patient with poor peripheral veins | 24 |
| Parenteral nutrition | 5 |
| Chemotherapy | 4 |
| Patient specifically requested a PICC | 1 |
| Unknown/other | 2 |
| PICC placed only for venous access, n (%) | |
| Yes | 135 (94) |
| No | 9 (6) |
| PICC placed only during hospitalization, n (%) | |
| Yes | 134 (93) |
| No | 10 (7) |
| Notified by a PICC nurse (or other provider) that patient may need or benefit from a PICC, n (%) | |
| Yes | 91 (63) |
| No | 53 (37) |
| How frequently PICCs are used to obtain blood for routine laboratory testing, n (%) | |
| Always | 106 (74) |
| Unknown/other | 38 (26) |
| How frequently PICCs are used to obtain blood for blood cultures, n (%) | |
| Always | 59 (41) |
| Unknown/other | 85 (59) |
| Hospitalist Opinions on PICCs | Total (N=144) |
| In your opinion, is it appropriate to place a vascular in a hospitalized patient if other forms of peripheral access cannot be obtained? n (%) | |
| Yes | 121 (84) |
| No | 21 (15) |
| Unknown | 2 (1) |
| In your opinion, should hospitalists be trained to insert PICCs? n (%) | |
| No | 57 (40) |
| Yes, this is an important skill set for hospitalists | 46 (32) |
| Unsure | 39 (27) |
| Unknown/other | 2 (1) |
| Do you think the increasing number of vascular nurses and PICC nursing teams has influenced the use of PICCs in hospitalized patients? n (%) | |
| Yes | 112 (78) |
| No | 30 (21) |
| Unknown | 2 (1) |
| What % of PICC insertions do you think may represent inappropriate use in your hospital? n (%) | |
| <10 | 53 (37) |
| 1025 | 68 (47) |
| 2550 | 18 (13) |
| >50 | 3 (2) |
| Unknown/other | 2 (1) |
Hospitalist Opinions Regarding Peripherally Inserted Central Catheters
Compared with CVCs, 69% of hospitalists felt that PICCs were safer and more efficient because they could stay in place longer and were less likely to cause infection. Most (65%) also agreed that PICCs were more convenient than CVCs because they were inserted by PICC teams. Additionally, 74% of hospitalists felt that their patients preferred PICCs because they minimize pain from routine peripheral IV changes and phlebotomy. A majority of respondents (84%) indicated that it was appropriate to place a PICC if other forms of peripheral venous access could not be obtained. However, when specifically questioned, 47% of hospitalists indicated that at least 10%25% of PICCs placed in their hospitals might represent inappropriate use. A majority (78%) agreed with the statement that the increase in numbers of vascular nurses had influenced use of PICCs in hospitalized patients, but most (45%) were neutral when asked if PICCs were more cost‐effective than traditional CVCs.
Hospitalist Knowledge Regarding Risk of Peripherally Inserted Central CatheterRelated Venous Thromboembolism and Bloodstream Infection
Although 65% of responding hospitalists disagreed with the statement that PICCs were less likely to lead to VTE, important knowledge gaps regarding PICCs and VTE were identified (Table 4). For instance, only 4% of hospitalists were correctly aware that the PICC‐tip position is checked to reduce risk of PICC‐related VTE, and only 12% knew that the site of PICC insertion has also been associated with VTE risk. Although 85% of respondents stated they would prescribe a therapeutic dose of an anticoagulant in the case of PICC‐associated VTE, deviations from the guideline‐recommended 3‐month treatment period were noted. For example, 6% of hospitalists reported treating with anticoagulation for 6 months, and 19% stated they would treat as long as the PICC remained in place, plus an additional period of time (eg, 24 weeks) after removal. With respect to bloodstream infection, 92% of responding hospitalists correctly identified PICC duration and prompt removal as factors promoting PICC‐related bloodstream infection and 78% accurately identified components of the catheter‐associated bloodstream infection bundle. When specifically asked about factors associated with risk of PICC‐related bloodstream infection, only half of respondents recognized the number of PICC lumens as being associated with this outcome.
| Total (N=144) | |
|---|---|
| |
| Why is the position of the PICC tip checked after bedside PICC insertion? n (%) | |
| To decrease the risk of arrhythmia related to right‐atrial positioning | 108 (75) |
| To minimize the risk of VTEa | 6 (4) |
| To ensure it is not accidentally placed into an artery | 16 (11) |
| For documentation purposes (to reduce the risk of lawsuits related to line‐insertion complications) | 6 (4) |
| Unsure/Unknown | 8 (6) |
| According to the 2012 ACCP Guidelines on VTE prevention, is pharmacologic prophylaxis for DVT recommended in patients who receive long‐term PICCs? n (%) | |
| No; no anticoagulant prophylaxis is recommended for patients who receive long‐term PICCsa | 107 (74) |
| Yes, but the choice and duration of anticoagulant is at the discretion of the provider | 23 (16) |
| Yes; aspirin is recommended for 3 months | 4 (3) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 3 months | 3 (2) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 6 months | 2 (1) |
| Unknown | 5 (4) |
| Assuming no contraindications exist, do you anticoagulate patients who develop a PICC‐associated DVT (with any therapeutic anticoagulant)? n (%) | |
| Yesa | 122 (85) |
| No | 16 (11) |
| Unknown | 6 (4) |
| How long do you usually prescribe anticoagulation for patients who develop PICC‐associated DVT? n (%) | |
| I don't prescribe anticoagulation | 12 (8) |
| 1 month | 4 (3) |
| 3 monthsa | 84 (58) |
| 6 months | 8 (6) |
| As long as the line remains in place; I stop anticoagulation once the PICC comes out | 3 (2) |
| As long as the line remains in place and for an additional specified period of time after line removal, such as 2 or 4 weeks | 27 (19) |
| Unknown | 6 (4) |
| As part of the treatment of PICC‐related DVT, do you routinely remove the PICC?b n (%) | |
| Yes | 102 (71) |
| No | 36 (25) |
| Unknown | 6 (4) |
Variation in Hospitalist Knowledge, Experience, or Opinions
We assessed whether any of our findings varied according to hospitalist type (full time versus part time), years of practice (<1, 15, >5), and model of care delivery (direct care vs learner‐based care). Our analyses suggested that part‐time hospitalists were more likely to select rarely when it came to finding patients with a PICC and a working peripheral IV at the same time (74% vs 45%, P=0.02). Interestingly, a higher percentage of those in practice <5 years indicated that 10%25% of PICCs represented inappropriate placement (58% vs 33%, P<0.01) and that vascular nurses had influenced the use of PICCs in hospitalized patients (88% vs 69%, P=0.01). Lastly, a higher percentage of hospitalists who provided direct patient care reported that PICCs were always used to obtain blood for microbiological culture (54% vs 37%, P=0.05).
DISCUSSION
In this survey of hospitalists practicing at 5 large healthcare systems in Michigan, we observed significant variation in experience, reported practice, opinions, and knowledge related to PICCs. Our findings highlight important concerns related to inpatient PICC use and suggest a need for greater scrutiny related to these devices in these settings.
The use of PICCs in hospitalized patients has risen dramatically over the past decade. Though such growth is multifactorial and relates in part to increasing inpatient volume and complexity, hospitalists have increasingly turned to PICCs as a convenient and reliable tool to obtain venous access.[7] Indeed, in our survey, PICCs that were only used during hospitalization were most likely to be placed for this very reason. Because PICCs are safer to insert than CVCs and the original evidence regarding PICC‐related VTE or bloodstream infection suggested low rates of these events,[8, 9, 10, 11, 12, 13, 14] many hospitalists may not perceive these devices as being associated with significant risks. In fact, some have suggested that hospitalists be specifically trained to insert these devices, given their safety compared with traditional CVCs.[7]
However, accumulating evidence suggests that PICCs are associated with important complications.[5, 15, 16] In studies examining risk of bloodstream infection, PICCs were associated with significant risk of this outcome.[6, 17, 18] Recently, the presence of a PICC was identified as an independent predictor of VTE in hospitalized patients.[19] Several studies and systematic reviews have repeatedly demonstrated these findings.[19, 20, 21, 22] A recent systematic review examining nonpharmacologic methods to prevent catheter‐related thrombosis specifically called for avoidance of PICC insertion to prevent thrombosis in hospitalized patients.[23] Despite this growing evidence base, the use of PICCs in the inpatient setting is likely to rise, and our survey highlights several practices that may contribute to adverse outcomes. For instance, hospitalists in our survey were unlikely to remove a PICC until a patient was discharged, irrespective of the need for this device. As each day with a PICC increases the risk of complications, such practice poses potential patient safety concerns. Similarly, many hospitalists believe that PICCs are safer than CVCs, a viewpoint that does not stand up to increasing scrutiny and highlights important knowledge gaps. The risk of PICC‐related complications appears not to be a stationary target, but rather a dynamic balance that is influenced by patient‐, provider‐, and device‐specific characteristics.[2] Increasing discretionary use (especially for patients with poor peripheral venous access), forgetting at times that a patient has a PICC, and the finding that up to 25% of PICCs placed in their hospitals may be unnecessary underscore concerns regarding the safety of current practice trends. Interestingly, the viewpoints of hospitalists in practice <5 years and those providing direct patient care were more likely to reflect concerns regarding inappropriate placement, influence of vascular nurses, and use of PICCs for blood culture. This finding may reflect that these nuances are more recent phenomena or perhaps most apparent when care is delivered directly.
Our study must be interpreted in the context of several limitations. First, as this was a survey‐based study of a small, convenience sample of hospitalists in a single state, recall, respondent, and systematic biases remain threats to our findings. However, all site PIs encouraged survey participation and (through local dialogue) none were aware of material differences between those who did or did not participate in the study. Similarly, Michigan is a diverse and relatively large state, and our results should be generalizable to other settings; however, national studies are necessary to confirm our findings. Second, our response rate may be perceived as low; however, our rates are in accordance with, and, in fact, superior to those of many existing physician surveys.[24] Finally, only 1 federal facility was included in this study; thus, this care‐delivery model is underrepresented, limiting generalization of findings to other such sites.
However, our study also has important strengths. First, this is the only survey that specifically examines hospitalist viewpoints when it comes to PICCs. As hospitalists frequently order and/or insert these devices, their perspectives are highly pertinent to discussions regarding current PICC use. Second, our survey highlights several instances that may be associated with preventable patient harm and identifies areas where interventions may be valuable. For example, forgetting the presence of a device, keeping PICCs in place throughout hospitalization, and rendering treatment for PICC‐related VTE not in accordance with accepted guidelines are remediable practices that may lead to poor outcomes. Interventions such as device‐reminder alerts, provider education regarding complications from PICCs, and systematic efforts to identify and remove unnecessary PICCs may mitigate these problems. Finally, our findings highlight the need for data repositories that track PICC use and hospitalist practice on a national scale. Given the risk and significance of the complications associated with these devices, understanding the epidemiology, use, and potential misuse of PICCs are important areas for hospitalist research.
In conclusion, our study of hospitalist experience, practice, opinions, and knowledge related to PICCs suggests important gaps between available evidence and current practice. There is growing need for the development of appropriateness criteria to guide vascular access in inpatient settings.[25, 26] Such criteria should consider not only type of venous access device, but granular details including rationale for venous access, nature of the infusate, optimal number of lumens, and safest gauge when recommending devices. Until such criteria and comparative studies become available, hospitals should consider instituting policies to monitor PICC use with specific attention to indication for insertion, duration of placement, and complications. These interventions represent a first and necessary step in improving patient safety when it comes to preventing PICC‐related complications.
Disclosures
The Blue Cross/Blue Shield of Michigan Foundation in Detroit funded this study through an investigator‐initiated research proposal (1931‐PIRAP). The funding source, however, played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.
Peripherally inserted central catheters (PICCs) have become among the most common central venous catheters (CVCs) used in contemporary medical practice.[1] Although they were originally developed for delivery of parenteral nutrition, the use of PICCs has expanded to include chemotherapy administration, long‐term intravenous (IV) antibiotic treatment, and venous access when obtaining peripheral veins is difficult (eg, occluded peripheral veins, unusual venous anatomies).[2] Despite these roles, little is known about PICC use in hospitalized patients. This knowledge gap is important, as PICCs are placed in inpatient settings for a variety of reasons. Some of these reasons may not be appropriate, and inappropriate PICC use may worsen outcomes and increase healthcare costs.[3] In addition, PICCs are not innocuous and are frequently associated with important complications including thrombophlebitis, central‐lineassociated bloodstream infection and venous thromboembolism.[4, 5, 6] Therefore, understanding patterns and knowledge associated with PICC use is also an important patient safety concern.
As the main providers of inpatient care, hospitalists frequently order the insertion of PICCs and treat PICC‐related complications. Unfortunately, to date, no study has surveyed hospitalists regarding management or use of PICCs. Understanding hospitalist experiences, practice, opinions, and knowledge related to PICCs is therefore of significant interest when examining present‐day PICC use. To bridge this important knowledge gap and better understand these practices, we conducted a Web‐based survey of hospitalists in 5 healthcare systems in the state of Michigan.
METHODS
A convenience sample of hospitalists (N=227) was assembled from 5 large healthcare systems (representing 10 hospitals) that participate in the Hospital Medicine Safety (HMS) Consortium, a Blue Cross/Blue Shield of Michiganfunded statewide collaborative quality initiative. Individuals engaged in research, quality improvement, or leadership at HMS sites were invited to serve as site principal investigators (site PIs). Site PIs were responsible for obtaining regulatory approval at their parent facilities and disseminating the survey to providers in their group. Participation in the survey was solicited via e‐mail invitations from site PIs to hospitalists within their provider group. To encourage participation, a $10 electronic gift card was offered to respondents who successfully completed the survey. Reminder e‐mails were also sent each week by site PIs to augment participation. To enhance study recruitment, all responses were collected anonymously. The survey was administered between August 2012 and September 2012; data collection occurred for 5 weeks during this interval.
Survey questions were derived from our published, evidence‐based conceptual framework of PICC‐related complications. Briefly, this model identifies complications related to PICCs as arising from domains related to patient‐, provider‐, and device‐related characteristics based on existing evidence.[2] For our survey, questions were sourced from each of these domains so as to improve understanding of hospitalist experience, practice, opinions, and knowledge regarding PICC use. To ensure clarity of the survey questions, all questions were first pilot‐tested with a group of randomly selected hospitalist respondents at the University of Michigan Health System. Direct feedback obtained from these respondents was then used to iteratively improve each question. In order to generate holistic responses, questions were designed to generate a response reflective of the participants typical PICC use/subenario. We used SurveyMonkey to collect and manage survey data.
Statistical Analyses
Variation in hospitalist experience, reported practice, opinions, and knowledge regarding PICCs was assessed by hospitalist type (full time vs part time), years of practice (<1, 15, >5), and care‐delivery model (direct care vs learner‐based care). Bivariate comparisons were made using the 2 or Fisher exact tests as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All analyses were conducted using Stata version 11 (StataCorp, College Station, TX). Local institutional review board approval was obtained at each site participating in the survey.
RESULTS
A total of 227 surveys were administered and 144 responses collected, for a survey response rate of 63%. Each participating site had unique characteristics including size, number of hospitalists, and modality of PICC insertion (Table 1). Of the hospitalists who completed the survey, 81% held full‐time clinical positions and had been in practice an average of 5.6 years. Surveyed hospitalists reported caring for an average of 40.6 patients per week and ordering a mean of 2.9 (range, 015) PICCs per week of clinical service. Among survey respondents, 36% provided direct patient care, 34% provided care either directly or through mid‐level providers and housestaff, and 9% delivered care exclusively through mid‐level providers or housestaff (Table 2). As our survey was conducted anonymously, potential identifying information such as age, race, and sex of those responding was not collected.
| Survey Site | No. of Hospitals | No. of Inpatient Beds | No. of Annual Inpatient Encounters | No. of Hospitalists | Full‐Time Hospitalists, % | Avg. No. Weeks/Year on Service | Avg. Years of Experience | No. PICCs/Week, 2012 | Modality of PICC Insertion Available |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| University of Michigan Health System | 1 | 900+ | 5,775 | 46 | 100 | 25 | 6 | 42 | Vascular access nurse |
| Ann Arbor VA Medical Center | 1 | 135 | 825 | 16 | 50 | 17.6 | 5.1 | 12 | Vascular access nurse |
| Spectrum Health System | 2 | 800 | 14,000 | 47 | 80 | 34 | 3.75 | 56 | Interventional radiology |
| Trinity Health System | 3 | 634 | 2,300 | 67 | 80 | 24 | 4 | 31 | Interventional radiology and hospitalists |
| Henry Ford Health System | 3 | 1,150 | 1,450 | 51 | 100 | 20.4 | 5.6 | 15 | Vascular access nurse |
| Characteristic | Total (N=144) |
|---|---|
| |
| Hospitalist type, n (%) | |
| Full time | 117 (81) |
| Part time | 19 (13) |
| Unknown | 8 (6) |
| Weeks/year on a clinical service, n (%) | |
| <20 | 24 (17) |
| 20 | 107 (74) |
| Unknown | 13 (9) |
| Mean (SD) | 25.5 (10.7) |
| Median | 26 |
| Type of patients treated, n (%) | |
| Adults only | 129 (90) |
| Adults and children | 7 (5) |
| Unknown | 8 (6) |
| Years in practice as a hospitalist, n (%) | |
| 5 | 81 (56) |
| >5 | 54 (38) |
| Unknown | 9 (6) |
| Model of care delivery, n (%) | |
| Direct | 52 (36) |
| Some midlevel or housestaff providers (<50% of all encounters) | 49 (34) |
| Mostly midlevel or housestaff providers (>50% of all encounters) | 22 (15) |
| Only midlevel or housestaff providers | 13 (9) |
| Unknown | 8 (6) |
| Location of practice | |
| Trinity Health System | 39 (27) |
| University of Michigan Health System | 37 (26) |
| Henry Ford Health System | 28 (19) |
| Spectrum Health System | 21 (15) |
| Ann Arbor VA Medical Center | 11 (8) |
| Unknown | 8 (6) |
Hospitalist Experiences and Practice Related to Peripherally Inserted Central Catheters
According to responding hospitalists, the most common indications for PICC placement were long‐term IV antibiotic treatment (64%), followed by inability to obtain peripheral venous access (24%). Hospitalists reported an average duration of PICC placement of 17 days (range, 342 days). A significant percentage of hospitalists (93%) stated that they had cared for patients where a PICC was placed only for use during hospitalization, with the most common reason for such insertion being difficulty in otherwise securing venous access (67%). Respondents also reported caring for patients who had both PICCs and peripheral IV catheters in place at the same time; 49% stated that they had experienced this <5 times, whereas 33% stated they had experienced this 510 times. Furthermore, 87% of respondents indicated having admitted a patient who specifically requested a PICC due to prior difficulties with venous access. More than half of surveyed hospitalists (63%) admitted to having been contacted by a PICC nurse enquiring as to whether their patient might benefit from PICC insertion.
The majority of hospitalists (66%) reported that they specified the number of lumens when ordering PICCs. Thirty‐eight percent indicated that this decision was based on type of medication, whereas 35% selected the lowest number of lumens possible. A power PICC (specialized PICCs that are designed to withstand high‐pressure contrast injections), was specifically requested for radiographic studies (56%), infusion of large volume of fluids (10%), or was the default PICC type at their facility (34%).
A majority (74%) of survey respondents also reported that once inserted, PICCs were always used to obtain blood for routine laboratory testing. Moreover, 41% indicated that PICCs were also always used to obtain blood for microbiological cultures. The 3 most frequently encountered PICC‐related complications reported by hospitalists in our survey were blockage of a PICC lumen, bloodstream infection, and venous thromboembolism (VTE; Table 3).
| Hospitalist Experiences With PICCs | Total (N=144) |
|---|---|
| |
| Primary indication for PICC placement* | |
| Long‐term IV antibiotics | 64 |
| Venous access in a patient with poor peripheral veins | 24 |
| Parenteral nutrition | 5 |
| Chemotherapy | 4 |
| Patient specifically requested a PICC | 1 |
| Unknown/other | 2 |
| PICC placed only for venous access, n (%) | |
| Yes | 135 (94) |
| No | 9 (6) |
| PICC placed only during hospitalization, n (%) | |
| Yes | 134 (93) |
| No | 10 (7) |
| Notified by a PICC nurse (or other provider) that patient may need or benefit from a PICC, n (%) | |
| Yes | 91 (63) |
| No | 53 (37) |
| How frequently PICCs are used to obtain blood for routine laboratory testing, n (%) | |
| Always | 106 (74) |
| Unknown/other | 38 (26) |
| How frequently PICCs are used to obtain blood for blood cultures, n (%) | |
| Always | 59 (41) |
| Unknown/other | 85 (59) |
| Hospitalist Opinions on PICCs | Total (N=144) |
| In your opinion, is it appropriate to place a vascular in a hospitalized patient if other forms of peripheral access cannot be obtained? n (%) | |
| Yes | 121 (84) |
| No | 21 (15) |
| Unknown | 2 (1) |
| In your opinion, should hospitalists be trained to insert PICCs? n (%) | |
| No | 57 (40) |
| Yes, this is an important skill set for hospitalists | 46 (32) |
| Unsure | 39 (27) |
| Unknown/other | 2 (1) |
| Do you think the increasing number of vascular nurses and PICC nursing teams has influenced the use of PICCs in hospitalized patients? n (%) | |
| Yes | 112 (78) |
| No | 30 (21) |
| Unknown | 2 (1) |
| What % of PICC insertions do you think may represent inappropriate use in your hospital? n (%) | |
| <10 | 53 (37) |
| 1025 | 68 (47) |
| 2550 | 18 (13) |
| >50 | 3 (2) |
| Unknown/other | 2 (1) |
Hospitalist Opinions Regarding Peripherally Inserted Central Catheters
Compared with CVCs, 69% of hospitalists felt that PICCs were safer and more efficient because they could stay in place longer and were less likely to cause infection. Most (65%) also agreed that PICCs were more convenient than CVCs because they were inserted by PICC teams. Additionally, 74% of hospitalists felt that their patients preferred PICCs because they minimize pain from routine peripheral IV changes and phlebotomy. A majority of respondents (84%) indicated that it was appropriate to place a PICC if other forms of peripheral venous access could not be obtained. However, when specifically questioned, 47% of hospitalists indicated that at least 10%25% of PICCs placed in their hospitals might represent inappropriate use. A majority (78%) agreed with the statement that the increase in numbers of vascular nurses had influenced use of PICCs in hospitalized patients, but most (45%) were neutral when asked if PICCs were more cost‐effective than traditional CVCs.
Hospitalist Knowledge Regarding Risk of Peripherally Inserted Central CatheterRelated Venous Thromboembolism and Bloodstream Infection
Although 65% of responding hospitalists disagreed with the statement that PICCs were less likely to lead to VTE, important knowledge gaps regarding PICCs and VTE were identified (Table 4). For instance, only 4% of hospitalists were correctly aware that the PICC‐tip position is checked to reduce risk of PICC‐related VTE, and only 12% knew that the site of PICC insertion has also been associated with VTE risk. Although 85% of respondents stated they would prescribe a therapeutic dose of an anticoagulant in the case of PICC‐associated VTE, deviations from the guideline‐recommended 3‐month treatment period were noted. For example, 6% of hospitalists reported treating with anticoagulation for 6 months, and 19% stated they would treat as long as the PICC remained in place, plus an additional period of time (eg, 24 weeks) after removal. With respect to bloodstream infection, 92% of responding hospitalists correctly identified PICC duration and prompt removal as factors promoting PICC‐related bloodstream infection and 78% accurately identified components of the catheter‐associated bloodstream infection bundle. When specifically asked about factors associated with risk of PICC‐related bloodstream infection, only half of respondents recognized the number of PICC lumens as being associated with this outcome.
| Total (N=144) | |
|---|---|
| |
| Why is the position of the PICC tip checked after bedside PICC insertion? n (%) | |
| To decrease the risk of arrhythmia related to right‐atrial positioning | 108 (75) |
| To minimize the risk of VTEa | 6 (4) |
| To ensure it is not accidentally placed into an artery | 16 (11) |
| For documentation purposes (to reduce the risk of lawsuits related to line‐insertion complications) | 6 (4) |
| Unsure/Unknown | 8 (6) |
| According to the 2012 ACCP Guidelines on VTE prevention, is pharmacologic prophylaxis for DVT recommended in patients who receive long‐term PICCs? n (%) | |
| No; no anticoagulant prophylaxis is recommended for patients who receive long‐term PICCsa | 107 (74) |
| Yes, but the choice and duration of anticoagulant is at the discretion of the provider | 23 (16) |
| Yes; aspirin is recommended for 3 months | 4 (3) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 3 months | 3 (2) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 6 months | 2 (1) |
| Unknown | 5 (4) |
| Assuming no contraindications exist, do you anticoagulate patients who develop a PICC‐associated DVT (with any therapeutic anticoagulant)? n (%) | |
| Yesa | 122 (85) |
| No | 16 (11) |
| Unknown | 6 (4) |
| How long do you usually prescribe anticoagulation for patients who develop PICC‐associated DVT? n (%) | |
| I don't prescribe anticoagulation | 12 (8) |
| 1 month | 4 (3) |
| 3 monthsa | 84 (58) |
| 6 months | 8 (6) |
| As long as the line remains in place; I stop anticoagulation once the PICC comes out | 3 (2) |
| As long as the line remains in place and for an additional specified period of time after line removal, such as 2 or 4 weeks | 27 (19) |
| Unknown | 6 (4) |
| As part of the treatment of PICC‐related DVT, do you routinely remove the PICC?b n (%) | |
| Yes | 102 (71) |
| No | 36 (25) |
| Unknown | 6 (4) |
Variation in Hospitalist Knowledge, Experience, or Opinions
We assessed whether any of our findings varied according to hospitalist type (full time versus part time), years of practice (<1, 15, >5), and model of care delivery (direct care vs learner‐based care). Our analyses suggested that part‐time hospitalists were more likely to select rarely when it came to finding patients with a PICC and a working peripheral IV at the same time (74% vs 45%, P=0.02). Interestingly, a higher percentage of those in practice <5 years indicated that 10%25% of PICCs represented inappropriate placement (58% vs 33%, P<0.01) and that vascular nurses had influenced the use of PICCs in hospitalized patients (88% vs 69%, P=0.01). Lastly, a higher percentage of hospitalists who provided direct patient care reported that PICCs were always used to obtain blood for microbiological culture (54% vs 37%, P=0.05).
DISCUSSION
In this survey of hospitalists practicing at 5 large healthcare systems in Michigan, we observed significant variation in experience, reported practice, opinions, and knowledge related to PICCs. Our findings highlight important concerns related to inpatient PICC use and suggest a need for greater scrutiny related to these devices in these settings.
The use of PICCs in hospitalized patients has risen dramatically over the past decade. Though such growth is multifactorial and relates in part to increasing inpatient volume and complexity, hospitalists have increasingly turned to PICCs as a convenient and reliable tool to obtain venous access.[7] Indeed, in our survey, PICCs that were only used during hospitalization were most likely to be placed for this very reason. Because PICCs are safer to insert than CVCs and the original evidence regarding PICC‐related VTE or bloodstream infection suggested low rates of these events,[8, 9, 10, 11, 12, 13, 14] many hospitalists may not perceive these devices as being associated with significant risks. In fact, some have suggested that hospitalists be specifically trained to insert these devices, given their safety compared with traditional CVCs.[7]
However, accumulating evidence suggests that PICCs are associated with important complications.[5, 15, 16] In studies examining risk of bloodstream infection, PICCs were associated with significant risk of this outcome.[6, 17, 18] Recently, the presence of a PICC was identified as an independent predictor of VTE in hospitalized patients.[19] Several studies and systematic reviews have repeatedly demonstrated these findings.[19, 20, 21, 22] A recent systematic review examining nonpharmacologic methods to prevent catheter‐related thrombosis specifically called for avoidance of PICC insertion to prevent thrombosis in hospitalized patients.[23] Despite this growing evidence base, the use of PICCs in the inpatient setting is likely to rise, and our survey highlights several practices that may contribute to adverse outcomes. For instance, hospitalists in our survey were unlikely to remove a PICC until a patient was discharged, irrespective of the need for this device. As each day with a PICC increases the risk of complications, such practice poses potential patient safety concerns. Similarly, many hospitalists believe that PICCs are safer than CVCs, a viewpoint that does not stand up to increasing scrutiny and highlights important knowledge gaps. The risk of PICC‐related complications appears not to be a stationary target, but rather a dynamic balance that is influenced by patient‐, provider‐, and device‐specific characteristics.[2] Increasing discretionary use (especially for patients with poor peripheral venous access), forgetting at times that a patient has a PICC, and the finding that up to 25% of PICCs placed in their hospitals may be unnecessary underscore concerns regarding the safety of current practice trends. Interestingly, the viewpoints of hospitalists in practice <5 years and those providing direct patient care were more likely to reflect concerns regarding inappropriate placement, influence of vascular nurses, and use of PICCs for blood culture. This finding may reflect that these nuances are more recent phenomena or perhaps most apparent when care is delivered directly.
Our study must be interpreted in the context of several limitations. First, as this was a survey‐based study of a small, convenience sample of hospitalists in a single state, recall, respondent, and systematic biases remain threats to our findings. However, all site PIs encouraged survey participation and (through local dialogue) none were aware of material differences between those who did or did not participate in the study. Similarly, Michigan is a diverse and relatively large state, and our results should be generalizable to other settings; however, national studies are necessary to confirm our findings. Second, our response rate may be perceived as low; however, our rates are in accordance with, and, in fact, superior to those of many existing physician surveys.[24] Finally, only 1 federal facility was included in this study; thus, this care‐delivery model is underrepresented, limiting generalization of findings to other such sites.
However, our study also has important strengths. First, this is the only survey that specifically examines hospitalist viewpoints when it comes to PICCs. As hospitalists frequently order and/or insert these devices, their perspectives are highly pertinent to discussions regarding current PICC use. Second, our survey highlights several instances that may be associated with preventable patient harm and identifies areas where interventions may be valuable. For example, forgetting the presence of a device, keeping PICCs in place throughout hospitalization, and rendering treatment for PICC‐related VTE not in accordance with accepted guidelines are remediable practices that may lead to poor outcomes. Interventions such as device‐reminder alerts, provider education regarding complications from PICCs, and systematic efforts to identify and remove unnecessary PICCs may mitigate these problems. Finally, our findings highlight the need for data repositories that track PICC use and hospitalist practice on a national scale. Given the risk and significance of the complications associated with these devices, understanding the epidemiology, use, and potential misuse of PICCs are important areas for hospitalist research.
In conclusion, our study of hospitalist experience, practice, opinions, and knowledge related to PICCs suggests important gaps between available evidence and current practice. There is growing need for the development of appropriateness criteria to guide vascular access in inpatient settings.[25, 26] Such criteria should consider not only type of venous access device, but granular details including rationale for venous access, nature of the infusate, optimal number of lumens, and safest gauge when recommending devices. Until such criteria and comparative studies become available, hospitals should consider instituting policies to monitor PICC use with specific attention to indication for insertion, duration of placement, and complications. These interventions represent a first and necessary step in improving patient safety when it comes to preventing PICC‐related complications.
Disclosures
The Blue Cross/Blue Shield of Michigan Foundation in Detroit funded this study through an investigator‐initiated research proposal (1931‐PIRAP). The funding source, however, played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.
- , , , et al. Hospital‐wide survey of the use of central venous catheters. J Hosp Infect. 2011;77(4):304–308.
- , , , , . Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med. 2012;125(8):733–741.
- , , . The problem with peripherally inserted central catheters. JAMA. 2012;308(15):1527–1528.
- , , , et al. Reduction of peripherally inserted central catheter associated deep venous thrombosis [published online ahead of print August 1, 2012]. Chest. doi: 10.1378/chest.12–0923.
- , , . Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia. 2012;67(1):65–71.
- , , , et al. Patient‐ and device‐specific risk factors for peripherally inserted central venous catheter‐related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
- , . Peripherally inserted central catheter use in the hospitalized patient: is there a role for the hospitalist? J Hosp Med. 2009;4(6):E1–E4.
- , , , , , . Peripherally inserted central catheter (PICC)‐associated upper‐extremity deep venous thrombosis (UEDVT) in critical‐care setting. Chest. 2005;128(4 suppl S):193S–194S.
- , , , , , . Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally inserted central catheters. Clin Nutr. 2000;19(4):237–243.
- , . Risk of catheter‐related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–495.
- , , , . Long‐term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer. 1979;43(5):1937–1943.
- , , , , . Central vs peripheral venous catheters in critically ill patients. Chest. 1986;90(6):806–809.
- , , , , . Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters. Am J Med. 1991;91(3B):95S–100S.
- , , , , . Upper‐extremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest. 1991;99(2):280–283.
- , , , et al. Risk factors for catheter‐related thrombosis (CRT) in cancer patients: a patient‐level data (IPD) meta‐analysis of clinical trials and prospective studies. J Thromb Haemost. 2011;9(2):312–319.
- , , , et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179–1183.
- , , , et al. Peripherally inserted central venous catheter–associated bloodstream infections in hospitalized adult patients. Infect Control Hosp Epidemiol. 2011;32(2):125–130.
- , , . Peripherally inserted central catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia. Ann Saudi Med. 2012;32(2):169–173.
- , , , et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med. 2011;124(10):947.e942–954.e942.
- , , , et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010;138(4):803–810.
- , , . The clinical significance of peripherally inserted central venous catheter‐related deep vein thrombosis. Neurocrit Care. 2011;15(3):454–460.
- , , , et al. Catheter‐associated bloodstream infection incidence and risk factors in adults with cancer: a prospective cohort study. J Hosp Infect. 2011;78(1):26–30.
- , , , . Nonpharmacologic interventions for prevention of catheter‐related thrombosis: a systematic review [published online ahead of print September 13, 2012]. J Crit Care. doi: 10.1016/j.jcrc.2012.07.007.
- , , . Why are response rates in clinician surveys declining? Can Fam Physician. 2012;58(4):e225–e228.
- , , , , , . Sensitivity and specificity of the RAND/UCLA Appropriateness Method to identify the overuse and underuse of coronary revascularization and hysterectomy. J Clin Epidemiol. 2001;54(10):1004–1010.
- , , , et al. Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures. Med Care. 1996;34(6):512–523.
- , , , et al. Hospital‐wide survey of the use of central venous catheters. J Hosp Infect. 2011;77(4):304–308.
- , , , , . Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med. 2012;125(8):733–741.
- , , . The problem with peripherally inserted central catheters. JAMA. 2012;308(15):1527–1528.
- , , , et al. Reduction of peripherally inserted central catheter associated deep venous thrombosis [published online ahead of print August 1, 2012]. Chest. doi: 10.1378/chest.12–0923.
- , , . Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia. 2012;67(1):65–71.
- , , , et al. Patient‐ and device‐specific risk factors for peripherally inserted central venous catheter‐related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
- , . Peripherally inserted central catheter use in the hospitalized patient: is there a role for the hospitalist? J Hosp Med. 2009;4(6):E1–E4.
- , , , , , . Peripherally inserted central catheter (PICC)‐associated upper‐extremity deep venous thrombosis (UEDVT) in critical‐care setting. Chest. 2005;128(4 suppl S):193S–194S.
- , , , , , . Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally inserted central catheters. Clin Nutr. 2000;19(4):237–243.
- , . Risk of catheter‐related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–495.
- , , , . Long‐term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer. 1979;43(5):1937–1943.
- , , , , . Central vs peripheral venous catheters in critically ill patients. Chest. 1986;90(6):806–809.
- , , , , . Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters. Am J Med. 1991;91(3B):95S–100S.
- , , , , . Upper‐extremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest. 1991;99(2):280–283.
- , , , et al. Risk factors for catheter‐related thrombosis (CRT) in cancer patients: a patient‐level data (IPD) meta‐analysis of clinical trials and prospective studies. J Thromb Haemost. 2011;9(2):312–319.
- , , , et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179–1183.
- , , , et al. Peripherally inserted central venous catheter–associated bloodstream infections in hospitalized adult patients. Infect Control Hosp Epidemiol. 2011;32(2):125–130.
- , , . Peripherally inserted central catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia. Ann Saudi Med. 2012;32(2):169–173.
- , , , et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med. 2011;124(10):947.e942–954.e942.
- , , , et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010;138(4):803–810.
- , , . The clinical significance of peripherally inserted central venous catheter‐related deep vein thrombosis. Neurocrit Care. 2011;15(3):454–460.
- , , , et al. Catheter‐associated bloodstream infection incidence and risk factors in adults with cancer: a prospective cohort study. J Hosp Infect. 2011;78(1):26–30.
- , , , . Nonpharmacologic interventions for prevention of catheter‐related thrombosis: a systematic review [published online ahead of print September 13, 2012]. J Crit Care. doi: 10.1016/j.jcrc.2012.07.007.
- , , . Why are response rates in clinician surveys declining? Can Fam Physician. 2012;58(4):e225–e228.
- , , , , , . Sensitivity and specificity of the RAND/UCLA Appropriateness Method to identify the overuse and underuse of coronary revascularization and hysterectomy. J Clin Epidemiol. 2001;54(10):1004–1010.
- , , , et al. Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures. Med Care. 1996;34(6):512–523.
Copyright © 2013 Society of Hospital Medicine
Epidemiology of Organ System Dysfunction
The International Consensus Conference (ICC) for sepsis defines severe sepsis as an infection leading to acute organ dysfunction.[1, 2] Severe sepsis afflicts over 1 million patients each year in Medicare alone, and is substantially more common among older Americans than acute myocardial infarction.[3, 4, 5] Recently, the Agency for Healthcare Research and Quality identified severe sepsis as the single most expensive cause of hospitalization in the United States.[6] The incidence of severe sepsis continues to rise.[4, 5]
Severe sepsis is often mischaracterized as a diagnosis cared for primarily in the intensive care unit (ICU). Yet, studies indicate that only 32% to 50% of patients with severe sepsis require ICU care, leaving the majority on the general care wards.[7, 8] These studies also reveal mortality rates of 26% to 30% among patients with severe sepsis who are not admitted to an ICU compared to 11% to 33% in the ICU.[7, 8]
Although a number of epidemiologic and interventional studies have focused on severe sepsis in the ICU,[3, 9, 10] much less is known about patients cared for on the general medicine wards. Without this information, clinicians cannot make informed choices about important management decisions such as targeted diagnostic testing, empirical antimicrobials, and other therapies. To this end, we sought to further characterize the infectious etiologies and resultant organ system dysfunctions in the subset of patients with severe sepsis admitted to non‐ICU medical services at a tertiary academic medical center.
METHODS
Population/Setting
All hospitalizations of adult patients (18 years old) who were initially admitted to non‐ICU medical services at the University of Michigan Hospital during 2009 through 2010 were included. The University of Michigan Hospital has 610 general medical‐surgical beds, including telemetry beds, with closed ICUs comprised of 179 beds staffed by intensivists. Patients transferred from other hospitals and those admitted to non‐medical services were excluded.
Data Abstraction and Definitions
All International Classification of Diseases, 9th Revision, Clinical Modification (ICD‐9‐CM) diagnosis codes for hospitalizations were screened using a previously published and validated algorithm for severe sepsis.[11] Following this screening, 3 randomly selected round‐numbered batches of hospitalizations were sampled with subsequent application of the exclusion criteria. Medical records including physicians' notes, consultants' notes, nurses' notes, physical therapy notes, discharge coordinators' notes, emergency room flow sheets, as well as ward flow sheets were reviewed in detail by 3 practicing hospitalists using a structured instrument closely aligned with the ICC definition of severe sepsis.[2] We also sampled a smaller number of patients whose ICD‐9‐CM diagnoses screened negative for severe sepsis. Sample size was selected as part of a project with multiple objectives, and reflected a pragmatic balance between the anticipated precision of the results and the resources available to conduct chart review.[11] All discrepancies were reconciled among the 3 reviewers.
Reviewers first assessed whether infection was present, then evaluated for evidence of each organ system dysfunction, and finally determined the extent to which those organ dysfunctions were a response to the infection. Infection was defined either as a patient with a microbiologic culture growing a pathologic organism in a normally sterile site or documentation of a suspected infection with other confirmatory evidence (radiological, physical exam finding) with resultant systemic inflammatory response and administration of antimicrobials. Community‐acquired and healthcare‐associated infections were not differentiated. Microbiologic data, confirmatory tests, and site of infection were abstracted in detail.
Organ dysfunction was defined as per the 2001 ICC criteria,[2] and was assessed for neurological, pulmonary, cardiovascular, renal, gastrointestinal, hematological, and hepatic system involvement in all patients. A summary of these clinical definitions is included in Table 1. Data on important comorbidities were also abstracted. Immunosuppression was defined as having any of the following: solid organ transplant, bone marrow/stem cell transplant, human immunodeficiency virus/acquired immunodeficiency syndrome, neutropenia (absolute neutrophil count <1000), hematologic malignancy, solid organ malignancy with chemotherapy within the past 12 months, or pharmacologic immunosuppression (prednisone >20 mg daily for >4 weeks, calcineurin inhibitor, methotrexate, tumor necrosis factor inhibitors, azathioprine, sulfasalazine, hydroxychloroquine). Last, each chart was evaluated for the presence of explicit documentation with the presence of the words or phrases: sepsis, septic shock, or severe sepsis, indicating that the clinical service recognized and fully documented that a patient had severe sepsis.
| Organ System | Parameters to Indicate Dysfunction |
|---|---|
| |
| Cardiovascular | Systolic BP <90, elevated lactate, MAP <70, requiring pressors >2 hours, decrease in systolic BP of >40 |
| Renal | Creatinine increase >0.5 mg/dL, oliguria |
| Neurological | Acute mental status changes |
| Pulmonary | Intubation, BiPAP, supplemental oxygen >6 LPM or 40% face mask, PaO2/FiO2 <300 |
| Hematologic | INR >1.5 or PTT >60 not on anticoagulation, platelets <100 or 50% of baseline |
| Ileus | Decreased bowel motility requiring a change in diet |
| Hepatic | Bilirubin >4 mg/dL and >1.5 baseline |
Data Analysis
Methods for assessment of reviewer concordance have been previously described and were summarized using the kappa statistic.[11] Initial data extraction was performed in SAS 9.1 (SAS Institute, Cary, NC) and all analyses were conducted in Stata 12 (StataCorp LP, College Station, TX). Binomial 95% confidence intervals (CIs) are presented. This project was approved by the University of Michigan Institutional Review Board.
RESULTS
Of 23,288 hospitalizations examined from 2009 through 2010, the ICD‐9based automated screen for severe sepsis was positive for 3,146 (14 %). A random sample of 111 medical records, of which 92 had screened positive for severe sepsis and 19 had screened negative, was reviewed in detail. After review by the hospitalists, 64 of these 111 hospitalizations were judged to have severe sepsis, 61 of the 92 screened positive cases (66%), and 3 of the 19 screened negative cases (16%). The 3 reviewers had a kappa of 0.70, indicating good agreement.
Characteristics of the 64 patients with severe sepsis are shown in Table 2. The mean age was 63 years old (standard deviation [SD]=17.7), and 41% were male. The mean length of stay was 13.7 days (SD=20.8). Thirty‐nine percent (95% CI, 27%‐52%) of patients (25/64) were immunosuppressed. Of patients initially admitted to the general medical ward, 25% (16/64; 95% CI, 15%‐37%) ultimately required ICU care during their admission. The overall in‐hospital mortality rate was 13% (8/64; 95% CI, 6%‐23%). Immunosuppressed patients had a mortality rate of 20% and nonimmunosuppressed patients had a mortality rate of 8%. Only 47% (30/64; 95% CI, 34%‐60%) of the medical records had explicit clinician documentation of severe sepsis.
| Age, mean (SD), y | 63 (18) |
|---|---|
| |
| Male sex, no. (%) | 26 (41) |
| Preexisting conditions, no. (%) | |
| History of diabetes | 20 (31) |
| End stage renal disease on chronic dialysis | 2 (3) |
| Chronic obstructive pulmonary disease on oxygen | 3 (5) |
| History of cancer | 15 (23) |
| Liver cirrhosis | 5 (8) |
| Immunosuppression | 25 (39) |
| Median length of stay (days) | 7.5 |
| Mean length of stay (SD) | 13.7 (20.8) |
The most common site of infection was found to be the genitourinary system, occurring in 41% (26/64; 95% CI, 29%‐54%) of patients (Table 3). Pulmonary and intra‐abdominal sites were also common, accounting for 14% (95% CI, 6.6%‐25%) and 13% (95% CI, 5.6%‐23%) of sites, respectively. An infecting organism was identified by culture in 66% (42/64; 95% CI, 53%‐77%) of case patients with specific pathogens listed in Table 4. Among patients with positive culture results, the majority grew Gram‐negative organisms (57%; 95% CI, 41%‐72%). Non‐Clostridium difficile Gram‐positive organisms were also prominent and identified in 48% (95% CI, 32%‐64%) of positive cultures. Candida was less common (12%, 95% CI, 4.0%‐26%). Fourteen cases (22%, 95% CI, 10%‐30%) had 2 or more concomitant infectious pathogens.
| Site | No. (%) |
|---|---|
| |
| Genitourinary | 26 (41) |
| Pulmonary | 9 (14) |
| Intra‐abdominal (not intraluminal) | 8 (13) |
| Bloodstream/cardiac | 5 (8) |
| Skin and soft tissue | 4 (6) |
| GI lumen | 4 (6) |
| Joint | 2 (3) |
| Multiple sites | 4 (6) |
| Unknown | 2 (2) |
| Absolute Frequency, Total Positive Culture Results, N=64, No. (%)*?>a | Patients With Cultures Growing at Least One of the Pathogens, N=42, No. (%)*?>a | |
|---|---|---|
| ||
| Gram‐negative pathogens | 30 (47) | 24 (57) |
| Escherichia coli | 12 (19) | 12 (29) |
| Escherichia coli (multidrug resistant) | 2 (3) | 2 (5) |
| Klebsiella | 6 (9) | 5 (12) |
| Pseudomonas aeruginosa | 6 (9) | 4 (10) |
| Pseudomonas aeruginosa (multidrug resistant) | 2 (3) | 2 (5) |
| Otherb | 6 (9) | 6 (14) |
| Gram‐positive pathogens | 29 (45) | 25 (59) |
| Enterococcus | 14 (22) | 13 (31) |
| Vancomycin‐resistant Enterococcus species | 5 (8) | 4 (10) |
| Staphylococcus aureus | 7 (11) | 7 (17) |
| Methicillin‐resistant Staphylococcus aureus | 3 (5) | 3 (7) |
| Streptococcus pneumoniae | 2 (3) | 2 (5) |
| Coagulase‐negative staphylococci | 1 (2) | 1 (2) |
| Clostridium difficile | 5 (8) | 5 (12) |
| Fungi | ||
| Candida species | 5 (8) | 5 (12) |
| Mycobacterium avium | 1 (2) | 1 (2) |
| Two organisms | 9 (21) | |
| Three or more organisms | 5 (12) | |
All 64 patients had at least 1 organ dysfunction, as required by the ICC definition of severe sepsis. Organ dysfunction in 2 or more organ systems occurred in 77% (95% CI, 64%‐86%) of the cases (49/64). The incidence for each organ system dysfunction is presented in Table 5, as well as its relationship to both mortality and ICU admission. The most common organ system dysfunctions were found to be cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of the cases, respectively. In this non‐ICU population, pulmonary dysfunction occurred in 30% of cases, but was frequently associated with transfer to the ICU, as 63% of the patients with pulmonary failure required ICU care. Patients with more organ systems affected were more likely to be transferred to the ICU and to die.
| No. (%) | ICU Transfer, No. (%) | Mortality, No. (%) | |
|---|---|---|---|
| |||
| Number of failed organs, N = 64 | |||
| 1 | 15 (23%) | 0 (0%) | 0 (0%) |
| 2 | 25 (39%) | 2 (8%) | 0 (0%) |
| 3 | 7 (11%) | 2 (29%) | 1 (14%) |
| 4 | 10 (16%) | 6 (60%) | 3 (30%) |
| >4 | 7 (11%) | 6 (86%) | 4 (57%) |
| Types of organ system dysfunction, all patients, N = 64*?>a | |||
| Cardiovascular | 42 (66%) | 16 (38%)b | 8 (19%)c |
| Renal | 41 (64%) | 10 (24%)b | 5 (12%)c |
| Central nervous system | 35 (54%) | 14 (40%)b | 7 (18%)c |
| Pulmonary | 19 (30%) | 12 (63%)b | 8 (42%)c |
| Hematologic | 15 (23%) | 6 (40%)b | 6 (40%)c |
| GI (ileus) | 8 (13%) | 5 (63%)b | 1 (13%)c |
| Hepatic | 5 (8%) | 4 (80%)b | 2 (40%)c |
DISCUSSION
Severe sepsis was common among patients admitted to the general medical ward in this tertiary care center. Our patient cohort differed in important ways from previously described typical cases of severe sepsis among ICU populations. Severe sepsis on the general medical wards was more commonly associated with Gram‐negative pathogens in the setting of genitourinary tract infections. This is in contrast to Gram‐positive organisms and respiratory tract infections, which are more common in the ICU.[3, 10] Renal and cardiac dysfunction were commonly observed organ failures, whereas in the ICU, severe sepsis has been reported to more likely involve respiratory failure. These results suggest that hospitalists seeking to provide evidence‐based care to prevent postsepsis morbidity and mortality for their non‐ICU patients need to heighten their index of suspicion when caring for an infected patient and appreciate that many severe sepsis patients may not fit neatly into traditional sepsis treatment algorithms.
Studies characterizing severe sepsis in the ICU setting indicate a predominance of pulmonary infections and respiratory failure with occurrence rates of 74% to 95% and 54% to 61%, respectively.[3, 12, 13] Given that either shock or pulmonary dysfunction is often required for admission to many ICUs, it is perhaps not surprising that these rates are dramatically different on the general medicine ward, with a relative scarcity of pulmonary infections (14%) and respiratory dysfunction (30%). Instead, genitourinary infections were noted in 41% (95% CI, 29%‐54%) of the cases, in contrast to the rates of genitourinary infections in ICU patients with severe sepsis, which have rates of 5.4% to 9.1%.[3, 10] Likely as a result of this, a Gram‐negative predominance is noted in the associated microbiology. Furthermore, our study indicates that C difficile and vancomycin‐resistant Enterococcus (VRE) species appear to represent an emerging cause of severe sepsis on the general medicine wards, as they have not been noted to be causative micro‐organisms in previous studies of sepsis. This is concordant with other studies showing increases in incidence and severity of disease for C difficile as well as VRE.[14, 15]
Previous epidemiologic studies of severe sepsis originating outside the ICU are lacking, but some work has been done. One study on the epidemiology of sepsis both with and without organ dysfunction aggregated all hospitalized patients and included those both admitted to the general medicine wards and directly to the ICU.[7] Similar to our study, this study also found a predominance of Gram‐negative causative organisms, as well as comparable in‐hospital mortality rates (12.8% vs 13%). Additionally, genitourinary infections were noted in 20% of the patients, notably higher than rates reported to have been found in patients with severe sepsis in the ICU, but not the magnitude found in our study, perhaps as a result of the combined ICU‐ward population studied. A similar high prevalence of genitourinary infections was also noted in a recent administrative data‐based study of emergency medical services‐transported patients with severe sepsis, half of whom required intensive care during their hospitalization.[16]
Our study is unique in that it focuses on severe sepsis in patients, commonly cared for by hospitalists, who were admitted to the general medical ward, and uses patient level data to elucidate more characteristics of the defining organ dysfunction. Furthermore, our results suggest that severe sepsis was poorly documented in this setting, indicating a potential impact on billing, coding, case mix index, and hospital mortality statistics that rely on very specific wording, as well as a possible need for increased awareness among hospitalists. Without this awareness, an opportunity may be missed for improved patient care via specific sepsis‐targeted measures,[13, 17, 18] including more aggressive resuscitative measures[19] or intensive physical and occupational therapy interventions aimed at impacting the cognitive and functional debilities[20] that result from severe sepsis. Highlighting this growing need to better assist clinicians assess the severity of septic patients and recognize these complex cases on the general medicine wards, 1 recent study evaluated the fitness of several clinical disease‐severity scoring systems for patients with sepsis in general internal medicine departments.[21] Perhaps with the help of tools such as these, which are being piloted in some hospitals, the care of this growing population can be enhanced.
Our study has a number of limitations that should be kept in mind. First, this is a single center study performed at an academic tertiary care center with a relatively high incidence of immunosuppression, which may influence the spectrum of infecting organisms. Our center also has a relatively large, closed‐model ICU, which often operates at near capacity, potentially affecting the severity of our non‐ICU population. Second, although we screened a large number of patients, as necessitated by our intensive and detailed review of clinical information, our sample size with hospitalist‐validated severe sepsis is relatively small. With this small sample size, less prevalent infections, patient characteristics, and organ dysfunctions may by chance have been under or over‐represented, and one could expect some variance in the occurrence rates of organ system dysfunction and infection rates by sampling error alone. Further larger scale studies are warranted to confirm these data and their generalizability. Third, the data necessary to calculate sequential organ failure assessment or multiple organ dysfunction score were not collected. This may limit the ability to directly compare the organ dysfunction noted in this study with others. Additionally, given the ICC definitions of organ dysfunction, some of the organ dysfunction noted, particularly for neurological dysfunction, was reliant on subjective clinical findings documented in the record. Finally, we relied on the lack of specific terminology to indicate a lack of documentation of sepsis, which does not necessarily indicate a lack of recognition or undertreatment of this condition. However, these limitations are offset by the strengths of this study, including the patient‐level medical record validation of severe sepsis by trained hospitalist physicians, high kappa statistic, and strict application of guideline‐based definitions.
This work has important implications for both clinicians and for future research on severe sepsis. The results suggest that severe sepsis may be quite common outside the ICU, and that patients presenting with this condition who are admitted to general medical wards are not routinely characterized by the profound hypoxemia and refractory shock of iconic cases. Certainly, further study looking at larger numbers of cases is needed to better understand the specifics and nuances of this important topic as well as to further evaluate clinicians' ability to recognize and treat such patients in this setting. Furthermore, future research on the treatment of severe sepsis, including both antimicrobials and disease‐modifying agents (eg, anti‐inflammatories) must continue to include and even focus on this large population of non‐ICU patients with severe sepsis, as the risk/benefit ratios of such potential treatments may vary with severity of illness.
In conclusion, severe sepsis was commonly found in patients admitted on the general medicine wards. The epidemiology of the infections and resultant organ dysfunction appears to differ from that found in the ICU. More studies are needed to provide a deeper understanding of this disease process, as this will enable clinicians to better recognize and treat patients thus afflicted, no matter the setting.
Acknowledgments
The authors thank Laetitia Shapiro, AM, for her programming assistance.
Disclosures: This work was supported in part by the US National Institutes of HealthK08, HL091249 (TJI) and the University of Michigan SpecialistHospitalist Allied Research Program (SHARP). This work was also supported in part by VA Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC).
- , , , et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101(6):1644–1655.
- , , , et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31(4):1250–1256.
- , , , , , . Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303–1310.
- , , , . Population burden of long‐term survivorship after severe sepsis in older americans. J Am Geriatr Soc. 2012;60(6):1070–1077.
- , , , . The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348(16):1546–1554.
- , , . Septicemia in U.S. hospitals, 2009: statistical brief #122. October 2011. In: Healthcare Cost and Utilization Project Statistical Briefs. Rockville, MD: Agency for Health Care Policy and Research; 2006. Available from: http://www.ncbi.nlm.nih.gov/books/NBK65391. Accessed June 2, 2012.
- , , , et al. Sepsis incidence and outcome: contrasting the intensive care unit with the hospital ward. Crit Care Med. 2007;35(5):1284–1289.
- , , , , . Epidemiology of sepsis in Victoria, Australia. Crit Care Med. 2005;33(1):71–80.
- , , , et al. Effect of empirical treatment with moxifloxacin and meropenem vs meropenem on sepsis‐related organ dysfunction in patients with severe sepsis: a randomized trial. JAMA. 2012;307(22):2390–2399.
- , , , , . Incidence and impact of organ dysfunctions associated with sepsis. Chest. 2005;127(3):942–951.
- , , , et al. Identifying patients with severe sepsis using administrative claims: patient‐level validation of the Angus Implementation of the International Consensus Conference definition of severe sepsis [published online ahead of print September 18, 2012]. Medical Care. doi: 10.1097/MLR.0b013e318268ac86.
- , , , . Current epidemiology of septic shock: the CUB‐Rea Network. Am J Respir Crit Care Med. 2003;168(2):165–172.
- . Management of sepsis. N Engl J Med. 2006;355(16):1699–1713.
- , , . Current status of Clostridium difficile infection ipidemiology. Clin Infect Dis. 2012;55(suppl 2):S65–S70.
- , . Vancomycin‐resistant enterococci. Semin Respir Infect. 2000;15(4):314–326.
- , , , , , . Severe sepsis in prehospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med. 2012;186(12):1264–1271.
- , . Novel Therapies for Septic Shock Over the Past 4 Decades. JAMA. 2011;306(2):194–199.
- , , , et al. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three‐year follow‐up quasi‐experimental study. Crit Care Med. 2010;38(4):1036–1043.
- , . Diagnosis and treatment of severe sepsis. Crit Care. 2007;11(suppl 5):S2.
- , , , . Long‐term cognitive impairment and functional disability among survivors of severe sepsis. JAMA. 2010;304(16):1787–1794.
- , , , , . Assessment of disease‐severity scoring systems for patients with sepsis in general internal medicine departments. Crit Care. 2011;15:R95.
The International Consensus Conference (ICC) for sepsis defines severe sepsis as an infection leading to acute organ dysfunction.[1, 2] Severe sepsis afflicts over 1 million patients each year in Medicare alone, and is substantially more common among older Americans than acute myocardial infarction.[3, 4, 5] Recently, the Agency for Healthcare Research and Quality identified severe sepsis as the single most expensive cause of hospitalization in the United States.[6] The incidence of severe sepsis continues to rise.[4, 5]
Severe sepsis is often mischaracterized as a diagnosis cared for primarily in the intensive care unit (ICU). Yet, studies indicate that only 32% to 50% of patients with severe sepsis require ICU care, leaving the majority on the general care wards.[7, 8] These studies also reveal mortality rates of 26% to 30% among patients with severe sepsis who are not admitted to an ICU compared to 11% to 33% in the ICU.[7, 8]
Although a number of epidemiologic and interventional studies have focused on severe sepsis in the ICU,[3, 9, 10] much less is known about patients cared for on the general medicine wards. Without this information, clinicians cannot make informed choices about important management decisions such as targeted diagnostic testing, empirical antimicrobials, and other therapies. To this end, we sought to further characterize the infectious etiologies and resultant organ system dysfunctions in the subset of patients with severe sepsis admitted to non‐ICU medical services at a tertiary academic medical center.
METHODS
Population/Setting
All hospitalizations of adult patients (18 years old) who were initially admitted to non‐ICU medical services at the University of Michigan Hospital during 2009 through 2010 were included. The University of Michigan Hospital has 610 general medical‐surgical beds, including telemetry beds, with closed ICUs comprised of 179 beds staffed by intensivists. Patients transferred from other hospitals and those admitted to non‐medical services were excluded.
Data Abstraction and Definitions
All International Classification of Diseases, 9th Revision, Clinical Modification (ICD‐9‐CM) diagnosis codes for hospitalizations were screened using a previously published and validated algorithm for severe sepsis.[11] Following this screening, 3 randomly selected round‐numbered batches of hospitalizations were sampled with subsequent application of the exclusion criteria. Medical records including physicians' notes, consultants' notes, nurses' notes, physical therapy notes, discharge coordinators' notes, emergency room flow sheets, as well as ward flow sheets were reviewed in detail by 3 practicing hospitalists using a structured instrument closely aligned with the ICC definition of severe sepsis.[2] We also sampled a smaller number of patients whose ICD‐9‐CM diagnoses screened negative for severe sepsis. Sample size was selected as part of a project with multiple objectives, and reflected a pragmatic balance between the anticipated precision of the results and the resources available to conduct chart review.[11] All discrepancies were reconciled among the 3 reviewers.
Reviewers first assessed whether infection was present, then evaluated for evidence of each organ system dysfunction, and finally determined the extent to which those organ dysfunctions were a response to the infection. Infection was defined either as a patient with a microbiologic culture growing a pathologic organism in a normally sterile site or documentation of a suspected infection with other confirmatory evidence (radiological, physical exam finding) with resultant systemic inflammatory response and administration of antimicrobials. Community‐acquired and healthcare‐associated infections were not differentiated. Microbiologic data, confirmatory tests, and site of infection were abstracted in detail.
Organ dysfunction was defined as per the 2001 ICC criteria,[2] and was assessed for neurological, pulmonary, cardiovascular, renal, gastrointestinal, hematological, and hepatic system involvement in all patients. A summary of these clinical definitions is included in Table 1. Data on important comorbidities were also abstracted. Immunosuppression was defined as having any of the following: solid organ transplant, bone marrow/stem cell transplant, human immunodeficiency virus/acquired immunodeficiency syndrome, neutropenia (absolute neutrophil count <1000), hematologic malignancy, solid organ malignancy with chemotherapy within the past 12 months, or pharmacologic immunosuppression (prednisone >20 mg daily for >4 weeks, calcineurin inhibitor, methotrexate, tumor necrosis factor inhibitors, azathioprine, sulfasalazine, hydroxychloroquine). Last, each chart was evaluated for the presence of explicit documentation with the presence of the words or phrases: sepsis, septic shock, or severe sepsis, indicating that the clinical service recognized and fully documented that a patient had severe sepsis.
| Organ System | Parameters to Indicate Dysfunction |
|---|---|
| |
| Cardiovascular | Systolic BP <90, elevated lactate, MAP <70, requiring pressors >2 hours, decrease in systolic BP of >40 |
| Renal | Creatinine increase >0.5 mg/dL, oliguria |
| Neurological | Acute mental status changes |
| Pulmonary | Intubation, BiPAP, supplemental oxygen >6 LPM or 40% face mask, PaO2/FiO2 <300 |
| Hematologic | INR >1.5 or PTT >60 not on anticoagulation, platelets <100 or 50% of baseline |
| Ileus | Decreased bowel motility requiring a change in diet |
| Hepatic | Bilirubin >4 mg/dL and >1.5 baseline |
Data Analysis
Methods for assessment of reviewer concordance have been previously described and were summarized using the kappa statistic.[11] Initial data extraction was performed in SAS 9.1 (SAS Institute, Cary, NC) and all analyses were conducted in Stata 12 (StataCorp LP, College Station, TX). Binomial 95% confidence intervals (CIs) are presented. This project was approved by the University of Michigan Institutional Review Board.
RESULTS
Of 23,288 hospitalizations examined from 2009 through 2010, the ICD‐9based automated screen for severe sepsis was positive for 3,146 (14 %). A random sample of 111 medical records, of which 92 had screened positive for severe sepsis and 19 had screened negative, was reviewed in detail. After review by the hospitalists, 64 of these 111 hospitalizations were judged to have severe sepsis, 61 of the 92 screened positive cases (66%), and 3 of the 19 screened negative cases (16%). The 3 reviewers had a kappa of 0.70, indicating good agreement.
Characteristics of the 64 patients with severe sepsis are shown in Table 2. The mean age was 63 years old (standard deviation [SD]=17.7), and 41% were male. The mean length of stay was 13.7 days (SD=20.8). Thirty‐nine percent (95% CI, 27%‐52%) of patients (25/64) were immunosuppressed. Of patients initially admitted to the general medical ward, 25% (16/64; 95% CI, 15%‐37%) ultimately required ICU care during their admission. The overall in‐hospital mortality rate was 13% (8/64; 95% CI, 6%‐23%). Immunosuppressed patients had a mortality rate of 20% and nonimmunosuppressed patients had a mortality rate of 8%. Only 47% (30/64; 95% CI, 34%‐60%) of the medical records had explicit clinician documentation of severe sepsis.
| Age, mean (SD), y | 63 (18) |
|---|---|
| |
| Male sex, no. (%) | 26 (41) |
| Preexisting conditions, no. (%) | |
| History of diabetes | 20 (31) |
| End stage renal disease on chronic dialysis | 2 (3) |
| Chronic obstructive pulmonary disease on oxygen | 3 (5) |
| History of cancer | 15 (23) |
| Liver cirrhosis | 5 (8) |
| Immunosuppression | 25 (39) |
| Median length of stay (days) | 7.5 |
| Mean length of stay (SD) | 13.7 (20.8) |
The most common site of infection was found to be the genitourinary system, occurring in 41% (26/64; 95% CI, 29%‐54%) of patients (Table 3). Pulmonary and intra‐abdominal sites were also common, accounting for 14% (95% CI, 6.6%‐25%) and 13% (95% CI, 5.6%‐23%) of sites, respectively. An infecting organism was identified by culture in 66% (42/64; 95% CI, 53%‐77%) of case patients with specific pathogens listed in Table 4. Among patients with positive culture results, the majority grew Gram‐negative organisms (57%; 95% CI, 41%‐72%). Non‐Clostridium difficile Gram‐positive organisms were also prominent and identified in 48% (95% CI, 32%‐64%) of positive cultures. Candida was less common (12%, 95% CI, 4.0%‐26%). Fourteen cases (22%, 95% CI, 10%‐30%) had 2 or more concomitant infectious pathogens.
| Site | No. (%) |
|---|---|
| |
| Genitourinary | 26 (41) |
| Pulmonary | 9 (14) |
| Intra‐abdominal (not intraluminal) | 8 (13) |
| Bloodstream/cardiac | 5 (8) |
| Skin and soft tissue | 4 (6) |
| GI lumen | 4 (6) |
| Joint | 2 (3) |
| Multiple sites | 4 (6) |
| Unknown | 2 (2) |
| Absolute Frequency, Total Positive Culture Results, N=64, No. (%)*?>a | Patients With Cultures Growing at Least One of the Pathogens, N=42, No. (%)*?>a | |
|---|---|---|
| ||
| Gram‐negative pathogens | 30 (47) | 24 (57) |
| Escherichia coli | 12 (19) | 12 (29) |
| Escherichia coli (multidrug resistant) | 2 (3) | 2 (5) |
| Klebsiella | 6 (9) | 5 (12) |
| Pseudomonas aeruginosa | 6 (9) | 4 (10) |
| Pseudomonas aeruginosa (multidrug resistant) | 2 (3) | 2 (5) |
| Otherb | 6 (9) | 6 (14) |
| Gram‐positive pathogens | 29 (45) | 25 (59) |
| Enterococcus | 14 (22) | 13 (31) |
| Vancomycin‐resistant Enterococcus species | 5 (8) | 4 (10) |
| Staphylococcus aureus | 7 (11) | 7 (17) |
| Methicillin‐resistant Staphylococcus aureus | 3 (5) | 3 (7) |
| Streptococcus pneumoniae | 2 (3) | 2 (5) |
| Coagulase‐negative staphylococci | 1 (2) | 1 (2) |
| Clostridium difficile | 5 (8) | 5 (12) |
| Fungi | ||
| Candida species | 5 (8) | 5 (12) |
| Mycobacterium avium | 1 (2) | 1 (2) |
| Two organisms | 9 (21) | |
| Three or more organisms | 5 (12) | |
All 64 patients had at least 1 organ dysfunction, as required by the ICC definition of severe sepsis. Organ dysfunction in 2 or more organ systems occurred in 77% (95% CI, 64%‐86%) of the cases (49/64). The incidence for each organ system dysfunction is presented in Table 5, as well as its relationship to both mortality and ICU admission. The most common organ system dysfunctions were found to be cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of the cases, respectively. In this non‐ICU population, pulmonary dysfunction occurred in 30% of cases, but was frequently associated with transfer to the ICU, as 63% of the patients with pulmonary failure required ICU care. Patients with more organ systems affected were more likely to be transferred to the ICU and to die.
| No. (%) | ICU Transfer, No. (%) | Mortality, No. (%) | |
|---|---|---|---|
| |||
| Number of failed organs, N = 64 | |||
| 1 | 15 (23%) | 0 (0%) | 0 (0%) |
| 2 | 25 (39%) | 2 (8%) | 0 (0%) |
| 3 | 7 (11%) | 2 (29%) | 1 (14%) |
| 4 | 10 (16%) | 6 (60%) | 3 (30%) |
| >4 | 7 (11%) | 6 (86%) | 4 (57%) |
| Types of organ system dysfunction, all patients, N = 64*?>a | |||
| Cardiovascular | 42 (66%) | 16 (38%)b | 8 (19%)c |
| Renal | 41 (64%) | 10 (24%)b | 5 (12%)c |
| Central nervous system | 35 (54%) | 14 (40%)b | 7 (18%)c |
| Pulmonary | 19 (30%) | 12 (63%)b | 8 (42%)c |
| Hematologic | 15 (23%) | 6 (40%)b | 6 (40%)c |
| GI (ileus) | 8 (13%) | 5 (63%)b | 1 (13%)c |
| Hepatic | 5 (8%) | 4 (80%)b | 2 (40%)c |
DISCUSSION
Severe sepsis was common among patients admitted to the general medical ward in this tertiary care center. Our patient cohort differed in important ways from previously described typical cases of severe sepsis among ICU populations. Severe sepsis on the general medical wards was more commonly associated with Gram‐negative pathogens in the setting of genitourinary tract infections. This is in contrast to Gram‐positive organisms and respiratory tract infections, which are more common in the ICU.[3, 10] Renal and cardiac dysfunction were commonly observed organ failures, whereas in the ICU, severe sepsis has been reported to more likely involve respiratory failure. These results suggest that hospitalists seeking to provide evidence‐based care to prevent postsepsis morbidity and mortality for their non‐ICU patients need to heighten their index of suspicion when caring for an infected patient and appreciate that many severe sepsis patients may not fit neatly into traditional sepsis treatment algorithms.
Studies characterizing severe sepsis in the ICU setting indicate a predominance of pulmonary infections and respiratory failure with occurrence rates of 74% to 95% and 54% to 61%, respectively.[3, 12, 13] Given that either shock or pulmonary dysfunction is often required for admission to many ICUs, it is perhaps not surprising that these rates are dramatically different on the general medicine ward, with a relative scarcity of pulmonary infections (14%) and respiratory dysfunction (30%). Instead, genitourinary infections were noted in 41% (95% CI, 29%‐54%) of the cases, in contrast to the rates of genitourinary infections in ICU patients with severe sepsis, which have rates of 5.4% to 9.1%.[3, 10] Likely as a result of this, a Gram‐negative predominance is noted in the associated microbiology. Furthermore, our study indicates that C difficile and vancomycin‐resistant Enterococcus (VRE) species appear to represent an emerging cause of severe sepsis on the general medicine wards, as they have not been noted to be causative micro‐organisms in previous studies of sepsis. This is concordant with other studies showing increases in incidence and severity of disease for C difficile as well as VRE.[14, 15]
Previous epidemiologic studies of severe sepsis originating outside the ICU are lacking, but some work has been done. One study on the epidemiology of sepsis both with and without organ dysfunction aggregated all hospitalized patients and included those both admitted to the general medicine wards and directly to the ICU.[7] Similar to our study, this study also found a predominance of Gram‐negative causative organisms, as well as comparable in‐hospital mortality rates (12.8% vs 13%). Additionally, genitourinary infections were noted in 20% of the patients, notably higher than rates reported to have been found in patients with severe sepsis in the ICU, but not the magnitude found in our study, perhaps as a result of the combined ICU‐ward population studied. A similar high prevalence of genitourinary infections was also noted in a recent administrative data‐based study of emergency medical services‐transported patients with severe sepsis, half of whom required intensive care during their hospitalization.[16]
Our study is unique in that it focuses on severe sepsis in patients, commonly cared for by hospitalists, who were admitted to the general medical ward, and uses patient level data to elucidate more characteristics of the defining organ dysfunction. Furthermore, our results suggest that severe sepsis was poorly documented in this setting, indicating a potential impact on billing, coding, case mix index, and hospital mortality statistics that rely on very specific wording, as well as a possible need for increased awareness among hospitalists. Without this awareness, an opportunity may be missed for improved patient care via specific sepsis‐targeted measures,[13, 17, 18] including more aggressive resuscitative measures[19] or intensive physical and occupational therapy interventions aimed at impacting the cognitive and functional debilities[20] that result from severe sepsis. Highlighting this growing need to better assist clinicians assess the severity of septic patients and recognize these complex cases on the general medicine wards, 1 recent study evaluated the fitness of several clinical disease‐severity scoring systems for patients with sepsis in general internal medicine departments.[21] Perhaps with the help of tools such as these, which are being piloted in some hospitals, the care of this growing population can be enhanced.
Our study has a number of limitations that should be kept in mind. First, this is a single center study performed at an academic tertiary care center with a relatively high incidence of immunosuppression, which may influence the spectrum of infecting organisms. Our center also has a relatively large, closed‐model ICU, which often operates at near capacity, potentially affecting the severity of our non‐ICU population. Second, although we screened a large number of patients, as necessitated by our intensive and detailed review of clinical information, our sample size with hospitalist‐validated severe sepsis is relatively small. With this small sample size, less prevalent infections, patient characteristics, and organ dysfunctions may by chance have been under or over‐represented, and one could expect some variance in the occurrence rates of organ system dysfunction and infection rates by sampling error alone. Further larger scale studies are warranted to confirm these data and their generalizability. Third, the data necessary to calculate sequential organ failure assessment or multiple organ dysfunction score were not collected. This may limit the ability to directly compare the organ dysfunction noted in this study with others. Additionally, given the ICC definitions of organ dysfunction, some of the organ dysfunction noted, particularly for neurological dysfunction, was reliant on subjective clinical findings documented in the record. Finally, we relied on the lack of specific terminology to indicate a lack of documentation of sepsis, which does not necessarily indicate a lack of recognition or undertreatment of this condition. However, these limitations are offset by the strengths of this study, including the patient‐level medical record validation of severe sepsis by trained hospitalist physicians, high kappa statistic, and strict application of guideline‐based definitions.
This work has important implications for both clinicians and for future research on severe sepsis. The results suggest that severe sepsis may be quite common outside the ICU, and that patients presenting with this condition who are admitted to general medical wards are not routinely characterized by the profound hypoxemia and refractory shock of iconic cases. Certainly, further study looking at larger numbers of cases is needed to better understand the specifics and nuances of this important topic as well as to further evaluate clinicians' ability to recognize and treat such patients in this setting. Furthermore, future research on the treatment of severe sepsis, including both antimicrobials and disease‐modifying agents (eg, anti‐inflammatories) must continue to include and even focus on this large population of non‐ICU patients with severe sepsis, as the risk/benefit ratios of such potential treatments may vary with severity of illness.
In conclusion, severe sepsis was commonly found in patients admitted on the general medicine wards. The epidemiology of the infections and resultant organ dysfunction appears to differ from that found in the ICU. More studies are needed to provide a deeper understanding of this disease process, as this will enable clinicians to better recognize and treat patients thus afflicted, no matter the setting.
Acknowledgments
The authors thank Laetitia Shapiro, AM, for her programming assistance.
Disclosures: This work was supported in part by the US National Institutes of HealthK08, HL091249 (TJI) and the University of Michigan SpecialistHospitalist Allied Research Program (SHARP). This work was also supported in part by VA Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC).
The International Consensus Conference (ICC) for sepsis defines severe sepsis as an infection leading to acute organ dysfunction.[1, 2] Severe sepsis afflicts over 1 million patients each year in Medicare alone, and is substantially more common among older Americans than acute myocardial infarction.[3, 4, 5] Recently, the Agency for Healthcare Research and Quality identified severe sepsis as the single most expensive cause of hospitalization in the United States.[6] The incidence of severe sepsis continues to rise.[4, 5]
Severe sepsis is often mischaracterized as a diagnosis cared for primarily in the intensive care unit (ICU). Yet, studies indicate that only 32% to 50% of patients with severe sepsis require ICU care, leaving the majority on the general care wards.[7, 8] These studies also reveal mortality rates of 26% to 30% among patients with severe sepsis who are not admitted to an ICU compared to 11% to 33% in the ICU.[7, 8]
Although a number of epidemiologic and interventional studies have focused on severe sepsis in the ICU,[3, 9, 10] much less is known about patients cared for on the general medicine wards. Without this information, clinicians cannot make informed choices about important management decisions such as targeted diagnostic testing, empirical antimicrobials, and other therapies. To this end, we sought to further characterize the infectious etiologies and resultant organ system dysfunctions in the subset of patients with severe sepsis admitted to non‐ICU medical services at a tertiary academic medical center.
METHODS
Population/Setting
All hospitalizations of adult patients (18 years old) who were initially admitted to non‐ICU medical services at the University of Michigan Hospital during 2009 through 2010 were included. The University of Michigan Hospital has 610 general medical‐surgical beds, including telemetry beds, with closed ICUs comprised of 179 beds staffed by intensivists. Patients transferred from other hospitals and those admitted to non‐medical services were excluded.
Data Abstraction and Definitions
All International Classification of Diseases, 9th Revision, Clinical Modification (ICD‐9‐CM) diagnosis codes for hospitalizations were screened using a previously published and validated algorithm for severe sepsis.[11] Following this screening, 3 randomly selected round‐numbered batches of hospitalizations were sampled with subsequent application of the exclusion criteria. Medical records including physicians' notes, consultants' notes, nurses' notes, physical therapy notes, discharge coordinators' notes, emergency room flow sheets, as well as ward flow sheets were reviewed in detail by 3 practicing hospitalists using a structured instrument closely aligned with the ICC definition of severe sepsis.[2] We also sampled a smaller number of patients whose ICD‐9‐CM diagnoses screened negative for severe sepsis. Sample size was selected as part of a project with multiple objectives, and reflected a pragmatic balance between the anticipated precision of the results and the resources available to conduct chart review.[11] All discrepancies were reconciled among the 3 reviewers.
Reviewers first assessed whether infection was present, then evaluated for evidence of each organ system dysfunction, and finally determined the extent to which those organ dysfunctions were a response to the infection. Infection was defined either as a patient with a microbiologic culture growing a pathologic organism in a normally sterile site or documentation of a suspected infection with other confirmatory evidence (radiological, physical exam finding) with resultant systemic inflammatory response and administration of antimicrobials. Community‐acquired and healthcare‐associated infections were not differentiated. Microbiologic data, confirmatory tests, and site of infection were abstracted in detail.
Organ dysfunction was defined as per the 2001 ICC criteria,[2] and was assessed for neurological, pulmonary, cardiovascular, renal, gastrointestinal, hematological, and hepatic system involvement in all patients. A summary of these clinical definitions is included in Table 1. Data on important comorbidities were also abstracted. Immunosuppression was defined as having any of the following: solid organ transplant, bone marrow/stem cell transplant, human immunodeficiency virus/acquired immunodeficiency syndrome, neutropenia (absolute neutrophil count <1000), hematologic malignancy, solid organ malignancy with chemotherapy within the past 12 months, or pharmacologic immunosuppression (prednisone >20 mg daily for >4 weeks, calcineurin inhibitor, methotrexate, tumor necrosis factor inhibitors, azathioprine, sulfasalazine, hydroxychloroquine). Last, each chart was evaluated for the presence of explicit documentation with the presence of the words or phrases: sepsis, septic shock, or severe sepsis, indicating that the clinical service recognized and fully documented that a patient had severe sepsis.
| Organ System | Parameters to Indicate Dysfunction |
|---|---|
| |
| Cardiovascular | Systolic BP <90, elevated lactate, MAP <70, requiring pressors >2 hours, decrease in systolic BP of >40 |
| Renal | Creatinine increase >0.5 mg/dL, oliguria |
| Neurological | Acute mental status changes |
| Pulmonary | Intubation, BiPAP, supplemental oxygen >6 LPM or 40% face mask, PaO2/FiO2 <300 |
| Hematologic | INR >1.5 or PTT >60 not on anticoagulation, platelets <100 or 50% of baseline |
| Ileus | Decreased bowel motility requiring a change in diet |
| Hepatic | Bilirubin >4 mg/dL and >1.5 baseline |
Data Analysis
Methods for assessment of reviewer concordance have been previously described and were summarized using the kappa statistic.[11] Initial data extraction was performed in SAS 9.1 (SAS Institute, Cary, NC) and all analyses were conducted in Stata 12 (StataCorp LP, College Station, TX). Binomial 95% confidence intervals (CIs) are presented. This project was approved by the University of Michigan Institutional Review Board.
RESULTS
Of 23,288 hospitalizations examined from 2009 through 2010, the ICD‐9based automated screen for severe sepsis was positive for 3,146 (14 %). A random sample of 111 medical records, of which 92 had screened positive for severe sepsis and 19 had screened negative, was reviewed in detail. After review by the hospitalists, 64 of these 111 hospitalizations were judged to have severe sepsis, 61 of the 92 screened positive cases (66%), and 3 of the 19 screened negative cases (16%). The 3 reviewers had a kappa of 0.70, indicating good agreement.
Characteristics of the 64 patients with severe sepsis are shown in Table 2. The mean age was 63 years old (standard deviation [SD]=17.7), and 41% were male. The mean length of stay was 13.7 days (SD=20.8). Thirty‐nine percent (95% CI, 27%‐52%) of patients (25/64) were immunosuppressed. Of patients initially admitted to the general medical ward, 25% (16/64; 95% CI, 15%‐37%) ultimately required ICU care during their admission. The overall in‐hospital mortality rate was 13% (8/64; 95% CI, 6%‐23%). Immunosuppressed patients had a mortality rate of 20% and nonimmunosuppressed patients had a mortality rate of 8%. Only 47% (30/64; 95% CI, 34%‐60%) of the medical records had explicit clinician documentation of severe sepsis.
| Age, mean (SD), y | 63 (18) |
|---|---|
| |
| Male sex, no. (%) | 26 (41) |
| Preexisting conditions, no. (%) | |
| History of diabetes | 20 (31) |
| End stage renal disease on chronic dialysis | 2 (3) |
| Chronic obstructive pulmonary disease on oxygen | 3 (5) |
| History of cancer | 15 (23) |
| Liver cirrhosis | 5 (8) |
| Immunosuppression | 25 (39) |
| Median length of stay (days) | 7.5 |
| Mean length of stay (SD) | 13.7 (20.8) |
The most common site of infection was found to be the genitourinary system, occurring in 41% (26/64; 95% CI, 29%‐54%) of patients (Table 3). Pulmonary and intra‐abdominal sites were also common, accounting for 14% (95% CI, 6.6%‐25%) and 13% (95% CI, 5.6%‐23%) of sites, respectively. An infecting organism was identified by culture in 66% (42/64; 95% CI, 53%‐77%) of case patients with specific pathogens listed in Table 4. Among patients with positive culture results, the majority grew Gram‐negative organisms (57%; 95% CI, 41%‐72%). Non‐Clostridium difficile Gram‐positive organisms were also prominent and identified in 48% (95% CI, 32%‐64%) of positive cultures. Candida was less common (12%, 95% CI, 4.0%‐26%). Fourteen cases (22%, 95% CI, 10%‐30%) had 2 or more concomitant infectious pathogens.
| Site | No. (%) |
|---|---|
| |
| Genitourinary | 26 (41) |
| Pulmonary | 9 (14) |
| Intra‐abdominal (not intraluminal) | 8 (13) |
| Bloodstream/cardiac | 5 (8) |
| Skin and soft tissue | 4 (6) |
| GI lumen | 4 (6) |
| Joint | 2 (3) |
| Multiple sites | 4 (6) |
| Unknown | 2 (2) |
| Absolute Frequency, Total Positive Culture Results, N=64, No. (%)*?>a | Patients With Cultures Growing at Least One of the Pathogens, N=42, No. (%)*?>a | |
|---|---|---|
| ||
| Gram‐negative pathogens | 30 (47) | 24 (57) |
| Escherichia coli | 12 (19) | 12 (29) |
| Escherichia coli (multidrug resistant) | 2 (3) | 2 (5) |
| Klebsiella | 6 (9) | 5 (12) |
| Pseudomonas aeruginosa | 6 (9) | 4 (10) |
| Pseudomonas aeruginosa (multidrug resistant) | 2 (3) | 2 (5) |
| Otherb | 6 (9) | 6 (14) |
| Gram‐positive pathogens | 29 (45) | 25 (59) |
| Enterococcus | 14 (22) | 13 (31) |
| Vancomycin‐resistant Enterococcus species | 5 (8) | 4 (10) |
| Staphylococcus aureus | 7 (11) | 7 (17) |
| Methicillin‐resistant Staphylococcus aureus | 3 (5) | 3 (7) |
| Streptococcus pneumoniae | 2 (3) | 2 (5) |
| Coagulase‐negative staphylococci | 1 (2) | 1 (2) |
| Clostridium difficile | 5 (8) | 5 (12) |
| Fungi | ||
| Candida species | 5 (8) | 5 (12) |
| Mycobacterium avium | 1 (2) | 1 (2) |
| Two organisms | 9 (21) | |
| Three or more organisms | 5 (12) | |
All 64 patients had at least 1 organ dysfunction, as required by the ICC definition of severe sepsis. Organ dysfunction in 2 or more organ systems occurred in 77% (95% CI, 64%‐86%) of the cases (49/64). The incidence for each organ system dysfunction is presented in Table 5, as well as its relationship to both mortality and ICU admission. The most common organ system dysfunctions were found to be cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of the cases, respectively. In this non‐ICU population, pulmonary dysfunction occurred in 30% of cases, but was frequently associated with transfer to the ICU, as 63% of the patients with pulmonary failure required ICU care. Patients with more organ systems affected were more likely to be transferred to the ICU and to die.
| No. (%) | ICU Transfer, No. (%) | Mortality, No. (%) | |
|---|---|---|---|
| |||
| Number of failed organs, N = 64 | |||
| 1 | 15 (23%) | 0 (0%) | 0 (0%) |
| 2 | 25 (39%) | 2 (8%) | 0 (0%) |
| 3 | 7 (11%) | 2 (29%) | 1 (14%) |
| 4 | 10 (16%) | 6 (60%) | 3 (30%) |
| >4 | 7 (11%) | 6 (86%) | 4 (57%) |
| Types of organ system dysfunction, all patients, N = 64*?>a | |||
| Cardiovascular | 42 (66%) | 16 (38%)b | 8 (19%)c |
| Renal | 41 (64%) | 10 (24%)b | 5 (12%)c |
| Central nervous system | 35 (54%) | 14 (40%)b | 7 (18%)c |
| Pulmonary | 19 (30%) | 12 (63%)b | 8 (42%)c |
| Hematologic | 15 (23%) | 6 (40%)b | 6 (40%)c |
| GI (ileus) | 8 (13%) | 5 (63%)b | 1 (13%)c |
| Hepatic | 5 (8%) | 4 (80%)b | 2 (40%)c |
DISCUSSION
Severe sepsis was common among patients admitted to the general medical ward in this tertiary care center. Our patient cohort differed in important ways from previously described typical cases of severe sepsis among ICU populations. Severe sepsis on the general medical wards was more commonly associated with Gram‐negative pathogens in the setting of genitourinary tract infections. This is in contrast to Gram‐positive organisms and respiratory tract infections, which are more common in the ICU.[3, 10] Renal and cardiac dysfunction were commonly observed organ failures, whereas in the ICU, severe sepsis has been reported to more likely involve respiratory failure. These results suggest that hospitalists seeking to provide evidence‐based care to prevent postsepsis morbidity and mortality for their non‐ICU patients need to heighten their index of suspicion when caring for an infected patient and appreciate that many severe sepsis patients may not fit neatly into traditional sepsis treatment algorithms.
Studies characterizing severe sepsis in the ICU setting indicate a predominance of pulmonary infections and respiratory failure with occurrence rates of 74% to 95% and 54% to 61%, respectively.[3, 12, 13] Given that either shock or pulmonary dysfunction is often required for admission to many ICUs, it is perhaps not surprising that these rates are dramatically different on the general medicine ward, with a relative scarcity of pulmonary infections (14%) and respiratory dysfunction (30%). Instead, genitourinary infections were noted in 41% (95% CI, 29%‐54%) of the cases, in contrast to the rates of genitourinary infections in ICU patients with severe sepsis, which have rates of 5.4% to 9.1%.[3, 10] Likely as a result of this, a Gram‐negative predominance is noted in the associated microbiology. Furthermore, our study indicates that C difficile and vancomycin‐resistant Enterococcus (VRE) species appear to represent an emerging cause of severe sepsis on the general medicine wards, as they have not been noted to be causative micro‐organisms in previous studies of sepsis. This is concordant with other studies showing increases in incidence and severity of disease for C difficile as well as VRE.[14, 15]
Previous epidemiologic studies of severe sepsis originating outside the ICU are lacking, but some work has been done. One study on the epidemiology of sepsis both with and without organ dysfunction aggregated all hospitalized patients and included those both admitted to the general medicine wards and directly to the ICU.[7] Similar to our study, this study also found a predominance of Gram‐negative causative organisms, as well as comparable in‐hospital mortality rates (12.8% vs 13%). Additionally, genitourinary infections were noted in 20% of the patients, notably higher than rates reported to have been found in patients with severe sepsis in the ICU, but not the magnitude found in our study, perhaps as a result of the combined ICU‐ward population studied. A similar high prevalence of genitourinary infections was also noted in a recent administrative data‐based study of emergency medical services‐transported patients with severe sepsis, half of whom required intensive care during their hospitalization.[16]
Our study is unique in that it focuses on severe sepsis in patients, commonly cared for by hospitalists, who were admitted to the general medical ward, and uses patient level data to elucidate more characteristics of the defining organ dysfunction. Furthermore, our results suggest that severe sepsis was poorly documented in this setting, indicating a potential impact on billing, coding, case mix index, and hospital mortality statistics that rely on very specific wording, as well as a possible need for increased awareness among hospitalists. Without this awareness, an opportunity may be missed for improved patient care via specific sepsis‐targeted measures,[13, 17, 18] including more aggressive resuscitative measures[19] or intensive physical and occupational therapy interventions aimed at impacting the cognitive and functional debilities[20] that result from severe sepsis. Highlighting this growing need to better assist clinicians assess the severity of septic patients and recognize these complex cases on the general medicine wards, 1 recent study evaluated the fitness of several clinical disease‐severity scoring systems for patients with sepsis in general internal medicine departments.[21] Perhaps with the help of tools such as these, which are being piloted in some hospitals, the care of this growing population can be enhanced.
Our study has a number of limitations that should be kept in mind. First, this is a single center study performed at an academic tertiary care center with a relatively high incidence of immunosuppression, which may influence the spectrum of infecting organisms. Our center also has a relatively large, closed‐model ICU, which often operates at near capacity, potentially affecting the severity of our non‐ICU population. Second, although we screened a large number of patients, as necessitated by our intensive and detailed review of clinical information, our sample size with hospitalist‐validated severe sepsis is relatively small. With this small sample size, less prevalent infections, patient characteristics, and organ dysfunctions may by chance have been under or over‐represented, and one could expect some variance in the occurrence rates of organ system dysfunction and infection rates by sampling error alone. Further larger scale studies are warranted to confirm these data and their generalizability. Third, the data necessary to calculate sequential organ failure assessment or multiple organ dysfunction score were not collected. This may limit the ability to directly compare the organ dysfunction noted in this study with others. Additionally, given the ICC definitions of organ dysfunction, some of the organ dysfunction noted, particularly for neurological dysfunction, was reliant on subjective clinical findings documented in the record. Finally, we relied on the lack of specific terminology to indicate a lack of documentation of sepsis, which does not necessarily indicate a lack of recognition or undertreatment of this condition. However, these limitations are offset by the strengths of this study, including the patient‐level medical record validation of severe sepsis by trained hospitalist physicians, high kappa statistic, and strict application of guideline‐based definitions.
This work has important implications for both clinicians and for future research on severe sepsis. The results suggest that severe sepsis may be quite common outside the ICU, and that patients presenting with this condition who are admitted to general medical wards are not routinely characterized by the profound hypoxemia and refractory shock of iconic cases. Certainly, further study looking at larger numbers of cases is needed to better understand the specifics and nuances of this important topic as well as to further evaluate clinicians' ability to recognize and treat such patients in this setting. Furthermore, future research on the treatment of severe sepsis, including both antimicrobials and disease‐modifying agents (eg, anti‐inflammatories) must continue to include and even focus on this large population of non‐ICU patients with severe sepsis, as the risk/benefit ratios of such potential treatments may vary with severity of illness.
In conclusion, severe sepsis was commonly found in patients admitted on the general medicine wards. The epidemiology of the infections and resultant organ dysfunction appears to differ from that found in the ICU. More studies are needed to provide a deeper understanding of this disease process, as this will enable clinicians to better recognize and treat patients thus afflicted, no matter the setting.
Acknowledgments
The authors thank Laetitia Shapiro, AM, for her programming assistance.
Disclosures: This work was supported in part by the US National Institutes of HealthK08, HL091249 (TJI) and the University of Michigan SpecialistHospitalist Allied Research Program (SHARP). This work was also supported in part by VA Ann Arbor Healthcare System, Geriatric Research Education and Clinical Center (GRECC).
- , , , et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101(6):1644–1655.
- , , , et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31(4):1250–1256.
- , , , , , . Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303–1310.
- , , , . Population burden of long‐term survivorship after severe sepsis in older americans. J Am Geriatr Soc. 2012;60(6):1070–1077.
- , , , . The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348(16):1546–1554.
- , , . Septicemia in U.S. hospitals, 2009: statistical brief #122. October 2011. In: Healthcare Cost and Utilization Project Statistical Briefs. Rockville, MD: Agency for Health Care Policy and Research; 2006. Available from: http://www.ncbi.nlm.nih.gov/books/NBK65391. Accessed June 2, 2012.
- , , , et al. Sepsis incidence and outcome: contrasting the intensive care unit with the hospital ward. Crit Care Med. 2007;35(5):1284–1289.
- , , , , . Epidemiology of sepsis in Victoria, Australia. Crit Care Med. 2005;33(1):71–80.
- , , , et al. Effect of empirical treatment with moxifloxacin and meropenem vs meropenem on sepsis‐related organ dysfunction in patients with severe sepsis: a randomized trial. JAMA. 2012;307(22):2390–2399.
- , , , , . Incidence and impact of organ dysfunctions associated with sepsis. Chest. 2005;127(3):942–951.
- , , , et al. Identifying patients with severe sepsis using administrative claims: patient‐level validation of the Angus Implementation of the International Consensus Conference definition of severe sepsis [published online ahead of print September 18, 2012]. Medical Care. doi: 10.1097/MLR.0b013e318268ac86.
- , , , . Current epidemiology of septic shock: the CUB‐Rea Network. Am J Respir Crit Care Med. 2003;168(2):165–172.
- . Management of sepsis. N Engl J Med. 2006;355(16):1699–1713.
- , , . Current status of Clostridium difficile infection ipidemiology. Clin Infect Dis. 2012;55(suppl 2):S65–S70.
- , . Vancomycin‐resistant enterococci. Semin Respir Infect. 2000;15(4):314–326.
- , , , , , . Severe sepsis in prehospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med. 2012;186(12):1264–1271.
- , . Novel Therapies for Septic Shock Over the Past 4 Decades. JAMA. 2011;306(2):194–199.
- , , , et al. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three‐year follow‐up quasi‐experimental study. Crit Care Med. 2010;38(4):1036–1043.
- , . Diagnosis and treatment of severe sepsis. Crit Care. 2007;11(suppl 5):S2.
- , , , . Long‐term cognitive impairment and functional disability among survivors of severe sepsis. JAMA. 2010;304(16):1787–1794.
- , , , , . Assessment of disease‐severity scoring systems for patients with sepsis in general internal medicine departments. Crit Care. 2011;15:R95.
- , , , et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;101(6):1644–1655.
- , , , et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31(4):1250–1256.
- , , , , , . Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303–1310.
- , , , . Population burden of long‐term survivorship after severe sepsis in older americans. J Am Geriatr Soc. 2012;60(6):1070–1077.
- , , , . The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;348(16):1546–1554.
- , , . Septicemia in U.S. hospitals, 2009: statistical brief #122. October 2011. In: Healthcare Cost and Utilization Project Statistical Briefs. Rockville, MD: Agency for Health Care Policy and Research; 2006. Available from: http://www.ncbi.nlm.nih.gov/books/NBK65391. Accessed June 2, 2012.
- , , , et al. Sepsis incidence and outcome: contrasting the intensive care unit with the hospital ward. Crit Care Med. 2007;35(5):1284–1289.
- , , , , . Epidemiology of sepsis in Victoria, Australia. Crit Care Med. 2005;33(1):71–80.
- , , , et al. Effect of empirical treatment with moxifloxacin and meropenem vs meropenem on sepsis‐related organ dysfunction in patients with severe sepsis: a randomized trial. JAMA. 2012;307(22):2390–2399.
- , , , , . Incidence and impact of organ dysfunctions associated with sepsis. Chest. 2005;127(3):942–951.
- , , , et al. Identifying patients with severe sepsis using administrative claims: patient‐level validation of the Angus Implementation of the International Consensus Conference definition of severe sepsis [published online ahead of print September 18, 2012]. Medical Care. doi: 10.1097/MLR.0b013e318268ac86.
- , , , . Current epidemiology of septic shock: the CUB‐Rea Network. Am J Respir Crit Care Med. 2003;168(2):165–172.
- . Management of sepsis. N Engl J Med. 2006;355(16):1699–1713.
- , , . Current status of Clostridium difficile infection ipidemiology. Clin Infect Dis. 2012;55(suppl 2):S65–S70.
- , . Vancomycin‐resistant enterococci. Semin Respir Infect. 2000;15(4):314–326.
- , , , , , . Severe sepsis in prehospital emergency care: analysis of incidence, care, and outcome. Am J Respir Crit Care Med. 2012;186(12):1264–1271.
- , . Novel Therapies for Septic Shock Over the Past 4 Decades. JAMA. 2011;306(2):194–199.
- , , , et al. Impact of the Surviving Sepsis Campaign protocols on hospital length of stay and mortality in septic shock patients: results of a three‐year follow‐up quasi‐experimental study. Crit Care Med. 2010;38(4):1036–1043.
- , . Diagnosis and treatment of severe sepsis. Crit Care. 2007;11(suppl 5):S2.
- , , , . Long‐term cognitive impairment and functional disability among survivors of severe sepsis. JAMA. 2010;304(16):1787–1794.
- , , , , . Assessment of disease‐severity scoring systems for patients with sepsis in general internal medicine departments. Crit Care. 2011;15:R95.
Copyright © 2013 Society of Hospital Medicine
Glycemic Control in the Hospital
Hyperglycemia is common in hospitalized patients, and hyperglycemia has been associated with poor hospital outcomes. The adverse physiologic effects of acute hyperglycemia are well established1 and several clinical studies have linked hyperglycemia with poor clinical outcomes in certain patient populations.28 Although the optimal target range for inpatient glycemic control has not yet been defined, these studies support the goal of metabolic control for hospital patients. However, there are many barriers to achieving adequate glycemic control in the hospital, and blood glucoses in the hospital are often far from recommended targets.9, 10 One barrier appears to be the low priority given to glycemic control in the hospital. Hyperglycemia in the hospital is often ignored,11 and insulin regimens are often chosen for simplicity as opposed to effectiveness.12 Other barriers to glycemic control in the hospital include the physiologic effects (stress) of acute illness, and the frequent nutritional changes and interruptions that occur.
Most hyperglycemic patients on a general medicine unit are treated with subcutaneous insulin, but the optimal strategy for prescribing insulin in the hospital remains uncertain. A technical review of the literature on the management of diabetes in the hospital setting from 2004 recommends prescribing insulin in a way that mimics physiologic insulin secretion (ie, physiologic or basal‐bolus insulin).1 This approach has been promulgated by experts, but there has been very little research to support these recommendations. One small, randomized trial concluded that a basal‐bolus approach achieved better glycemic control than the use of sliding‐scale insulin alone,13 and 2 quality improvement studies using a before/after design have demonstrated improvements in glycemic control after the implementation of interventions designed to encourage physiologic insulin use.14, 15
In this study we hypothesized that a few simple interventions (education for physicians and nurses, and a standardized insulin order form) would lead to a higher rate of basal‐bolus insulin use and simultaneously improve glycemic control and patient safety.
Methods
Study Design
This study was performed at the University of Michigan Hospital over a 6‐month period, and the protocol was approved by the Institutional Review Board. We performed a quasi‐experimental study comparing 3 patient groups. The intervention group (IG) was subject to all of the interventions discussed below (physician education, nurse education, and the standardized order form). The concurrent control group (CCG) was hospitalized during the same time period as the IG, but was only subject to 1 of the interventions (physician education). These patients were cared for by the same physicians as the IG, but on a different unit where the nurses had not received the education and where the standardized insulin order form was not available. Patients were admitted to the IG unit or the CCG unit via the institution's usual admission process. In addition, we examined an historic control group (HCG) which was hospitalized during the same months of the year, but 2 years prior. The HCG was not subject to any of the interventions.
Interventions
Standardized Subcutaneous Insulin Order Form
This form (Supporting Information Appendix 1) was designed to encourage physicians to prescribe insulin in a physiologic way, providing basal, nutritional, and correctional insulin. The form is based on best practice guidelines,1 and is in agreement with the principles of the inpatient management of diabetes and hyperglycemia endorsed by several professional organizations.16, 17 The form was engineered by a multidisciplinary team, including an endocrinologist, several hospitalists, several nurses, a certified diabetes educator, a pharmacist, and others. It is derived from the extensive experience of the University of Michigan Hospital Intensive Insulin Program (HIIP) in the Division of Endocrinology, and on work done by the Society of Hospital Medicine (SHM) Glycemic Control Task Force.1719 This form was only used in the care of patients in the IG. The form, which was not approved for use on other floors, did not creep to other units. The standardized order form was the only way to order insulin or to modify the insulin regimen on the IG unit. The frequency of review or revision of the insulin orders was left to the discretion of the inpatient physicians.
Physician/Midlevel Provider Education
Physicians and midlevel providers caring for patients in the IG and the CCG were given specific education about the best practice recommendations for the management of diabetes and hyperglycemia in hospitalized patients. This education was based on the principles of anticipatory, physiologic insulin use. On nonhouse staff services, the education was provided to the attending physicians and midlevel providers, and on house staff services, the education was provided to the residents. All physician education was provided by the physician authors (D.W. and R.G.). A summary of the content of the physician education is provided in Supporting Information Appendix 2.
Nurse Education
Nurses caring for patients in the IG were given education similar to that which was provided to the physicians (see above), with an emphasis on practical issues related to delivering physiologic insulin. It included topics such as blood glucose monitoring, and the real‐time manipulation of nutritional insulin doses in accordance with the clinical situation (decision‐making that was specifically delegated to the nursing staff by the order set).
Patients
Patients were eligible for inclusion in the analysis if they met the following inclusion criteria: they were admitted to the inpatient General Internal Medicine Services; subcutaneous insulin was provided to the patient during the hospitalization; they had at least 2 blood glucose values >180 mg/dL; they were discharged from the hospital on a pharmacologic glucose lowering agent (insulin or oral); and their total length‐of‐stay was 3 days to 14 days. Patients were excluded from the analysis if they were admitted with a primary diagnosis of diabetic ketoacidosis, diabetic hyperosmolar state, or hypoglycemia. Up to 10 consecutive days of glucose data were recorded for each patient, and the first day on which blood glucose information was available from the admitting floor was excluded from the analysis. Also, specific patient‐days were not analyzed if there were no bedside glucoses recorded, or if the patient was treated with an IV insulin infusion on that day.
Outcomes
The primary outcome was glycemic control. The primary unit of measure was the patient‐day (ie, all of the information for 1 patient on a single qualifying day). This was done to correct for the phenomenon of frequent repeat testing in response to abnormal values. It also allows for a more clinically relevant description of the actual glycemic control on a given day. Specifically, each patient‐day was categorized as in‐range (70‐180 mg/dL), hyperglycemic (>180 mg/dL), severely hyperglycemic (>250 mg/dL), hypoglycemic (<70 mg/dL), and/or severely hypoglycemic (<50 mg/dL). The primary endpoint was glycemic control in‐range. For a patient‐day to be in‐range, all readings for that particular day were within 70 mg/dL to180 mg/dL. For the readings that were not in the desired range, a minimum of 1 deviant reading in a particular day constituted classification into that category, and a single out‐of‐range patient‐day could be included in 1 or more of the out‐of‐range categories (eg, a patient‐day could be categorized as both severely hyperglycemic and hypoglycemic if it contained glucose readings in both of those ranges).
The day‐weighted mean blood glucose value was also calculated for each of the groups. This calculation utilized the mean blood glucose for each patient‐day, and then averaged these values for each group. These metrics have been endorsed as appropriate measures of glycemic control by the SHM Glycemic Control Task Force.20
Other Data
Several other clinical features were also examined, including the following: primary diagnoses listed in the hospital discharge summary for each patient (3 maximum); possible confounders including patient weight, length‐of‐stay, days receiving tube feeds, days receiving parenteral nutrition, and days during which patients were treated with high‐dose glucocorticoids (>10 mg/day of prednisone, or its equivalent) or oral diabetes medications; and the composition of the insulin regimen on each hospital day. Definitions of insulin regimens are provided in Table 1.
| |
| Any basal insulin day | Any day in which intermediate‐acting or long‐acting, scheduled insulin was given. |
| Basal insulin alone day | A day in which intermediate‐acting or long‐acting insulin was the only scheduled insulin given. |
| Any nutritional insulin day | Any day in which rapid‐acting or short‐acting, scheduled insulin was given. |
| Nutritional insulin alone day | A day in which rapid‐acting or short‐acting insulin was the only scheduled insulin given. |
| Basal plus nutritional day | A day in which both scheduled, intermediate‐acting or long‐acting insulin and scheduled, rapid‐acting or short‐acting insulin were given. |
| Pre‐mixed insulin day | Any day in which a pre‐mixed combination insulin was given. |
| Basal plus nutritional or pre‐mixed insulin day | A composite of the basal plus nutritional day category and the mixed insulin day category described above. This group includes any day in which either a pre‐mixed combination insulin was given OR a day in which both: (a) scheduled, intermediate‐acting or long‐acting and (b) scheduled, rapid‐acting or short‐acting insulin were given. |
| Sliding scale insulin alone day* | Any day when only correctional (as needed) insulin was given. |
Statistical Analysis
Bivariate analyses (chi‐square, and t‐tests) were carried out to compare demographic characteristics of the intervention and control populations. Since there were multiple glucose readings nested within individuals, multilevel mixed‐effects logistic regression was used to evaluate the association between the intervention and outcomes. A 2‐level hierarchical model was developed in which patient‐days were nested within patients; this accounted for the correlation between glycemic control across days for a given patient. Patient‐day was modeled as a random intercept and the log likelihood was estimated using adaptive Gaussian quadrature with 7 integration points. Alpha was set at 0.05, 2‐tailed. The final model was adjusted for gender, age, weight, length‐of‐stay, use of oral diabetes agents, use of sulfonylureas, and use of high‐dose corticosteroids. The use of a nonoral feeding route (eg, tube feeding or parenteral nutrition) was too infrequent to be considered in the adjusted analysis. All analyses were conducted in Stata/IC 10.0 (College Station, TX).
Results
A total of 245 patients provided 1315 patient‐days. Patient demographics are shown in Table 2. The patients' weight, length‐of‐stay, and primary diagnoses were similar across the 3 groups. There was a higher percentage of males in the IG as compared to the HCG.
| IG | CCG | P Value IG vs. CCG | HCG | P Value IG vs. HCG | |
|---|---|---|---|---|---|
| |||||
| Number of patients | 84 | 86 | 75 | ||
| Age, years, mean (SD) | 59.3 (15.3) | 60.4 (15.9) | 0.68 | 59.2 (17.2) | 0.96 |
| Range (n = 245) | 18‐94 | 20‐87 | 24‐92 | ||
| Weight in kg, mean (SD) | 92.2 (29.5) | 89.5 (27.2) | 0.57 | 94.2 (35.4) | 0.69 |
| Range (n = 237) | 40‐198 | 40‐188 | 42‐235 | ||
| Sex, n (%) (n = 245) | 0.17 | 0.04 | |||
| Male | 45 (53.6) | 37 (43.0) | 28 (37.3) | ||
| Female | 39(46.4) | 49 (57.0) | 47 (62.7) | ||
| Length of stay, mean (SD) | 7.6 (3.3) | 7.4 (3.0) | 0.62 | 7.0 (2.5) | 0.14 |
| Range (n = 245) | 4‐15 | 4‐15 | 4‐14 | ||
| Number of diagnoses | 169 | 158 | 160 | ||
| Primary diagnoses, n (%) | 0.56 | 0.10 | |||
| Infections | 40 (23.7) | 45 (28.5) | 49 (30.6) | ||
| Gastrointestinal | 33 (19.5) | 19 (12.0) | 14 (8.8) | ||
| Rheumatologic | 13 (7.7) | 12 (7.6) | 18 (11.2) | ||
| Renal | 14 (8.3) | 10 (6.3) | 16 (10.0) | ||
| Diabetes‐related | 11 (6.5) | 11 (7.0) | 10 (6.2) | ||
| Neurologic | 8 (4.7) | 11 (7.0) | 11 (6.9) | ||
| *Misc/other | 50 (29.6) | 50 (31.6) | 42 (26.3) | ||
Table 3 shows the insulin regimens used in the different groups. The use of basal insulin was similar between groups. Congruent with the goals of the education session and the order set, patients in the IG were more likely to be treated with a combination of basal and nutritional insulin than patients in the other groups. Patients in the HCG were more likely to be treated with a premixed insulin than patients in the other groups. However, even when premixed insulin was categorized as a form of basal plus nutritional insulin and combined into a composite group with the combined basal and nutritional days, this type of regimen remained more common in the IG than in the HCG. The rate of sliding scale insulin use alone (ie, without any scheduled insulin) was similar in the 3 groups.
| Patient‐days on the following | IG (n = 453) | CCG (n = 471) | P Value IG vs. CCG | HCG (n = 391) | P Value IG vs. HCG |
|---|---|---|---|---|---|
| |||||
| Sliding scale alone, n (%) | 105 (23.2) | 130 (27.6) | 0.12 | 89 (22.8) | 0.89 |
| Basal alone, n (%) | 132 (29.1) | 231 (49.0) | <0.01 | 199 (50.9) | <0.01 |
| Nutritional alone, n (%) | 22 (4.9) | 5 (1.1) | <0.01 | 8 (2.0) | 0.03 |
| Basal plus nutritional, n (%) | 166 (36.6) | 71 (15.1) | <0.01 | 14 (3.6) | <0.01 |
| Pre‐mixed insulin included, n (%) | 27 (6.0) | 32 (6.8) | 0.60 | 78 (20.0) | <0.01 |
| No insulin, n (%) | 1 (<1) | 2 (<1) | 0.59 | 3 (<1) | 0.28 |
| Any basal, n (%) | 325 (71.7) | 334 (70.9) | 0.78 | 291 (74.4) | 0.38 |
| Any nutritional, n (%) | 215 (47.5) | 108 (22.9) | <0.01 | 100 (25.6) | <0.01 |
| Basal plus nutritional or pre‐mixed, n (%) | 193 (42.6) | 103 (21.9) | <0.01 | 92 (23.5) | <0.01 |
| Oral diabetes agents, n (%) | 79 (17.4) | 83 (17.6) | 0.94 | 74 (18.9) | 0.58 |
| Sulfonylureas, n (%) | 40 (8.8) | 63 (13.4) | 0.03 | 37 (9.5) | 0.75 |
| Parenteral nutrition/tube feeds, n (%) | 0 (0) | 18 (3.8) | 8 (2.0) | ||
| High dose corticosteroids, n (%) | 66 (14.6) | 93 (19.8) | 0.04 | 51 (13.0) | 0.52 |
Other relevant measures are also shown in Table 3. The use of oral diabetes agents was similar in the 3 groups. The use of a nonoral feeding route (eg, tube feeding or parenteral nutrition) was infrequent.
A comparison of glycemic control in the three groups is shown in Table 4. In contrast to the CCG, patients in the IG experienced more days within the target glucose range (17% vs. 10.6%, P < 0.01), fewer days with severe hyperglycemia (48.3% vs. 59.2%, P < 0.01), and had a lower day‐weighted average blood glucose (195.9 vs. 212.6, P < 0.01). Compared to the HCG, patients in the IG experienced similar rates of hyperglycemia, but fewer hypoglycemic days (5.1% vs. 9.2%, P = 0.02).
| IG (n = 453) | CCG (n = 471) | P Value IG vs. CCG | HCG (n = 391) | P Value IG vs. HCG | |
|---|---|---|---|---|---|
| |||||
| Patient‐days | |||||
| In range, n (%) | 77 (17.0) | 50 (10.6) | <0.01 | 66 (16.9) | 0.98 |
| Out of range, n (%) | 376 (83.0) | 421 (89.4) | <0.01 | 325 (83.1) | 0.98 |
| Hyperglycemic, n (%) | 289 (63.8) | 310 (65.8) | 0.52 | 248 (63.4) | 0.91 |
| Severely hyperglycemic, n (%) | 219 (48.3) | 279 (59.2) | <0.01 | 176 (45.0) | 0.32 |
| Hypoglycemic, n (%) | 23 (5.1) | 36 (7.6) | 0.11 | 36 (9.2) | 0.02 |
| Severely hypoglycemic, n (%) | 13 (2.9) | 10 (2.1) | 0.47 | 15 (3.8) | 0.44 |
| Day weighted average blood glucose (SD) | 195.9 (66.8) | 212.6 (73.4) | <0.01 | 190.5 (63.1) | 0.25 |
The percentages of patients with severe hyperglycemia in each group are shown in Figure 1 by hospital day. Severe hyperglycemia was common, but there was a trend towards a decrease in the prevalence of severe hyperglycemia with increasing hospital days for all study groups, although it was consistently higher in the CCG than in the IG. Figure 2 shows the types of insulin regimens used by hospital day (composite for all groups). The use of basal plus nutritional insulin (the recommended regimen) increased gradually with increasing hospital days. When taken together, the information in both figures support the hypothesis that the use of the recommended insulin regimen may have contributed to the modest improvements in glycemic control seen in the IG.
In the final adjusted regression model, the intervention had a positive impact on glycemic control (Table 5). Subjects in the IG had a 72% increase in the odds of being in the target glucose range when compared to subjects in the CCG (P = 0.01). In addition, subjects in the IG had a 35% reduction in the odds of being severely hyperglycemic when compared to those in the CCG (P < 0.01). Finally, the odds ratio (OR) for being hypoglycemic among intervention subjects was 0.59 (P = 0.06) when compared to subjects in the CCG and 0.48 (P = 0.01) when compared to subjects in the HCG.
| Adjusted OR* IG vs. CCG | 95% CI | P value IG vs. CCG | Adjusted OR* IG vs. HCG | 95% CI | P Value IG vs. HCG | |
|---|---|---|---|---|---|---|
| ||||||
| In range | 1.72 | 1.16,2.55 | 0.01 | 1.08 | 0.74,1.58 | 0.68 |
| Hyperglycemic | 0.93 | 0.70,1.22 | 0.58 | 0.95 | 0.71,1.28 | 0.74 |
| Severely Hyperglycemic | 0.65 | 0.49,0.85 | <0.01 | 1.10 | 0.82,1.47 | 0.52 |
| Hypoglycemic | 0.59 | 0.34,1.02 | 0.06 | 0.48 | 0.27,0.85 | 0.01 |
| Severely Hypoglycemic | 1.36 | 0.59,3.14 | 0.47 | 0.97 | 0.29,1.44 | 0.28 |
Discussion
In this study, we investigated the effects of a standardized insulin order set, coupled with physician and nurse education, on glycemic control in hyperglycemic hospitalized patients. These interventions were designed to encourage a standardized approach to the treatment of hyperglycemia in hospitalized patients, based on the principles of physiologic insulin use, as described above. Our data suggest that the interventions did, indeed, alter the way insulin was prescribed, as more patients in the IG received a combination of basal plus nutritional insulin (the recommended regimen) than in the other groups. These interventions were associated with improved glycemic outcomes in the IG as compared to the CCG. The IG experienced a higher percentage of days in the target range and a trend toward fewer hypoglycemic days than the CCG. Although the IG experienced a similar percentage of days in the target range, it had significantly fewer hypoglycemic days than the HCG.
It is useful to consider the results of our study in the context of 2 other similar studies performed by Schnipper et al.14 and Maynard et al.15 Although each of these 3 studies have different study designs, they are similar in intent (to test the effects of simple quality improvement interventions on glycemic control in the hospital) and results (all showed significant improvements in some aspect of glycemic control). In our study, and the study by Maynard et al.,15 the interventions also led to decreases in the rates of hypoglycemia, whereas Schnipper et al.14 observed no difference in hypoglycemia. Of interest, in each of the three studies the interventions were associated with an increase in the use of some type of scheduled insulin. In our study and the study from Schnipper et al.14 the baseline use of basal insulin was quite high, and the interventions were associated with a significant increase in the addition of nutritional insulin. In the Maynard et al.15 study, the baseline use of sliding scale insulin alone was prevalent, and the interventions resulted in an increase in the use of basal insulin. The results of these studies, taken together, prompt us to conclude that the interventions employed in these studies are likely to lead to more frequent prescription of scheduled (anticipatory) insulin, and a modest improvement in glycemic control, without an increase (and perhaps with a decrease) in hypoglycemia.
A few of our study results are unexpected, or difficult to explain. In contrast to the other studies discussed above, our interventions did not affect the frequency of the use of sliding‐scale insulin alone (without any scheduled insulin), which was similar in the 3 groups. Although the reason for this is uncertain, we hypothesize that the high baseline use of basal insulin in our institution, and the lack of a hard stop preventing the use of sliding scale insulin alone explain this finding. Also, it is difficult to explain why measures of hyperglycemia were similar between the IG and the HCG despite the fact that the HCG was less often treated with a combination of basal and nutritional insulin and more often treated with mixed insulin.
There are several different mechanisms by which the interventions might have resulted in improved glycemic control in the IG compared to CCG. Our data clearly shows that insulin was prescribed differently in the IG, and the more frequent use of a combination of scheduled basal and nutritional insulin might have contributed to the differences between the groups. However, the effects of our interventions clearly went beyond physician education into the realm of true process improvement and standardization. The standardized order form was designed to prompt physicians to use a basal‐bolus insulin regimen. The order form also created nursing expectations of how insulin should be ordered, and clarified the roles of the different insulins that were prescribed.
On the medication administration record, each insulin was labeled as basal insulin (to be given even when fasting) or nutritional insulin (to be given along with the meal). The nurses caring for the IG also attended an education program that reinforced the role of the nurse in the bedside management of insulin administration. Specifically, nurses were taught to assess the premeal blood glucose and the patient's nutritional situation before giving the nutritional insulin (ie, Does the patient have food available? Will he tolerate eating the food?). In situations where is was not clear if the patient would be able to tolerate the ordered nutrition, the order set empowered the nurse to give the nutritional insulin after the meal, and to reduce the dose to match the patient's actual intake. These interventions resulted in some fundamental improvements in the nursing process of delivering insulin to the patient, and these changes might have resulted in improvements via mechanisms that are difficult to directly measure. Since the same physicians cared for both the IG and the CCG, interventions other than physician education clearly contributed to the observed improvements in the IG.
This study was not a randomized study, and there could be important undetected differences between the groups. However, all of the patients were admitted to the General Medicine Inpatient Services and the comparison of the general patient demographics and primary diagnoses between the groups do not suggest major differences.
Although the improvements in glycemic control seen in this study were statistically significant, they were quantitatively modest. The rates of hyperglycemia seen in this study, on the other hand, are quite remarkable. Both the American Diabetes Association and the American College of Endocrinology have recommended that blood glucoses in hospitalized patients not exceed a maximum value of 180 mg/dL, but the day‐weighted average blood glucose in this study was above that for each group. Even in the IG, over 80% of all patient‐days included at least 1 blood glucose value outside of the target range. These data suggest that better strategies for achieving metabolic control in hospitalized patients are needed.
It is worth mentioning that our interventions were not aggressively enforced. While the use of the order set was mandatory for the IG, it was flexible enough to allow for substantial practice variation, especially with respect to the dose of insulin prescribed. Although the education sessions discussed the specifics of insulin dosing in hospitalized patients, the order form did not offer dosing guidelines. It is possible that our interventions may have had a larger impact if a starting dose of insulin had been specified on the form. Although the insulin order form prompted physicians to act, there were no forced functions. Also, not all house staff attended the education sessions for physicians, and there was no feedback provided to physicians related to how they might improve their adherence to the recommendations presented in the educational module. Therefore, it is likely that more aggressive interventions could have led to greater changes in physician practice.
In conclusion, this study demonstrates that interventions including physician and nurse education and a standardized insulin order set can lead to improvement in glycemic control and patient safety in hospitalized patients treated with subcutaneous insulin. However, the observed improvements are modest, and poor metabolic control remains common, despite these interventions. These data suggest that standardization of the process of ordering and delivering subcutaneous insulin in the hospital may lead to a reduction in both hyperglycemia and hypoglycemia. However, it is clear that the interventions used in this study were not potent enough to achieve the recommended glycemic targets for the majority of patients. Additional research is needed to determine the best strategy for achieving safe and effective metabolic control in hospitalized, hyperglycemic, noncritically ill patients.
Acknowledgements
The authors thank David Conway for his work in data collection and management.
- ,,, et al.Management of diabetes and hyperglycemia in hospitals.Diabetes Care.2004;27:553–591.
- ,,, et al.Intensive insulin therapy in the critically ill patients.N Engl J Med.2001;345:1359–1367.
- ,,, et al.Intensive insulin therapy in the medical ICU.N Engl J Med.2006;354:449–461.
- ,,,.Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures.Ann Thorac Surg.1999;67:352–360; discussion360–352.
- ,,, et al.Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting.J Thorac Cardiovasc Surg.2003;125:1007–1021.
- ,,,,,.Hyperglycemia: an independent marker of in‐hospital mortality in patients with undiagnosed diabetes.J Clin Endocrinol Metab.2002;87:978–982.
- ,,, et al.Early postoperative glucose control predicts nosocomial infection rate in diabetic patients.JPEN J Parenter Enteral Nutr.1998;22:77–81.
- ,,,,,.The relation between hyperglycemia and outcomes in 2,471 patients admitted to the hospital with community‐acquired pneumonia.Diabetes Care.2005;28:810–815.
- ,.Glycemic chaos (not glycemic control) still the rule for inpatient care: how do we stop the insanity?J Hosp Med.2006;1:141–144.
- ,,, et al.Evaluation of hospital glycemic control at US Academic Medical Centers.J Hosp Med.2009;4:35–44.
- ,,, et al.Diabetes care in the hospital: is there clinical inertia?J Hosp Med.2006;1:151–160.
- ,,,,.Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital.J Hosp Med.2006;1:145–150.
- ,,, et al.Randomized study of basal‐bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial).Diabetes Care.2007;30:2181–2186.
- ,,,.Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial.J Hosp Med.2009;4:16–27.
- ,,,,.Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm.J Hosp Med.2009;4:3–15.
- ,,, et al.American College of Endocrinology position statement on inpatient diabetes and metabolic control.Endocr Pract.2004;10:77–82.
- Society of Hospital Medicine. Glycemic Control Resource Room. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section= Quality_Improvement_Resource_Rooms3(5 Suppl):17–28.
- ,,,.Subcutaneous insulin order sets and protocols: effective design and implementation strategies.J Hosp Med.2008;3(5 Suppl):29–41.
- ,,,,.Society of Hospital Medicine Glycemic Control Task Force summary: practical recommendations for assessing the impact of glycemic control efforts.J Hosp Med.2008;3(5 Suppl):66–75.
Hyperglycemia is common in hospitalized patients, and hyperglycemia has been associated with poor hospital outcomes. The adverse physiologic effects of acute hyperglycemia are well established1 and several clinical studies have linked hyperglycemia with poor clinical outcomes in certain patient populations.28 Although the optimal target range for inpatient glycemic control has not yet been defined, these studies support the goal of metabolic control for hospital patients. However, there are many barriers to achieving adequate glycemic control in the hospital, and blood glucoses in the hospital are often far from recommended targets.9, 10 One barrier appears to be the low priority given to glycemic control in the hospital. Hyperglycemia in the hospital is often ignored,11 and insulin regimens are often chosen for simplicity as opposed to effectiveness.12 Other barriers to glycemic control in the hospital include the physiologic effects (stress) of acute illness, and the frequent nutritional changes and interruptions that occur.
Most hyperglycemic patients on a general medicine unit are treated with subcutaneous insulin, but the optimal strategy for prescribing insulin in the hospital remains uncertain. A technical review of the literature on the management of diabetes in the hospital setting from 2004 recommends prescribing insulin in a way that mimics physiologic insulin secretion (ie, physiologic or basal‐bolus insulin).1 This approach has been promulgated by experts, but there has been very little research to support these recommendations. One small, randomized trial concluded that a basal‐bolus approach achieved better glycemic control than the use of sliding‐scale insulin alone,13 and 2 quality improvement studies using a before/after design have demonstrated improvements in glycemic control after the implementation of interventions designed to encourage physiologic insulin use.14, 15
In this study we hypothesized that a few simple interventions (education for physicians and nurses, and a standardized insulin order form) would lead to a higher rate of basal‐bolus insulin use and simultaneously improve glycemic control and patient safety.
Methods
Study Design
This study was performed at the University of Michigan Hospital over a 6‐month period, and the protocol was approved by the Institutional Review Board. We performed a quasi‐experimental study comparing 3 patient groups. The intervention group (IG) was subject to all of the interventions discussed below (physician education, nurse education, and the standardized order form). The concurrent control group (CCG) was hospitalized during the same time period as the IG, but was only subject to 1 of the interventions (physician education). These patients were cared for by the same physicians as the IG, but on a different unit where the nurses had not received the education and where the standardized insulin order form was not available. Patients were admitted to the IG unit or the CCG unit via the institution's usual admission process. In addition, we examined an historic control group (HCG) which was hospitalized during the same months of the year, but 2 years prior. The HCG was not subject to any of the interventions.
Interventions
Standardized Subcutaneous Insulin Order Form
This form (Supporting Information Appendix 1) was designed to encourage physicians to prescribe insulin in a physiologic way, providing basal, nutritional, and correctional insulin. The form is based on best practice guidelines,1 and is in agreement with the principles of the inpatient management of diabetes and hyperglycemia endorsed by several professional organizations.16, 17 The form was engineered by a multidisciplinary team, including an endocrinologist, several hospitalists, several nurses, a certified diabetes educator, a pharmacist, and others. It is derived from the extensive experience of the University of Michigan Hospital Intensive Insulin Program (HIIP) in the Division of Endocrinology, and on work done by the Society of Hospital Medicine (SHM) Glycemic Control Task Force.1719 This form was only used in the care of patients in the IG. The form, which was not approved for use on other floors, did not creep to other units. The standardized order form was the only way to order insulin or to modify the insulin regimen on the IG unit. The frequency of review or revision of the insulin orders was left to the discretion of the inpatient physicians.
Physician/Midlevel Provider Education
Physicians and midlevel providers caring for patients in the IG and the CCG were given specific education about the best practice recommendations for the management of diabetes and hyperglycemia in hospitalized patients. This education was based on the principles of anticipatory, physiologic insulin use. On nonhouse staff services, the education was provided to the attending physicians and midlevel providers, and on house staff services, the education was provided to the residents. All physician education was provided by the physician authors (D.W. and R.G.). A summary of the content of the physician education is provided in Supporting Information Appendix 2.
Nurse Education
Nurses caring for patients in the IG were given education similar to that which was provided to the physicians (see above), with an emphasis on practical issues related to delivering physiologic insulin. It included topics such as blood glucose monitoring, and the real‐time manipulation of nutritional insulin doses in accordance with the clinical situation (decision‐making that was specifically delegated to the nursing staff by the order set).
Patients
Patients were eligible for inclusion in the analysis if they met the following inclusion criteria: they were admitted to the inpatient General Internal Medicine Services; subcutaneous insulin was provided to the patient during the hospitalization; they had at least 2 blood glucose values >180 mg/dL; they were discharged from the hospital on a pharmacologic glucose lowering agent (insulin or oral); and their total length‐of‐stay was 3 days to 14 days. Patients were excluded from the analysis if they were admitted with a primary diagnosis of diabetic ketoacidosis, diabetic hyperosmolar state, or hypoglycemia. Up to 10 consecutive days of glucose data were recorded for each patient, and the first day on which blood glucose information was available from the admitting floor was excluded from the analysis. Also, specific patient‐days were not analyzed if there were no bedside glucoses recorded, or if the patient was treated with an IV insulin infusion on that day.
Outcomes
The primary outcome was glycemic control. The primary unit of measure was the patient‐day (ie, all of the information for 1 patient on a single qualifying day). This was done to correct for the phenomenon of frequent repeat testing in response to abnormal values. It also allows for a more clinically relevant description of the actual glycemic control on a given day. Specifically, each patient‐day was categorized as in‐range (70‐180 mg/dL), hyperglycemic (>180 mg/dL), severely hyperglycemic (>250 mg/dL), hypoglycemic (<70 mg/dL), and/or severely hypoglycemic (<50 mg/dL). The primary endpoint was glycemic control in‐range. For a patient‐day to be in‐range, all readings for that particular day were within 70 mg/dL to180 mg/dL. For the readings that were not in the desired range, a minimum of 1 deviant reading in a particular day constituted classification into that category, and a single out‐of‐range patient‐day could be included in 1 or more of the out‐of‐range categories (eg, a patient‐day could be categorized as both severely hyperglycemic and hypoglycemic if it contained glucose readings in both of those ranges).
The day‐weighted mean blood glucose value was also calculated for each of the groups. This calculation utilized the mean blood glucose for each patient‐day, and then averaged these values for each group. These metrics have been endorsed as appropriate measures of glycemic control by the SHM Glycemic Control Task Force.20
Other Data
Several other clinical features were also examined, including the following: primary diagnoses listed in the hospital discharge summary for each patient (3 maximum); possible confounders including patient weight, length‐of‐stay, days receiving tube feeds, days receiving parenteral nutrition, and days during which patients were treated with high‐dose glucocorticoids (>10 mg/day of prednisone, or its equivalent) or oral diabetes medications; and the composition of the insulin regimen on each hospital day. Definitions of insulin regimens are provided in Table 1.
| |
| Any basal insulin day | Any day in which intermediate‐acting or long‐acting, scheduled insulin was given. |
| Basal insulin alone day | A day in which intermediate‐acting or long‐acting insulin was the only scheduled insulin given. |
| Any nutritional insulin day | Any day in which rapid‐acting or short‐acting, scheduled insulin was given. |
| Nutritional insulin alone day | A day in which rapid‐acting or short‐acting insulin was the only scheduled insulin given. |
| Basal plus nutritional day | A day in which both scheduled, intermediate‐acting or long‐acting insulin and scheduled, rapid‐acting or short‐acting insulin were given. |
| Pre‐mixed insulin day | Any day in which a pre‐mixed combination insulin was given. |
| Basal plus nutritional or pre‐mixed insulin day | A composite of the basal plus nutritional day category and the mixed insulin day category described above. This group includes any day in which either a pre‐mixed combination insulin was given OR a day in which both: (a) scheduled, intermediate‐acting or long‐acting and (b) scheduled, rapid‐acting or short‐acting insulin were given. |
| Sliding scale insulin alone day* | Any day when only correctional (as needed) insulin was given. |
Statistical Analysis
Bivariate analyses (chi‐square, and t‐tests) were carried out to compare demographic characteristics of the intervention and control populations. Since there were multiple glucose readings nested within individuals, multilevel mixed‐effects logistic regression was used to evaluate the association between the intervention and outcomes. A 2‐level hierarchical model was developed in which patient‐days were nested within patients; this accounted for the correlation between glycemic control across days for a given patient. Patient‐day was modeled as a random intercept and the log likelihood was estimated using adaptive Gaussian quadrature with 7 integration points. Alpha was set at 0.05, 2‐tailed. The final model was adjusted for gender, age, weight, length‐of‐stay, use of oral diabetes agents, use of sulfonylureas, and use of high‐dose corticosteroids. The use of a nonoral feeding route (eg, tube feeding or parenteral nutrition) was too infrequent to be considered in the adjusted analysis. All analyses were conducted in Stata/IC 10.0 (College Station, TX).
Results
A total of 245 patients provided 1315 patient‐days. Patient demographics are shown in Table 2. The patients' weight, length‐of‐stay, and primary diagnoses were similar across the 3 groups. There was a higher percentage of males in the IG as compared to the HCG.
| IG | CCG | P Value IG vs. CCG | HCG | P Value IG vs. HCG | |
|---|---|---|---|---|---|
| |||||
| Number of patients | 84 | 86 | 75 | ||
| Age, years, mean (SD) | 59.3 (15.3) | 60.4 (15.9) | 0.68 | 59.2 (17.2) | 0.96 |
| Range (n = 245) | 18‐94 | 20‐87 | 24‐92 | ||
| Weight in kg, mean (SD) | 92.2 (29.5) | 89.5 (27.2) | 0.57 | 94.2 (35.4) | 0.69 |
| Range (n = 237) | 40‐198 | 40‐188 | 42‐235 | ||
| Sex, n (%) (n = 245) | 0.17 | 0.04 | |||
| Male | 45 (53.6) | 37 (43.0) | 28 (37.3) | ||
| Female | 39(46.4) | 49 (57.0) | 47 (62.7) | ||
| Length of stay, mean (SD) | 7.6 (3.3) | 7.4 (3.0) | 0.62 | 7.0 (2.5) | 0.14 |
| Range (n = 245) | 4‐15 | 4‐15 | 4‐14 | ||
| Number of diagnoses | 169 | 158 | 160 | ||
| Primary diagnoses, n (%) | 0.56 | 0.10 | |||
| Infections | 40 (23.7) | 45 (28.5) | 49 (30.6) | ||
| Gastrointestinal | 33 (19.5) | 19 (12.0) | 14 (8.8) | ||
| Rheumatologic | 13 (7.7) | 12 (7.6) | 18 (11.2) | ||
| Renal | 14 (8.3) | 10 (6.3) | 16 (10.0) | ||
| Diabetes‐related | 11 (6.5) | 11 (7.0) | 10 (6.2) | ||
| Neurologic | 8 (4.7) | 11 (7.0) | 11 (6.9) | ||
| *Misc/other | 50 (29.6) | 50 (31.6) | 42 (26.3) | ||
Table 3 shows the insulin regimens used in the different groups. The use of basal insulin was similar between groups. Congruent with the goals of the education session and the order set, patients in the IG were more likely to be treated with a combination of basal and nutritional insulin than patients in the other groups. Patients in the HCG were more likely to be treated with a premixed insulin than patients in the other groups. However, even when premixed insulin was categorized as a form of basal plus nutritional insulin and combined into a composite group with the combined basal and nutritional days, this type of regimen remained more common in the IG than in the HCG. The rate of sliding scale insulin use alone (ie, without any scheduled insulin) was similar in the 3 groups.
| Patient‐days on the following | IG (n = 453) | CCG (n = 471) | P Value IG vs. CCG | HCG (n = 391) | P Value IG vs. HCG |
|---|---|---|---|---|---|
| |||||
| Sliding scale alone, n (%) | 105 (23.2) | 130 (27.6) | 0.12 | 89 (22.8) | 0.89 |
| Basal alone, n (%) | 132 (29.1) | 231 (49.0) | <0.01 | 199 (50.9) | <0.01 |
| Nutritional alone, n (%) | 22 (4.9) | 5 (1.1) | <0.01 | 8 (2.0) | 0.03 |
| Basal plus nutritional, n (%) | 166 (36.6) | 71 (15.1) | <0.01 | 14 (3.6) | <0.01 |
| Pre‐mixed insulin included, n (%) | 27 (6.0) | 32 (6.8) | 0.60 | 78 (20.0) | <0.01 |
| No insulin, n (%) | 1 (<1) | 2 (<1) | 0.59 | 3 (<1) | 0.28 |
| Any basal, n (%) | 325 (71.7) | 334 (70.9) | 0.78 | 291 (74.4) | 0.38 |
| Any nutritional, n (%) | 215 (47.5) | 108 (22.9) | <0.01 | 100 (25.6) | <0.01 |
| Basal plus nutritional or pre‐mixed, n (%) | 193 (42.6) | 103 (21.9) | <0.01 | 92 (23.5) | <0.01 |
| Oral diabetes agents, n (%) | 79 (17.4) | 83 (17.6) | 0.94 | 74 (18.9) | 0.58 |
| Sulfonylureas, n (%) | 40 (8.8) | 63 (13.4) | 0.03 | 37 (9.5) | 0.75 |
| Parenteral nutrition/tube feeds, n (%) | 0 (0) | 18 (3.8) | 8 (2.0) | ||
| High dose corticosteroids, n (%) | 66 (14.6) | 93 (19.8) | 0.04 | 51 (13.0) | 0.52 |
Other relevant measures are also shown in Table 3. The use of oral diabetes agents was similar in the 3 groups. The use of a nonoral feeding route (eg, tube feeding or parenteral nutrition) was infrequent.
A comparison of glycemic control in the three groups is shown in Table 4. In contrast to the CCG, patients in the IG experienced more days within the target glucose range (17% vs. 10.6%, P < 0.01), fewer days with severe hyperglycemia (48.3% vs. 59.2%, P < 0.01), and had a lower day‐weighted average blood glucose (195.9 vs. 212.6, P < 0.01). Compared to the HCG, patients in the IG experienced similar rates of hyperglycemia, but fewer hypoglycemic days (5.1% vs. 9.2%, P = 0.02).
| IG (n = 453) | CCG (n = 471) | P Value IG vs. CCG | HCG (n = 391) | P Value IG vs. HCG | |
|---|---|---|---|---|---|
| |||||
| Patient‐days | |||||
| In range, n (%) | 77 (17.0) | 50 (10.6) | <0.01 | 66 (16.9) | 0.98 |
| Out of range, n (%) | 376 (83.0) | 421 (89.4) | <0.01 | 325 (83.1) | 0.98 |
| Hyperglycemic, n (%) | 289 (63.8) | 310 (65.8) | 0.52 | 248 (63.4) | 0.91 |
| Severely hyperglycemic, n (%) | 219 (48.3) | 279 (59.2) | <0.01 | 176 (45.0) | 0.32 |
| Hypoglycemic, n (%) | 23 (5.1) | 36 (7.6) | 0.11 | 36 (9.2) | 0.02 |
| Severely hypoglycemic, n (%) | 13 (2.9) | 10 (2.1) | 0.47 | 15 (3.8) | 0.44 |
| Day weighted average blood glucose (SD) | 195.9 (66.8) | 212.6 (73.4) | <0.01 | 190.5 (63.1) | 0.25 |
The percentages of patients with severe hyperglycemia in each group are shown in Figure 1 by hospital day. Severe hyperglycemia was common, but there was a trend towards a decrease in the prevalence of severe hyperglycemia with increasing hospital days for all study groups, although it was consistently higher in the CCG than in the IG. Figure 2 shows the types of insulin regimens used by hospital day (composite for all groups). The use of basal plus nutritional insulin (the recommended regimen) increased gradually with increasing hospital days. When taken together, the information in both figures support the hypothesis that the use of the recommended insulin regimen may have contributed to the modest improvements in glycemic control seen in the IG.
In the final adjusted regression model, the intervention had a positive impact on glycemic control (Table 5). Subjects in the IG had a 72% increase in the odds of being in the target glucose range when compared to subjects in the CCG (P = 0.01). In addition, subjects in the IG had a 35% reduction in the odds of being severely hyperglycemic when compared to those in the CCG (P < 0.01). Finally, the odds ratio (OR) for being hypoglycemic among intervention subjects was 0.59 (P = 0.06) when compared to subjects in the CCG and 0.48 (P = 0.01) when compared to subjects in the HCG.
| Adjusted OR* IG vs. CCG | 95% CI | P value IG vs. CCG | Adjusted OR* IG vs. HCG | 95% CI | P Value IG vs. HCG | |
|---|---|---|---|---|---|---|
| ||||||
| In range | 1.72 | 1.16,2.55 | 0.01 | 1.08 | 0.74,1.58 | 0.68 |
| Hyperglycemic | 0.93 | 0.70,1.22 | 0.58 | 0.95 | 0.71,1.28 | 0.74 |
| Severely Hyperglycemic | 0.65 | 0.49,0.85 | <0.01 | 1.10 | 0.82,1.47 | 0.52 |
| Hypoglycemic | 0.59 | 0.34,1.02 | 0.06 | 0.48 | 0.27,0.85 | 0.01 |
| Severely Hypoglycemic | 1.36 | 0.59,3.14 | 0.47 | 0.97 | 0.29,1.44 | 0.28 |
Discussion
In this study, we investigated the effects of a standardized insulin order set, coupled with physician and nurse education, on glycemic control in hyperglycemic hospitalized patients. These interventions were designed to encourage a standardized approach to the treatment of hyperglycemia in hospitalized patients, based on the principles of physiologic insulin use, as described above. Our data suggest that the interventions did, indeed, alter the way insulin was prescribed, as more patients in the IG received a combination of basal plus nutritional insulin (the recommended regimen) than in the other groups. These interventions were associated with improved glycemic outcomes in the IG as compared to the CCG. The IG experienced a higher percentage of days in the target range and a trend toward fewer hypoglycemic days than the CCG. Although the IG experienced a similar percentage of days in the target range, it had significantly fewer hypoglycemic days than the HCG.
It is useful to consider the results of our study in the context of 2 other similar studies performed by Schnipper et al.14 and Maynard et al.15 Although each of these 3 studies have different study designs, they are similar in intent (to test the effects of simple quality improvement interventions on glycemic control in the hospital) and results (all showed significant improvements in some aspect of glycemic control). In our study, and the study by Maynard et al.,15 the interventions also led to decreases in the rates of hypoglycemia, whereas Schnipper et al.14 observed no difference in hypoglycemia. Of interest, in each of the three studies the interventions were associated with an increase in the use of some type of scheduled insulin. In our study and the study from Schnipper et al.14 the baseline use of basal insulin was quite high, and the interventions were associated with a significant increase in the addition of nutritional insulin. In the Maynard et al.15 study, the baseline use of sliding scale insulin alone was prevalent, and the interventions resulted in an increase in the use of basal insulin. The results of these studies, taken together, prompt us to conclude that the interventions employed in these studies are likely to lead to more frequent prescription of scheduled (anticipatory) insulin, and a modest improvement in glycemic control, without an increase (and perhaps with a decrease) in hypoglycemia.
A few of our study results are unexpected, or difficult to explain. In contrast to the other studies discussed above, our interventions did not affect the frequency of the use of sliding‐scale insulin alone (without any scheduled insulin), which was similar in the 3 groups. Although the reason for this is uncertain, we hypothesize that the high baseline use of basal insulin in our institution, and the lack of a hard stop preventing the use of sliding scale insulin alone explain this finding. Also, it is difficult to explain why measures of hyperglycemia were similar between the IG and the HCG despite the fact that the HCG was less often treated with a combination of basal and nutritional insulin and more often treated with mixed insulin.
There are several different mechanisms by which the interventions might have resulted in improved glycemic control in the IG compared to CCG. Our data clearly shows that insulin was prescribed differently in the IG, and the more frequent use of a combination of scheduled basal and nutritional insulin might have contributed to the differences between the groups. However, the effects of our interventions clearly went beyond physician education into the realm of true process improvement and standardization. The standardized order form was designed to prompt physicians to use a basal‐bolus insulin regimen. The order form also created nursing expectations of how insulin should be ordered, and clarified the roles of the different insulins that were prescribed.
On the medication administration record, each insulin was labeled as basal insulin (to be given even when fasting) or nutritional insulin (to be given along with the meal). The nurses caring for the IG also attended an education program that reinforced the role of the nurse in the bedside management of insulin administration. Specifically, nurses were taught to assess the premeal blood glucose and the patient's nutritional situation before giving the nutritional insulin (ie, Does the patient have food available? Will he tolerate eating the food?). In situations where is was not clear if the patient would be able to tolerate the ordered nutrition, the order set empowered the nurse to give the nutritional insulin after the meal, and to reduce the dose to match the patient's actual intake. These interventions resulted in some fundamental improvements in the nursing process of delivering insulin to the patient, and these changes might have resulted in improvements via mechanisms that are difficult to directly measure. Since the same physicians cared for both the IG and the CCG, interventions other than physician education clearly contributed to the observed improvements in the IG.
This study was not a randomized study, and there could be important undetected differences between the groups. However, all of the patients were admitted to the General Medicine Inpatient Services and the comparison of the general patient demographics and primary diagnoses between the groups do not suggest major differences.
Although the improvements in glycemic control seen in this study were statistically significant, they were quantitatively modest. The rates of hyperglycemia seen in this study, on the other hand, are quite remarkable. Both the American Diabetes Association and the American College of Endocrinology have recommended that blood glucoses in hospitalized patients not exceed a maximum value of 180 mg/dL, but the day‐weighted average blood glucose in this study was above that for each group. Even in the IG, over 80% of all patient‐days included at least 1 blood glucose value outside of the target range. These data suggest that better strategies for achieving metabolic control in hospitalized patients are needed.
It is worth mentioning that our interventions were not aggressively enforced. While the use of the order set was mandatory for the IG, it was flexible enough to allow for substantial practice variation, especially with respect to the dose of insulin prescribed. Although the education sessions discussed the specifics of insulin dosing in hospitalized patients, the order form did not offer dosing guidelines. It is possible that our interventions may have had a larger impact if a starting dose of insulin had been specified on the form. Although the insulin order form prompted physicians to act, there were no forced functions. Also, not all house staff attended the education sessions for physicians, and there was no feedback provided to physicians related to how they might improve their adherence to the recommendations presented in the educational module. Therefore, it is likely that more aggressive interventions could have led to greater changes in physician practice.
In conclusion, this study demonstrates that interventions including physician and nurse education and a standardized insulin order set can lead to improvement in glycemic control and patient safety in hospitalized patients treated with subcutaneous insulin. However, the observed improvements are modest, and poor metabolic control remains common, despite these interventions. These data suggest that standardization of the process of ordering and delivering subcutaneous insulin in the hospital may lead to a reduction in both hyperglycemia and hypoglycemia. However, it is clear that the interventions used in this study were not potent enough to achieve the recommended glycemic targets for the majority of patients. Additional research is needed to determine the best strategy for achieving safe and effective metabolic control in hospitalized, hyperglycemic, noncritically ill patients.
Acknowledgements
The authors thank David Conway for his work in data collection and management.
Hyperglycemia is common in hospitalized patients, and hyperglycemia has been associated with poor hospital outcomes. The adverse physiologic effects of acute hyperglycemia are well established1 and several clinical studies have linked hyperglycemia with poor clinical outcomes in certain patient populations.28 Although the optimal target range for inpatient glycemic control has not yet been defined, these studies support the goal of metabolic control for hospital patients. However, there are many barriers to achieving adequate glycemic control in the hospital, and blood glucoses in the hospital are often far from recommended targets.9, 10 One barrier appears to be the low priority given to glycemic control in the hospital. Hyperglycemia in the hospital is often ignored,11 and insulin regimens are often chosen for simplicity as opposed to effectiveness.12 Other barriers to glycemic control in the hospital include the physiologic effects (stress) of acute illness, and the frequent nutritional changes and interruptions that occur.
Most hyperglycemic patients on a general medicine unit are treated with subcutaneous insulin, but the optimal strategy for prescribing insulin in the hospital remains uncertain. A technical review of the literature on the management of diabetes in the hospital setting from 2004 recommends prescribing insulin in a way that mimics physiologic insulin secretion (ie, physiologic or basal‐bolus insulin).1 This approach has been promulgated by experts, but there has been very little research to support these recommendations. One small, randomized trial concluded that a basal‐bolus approach achieved better glycemic control than the use of sliding‐scale insulin alone,13 and 2 quality improvement studies using a before/after design have demonstrated improvements in glycemic control after the implementation of interventions designed to encourage physiologic insulin use.14, 15
In this study we hypothesized that a few simple interventions (education for physicians and nurses, and a standardized insulin order form) would lead to a higher rate of basal‐bolus insulin use and simultaneously improve glycemic control and patient safety.
Methods
Study Design
This study was performed at the University of Michigan Hospital over a 6‐month period, and the protocol was approved by the Institutional Review Board. We performed a quasi‐experimental study comparing 3 patient groups. The intervention group (IG) was subject to all of the interventions discussed below (physician education, nurse education, and the standardized order form). The concurrent control group (CCG) was hospitalized during the same time period as the IG, but was only subject to 1 of the interventions (physician education). These patients were cared for by the same physicians as the IG, but on a different unit where the nurses had not received the education and where the standardized insulin order form was not available. Patients were admitted to the IG unit or the CCG unit via the institution's usual admission process. In addition, we examined an historic control group (HCG) which was hospitalized during the same months of the year, but 2 years prior. The HCG was not subject to any of the interventions.
Interventions
Standardized Subcutaneous Insulin Order Form
This form (Supporting Information Appendix 1) was designed to encourage physicians to prescribe insulin in a physiologic way, providing basal, nutritional, and correctional insulin. The form is based on best practice guidelines,1 and is in agreement with the principles of the inpatient management of diabetes and hyperglycemia endorsed by several professional organizations.16, 17 The form was engineered by a multidisciplinary team, including an endocrinologist, several hospitalists, several nurses, a certified diabetes educator, a pharmacist, and others. It is derived from the extensive experience of the University of Michigan Hospital Intensive Insulin Program (HIIP) in the Division of Endocrinology, and on work done by the Society of Hospital Medicine (SHM) Glycemic Control Task Force.1719 This form was only used in the care of patients in the IG. The form, which was not approved for use on other floors, did not creep to other units. The standardized order form was the only way to order insulin or to modify the insulin regimen on the IG unit. The frequency of review or revision of the insulin orders was left to the discretion of the inpatient physicians.
Physician/Midlevel Provider Education
Physicians and midlevel providers caring for patients in the IG and the CCG were given specific education about the best practice recommendations for the management of diabetes and hyperglycemia in hospitalized patients. This education was based on the principles of anticipatory, physiologic insulin use. On nonhouse staff services, the education was provided to the attending physicians and midlevel providers, and on house staff services, the education was provided to the residents. All physician education was provided by the physician authors (D.W. and R.G.). A summary of the content of the physician education is provided in Supporting Information Appendix 2.
Nurse Education
Nurses caring for patients in the IG were given education similar to that which was provided to the physicians (see above), with an emphasis on practical issues related to delivering physiologic insulin. It included topics such as blood glucose monitoring, and the real‐time manipulation of nutritional insulin doses in accordance with the clinical situation (decision‐making that was specifically delegated to the nursing staff by the order set).
Patients
Patients were eligible for inclusion in the analysis if they met the following inclusion criteria: they were admitted to the inpatient General Internal Medicine Services; subcutaneous insulin was provided to the patient during the hospitalization; they had at least 2 blood glucose values >180 mg/dL; they were discharged from the hospital on a pharmacologic glucose lowering agent (insulin or oral); and their total length‐of‐stay was 3 days to 14 days. Patients were excluded from the analysis if they were admitted with a primary diagnosis of diabetic ketoacidosis, diabetic hyperosmolar state, or hypoglycemia. Up to 10 consecutive days of glucose data were recorded for each patient, and the first day on which blood glucose information was available from the admitting floor was excluded from the analysis. Also, specific patient‐days were not analyzed if there were no bedside glucoses recorded, or if the patient was treated with an IV insulin infusion on that day.
Outcomes
The primary outcome was glycemic control. The primary unit of measure was the patient‐day (ie, all of the information for 1 patient on a single qualifying day). This was done to correct for the phenomenon of frequent repeat testing in response to abnormal values. It also allows for a more clinically relevant description of the actual glycemic control on a given day. Specifically, each patient‐day was categorized as in‐range (70‐180 mg/dL), hyperglycemic (>180 mg/dL), severely hyperglycemic (>250 mg/dL), hypoglycemic (<70 mg/dL), and/or severely hypoglycemic (<50 mg/dL). The primary endpoint was glycemic control in‐range. For a patient‐day to be in‐range, all readings for that particular day were within 70 mg/dL to180 mg/dL. For the readings that were not in the desired range, a minimum of 1 deviant reading in a particular day constituted classification into that category, and a single out‐of‐range patient‐day could be included in 1 or more of the out‐of‐range categories (eg, a patient‐day could be categorized as both severely hyperglycemic and hypoglycemic if it contained glucose readings in both of those ranges).
The day‐weighted mean blood glucose value was also calculated for each of the groups. This calculation utilized the mean blood glucose for each patient‐day, and then averaged these values for each group. These metrics have been endorsed as appropriate measures of glycemic control by the SHM Glycemic Control Task Force.20
Other Data
Several other clinical features were also examined, including the following: primary diagnoses listed in the hospital discharge summary for each patient (3 maximum); possible confounders including patient weight, length‐of‐stay, days receiving tube feeds, days receiving parenteral nutrition, and days during which patients were treated with high‐dose glucocorticoids (>10 mg/day of prednisone, or its equivalent) or oral diabetes medications; and the composition of the insulin regimen on each hospital day. Definitions of insulin regimens are provided in Table 1.
| |
| Any basal insulin day | Any day in which intermediate‐acting or long‐acting, scheduled insulin was given. |
| Basal insulin alone day | A day in which intermediate‐acting or long‐acting insulin was the only scheduled insulin given. |
| Any nutritional insulin day | Any day in which rapid‐acting or short‐acting, scheduled insulin was given. |
| Nutritional insulin alone day | A day in which rapid‐acting or short‐acting insulin was the only scheduled insulin given. |
| Basal plus nutritional day | A day in which both scheduled, intermediate‐acting or long‐acting insulin and scheduled, rapid‐acting or short‐acting insulin were given. |
| Pre‐mixed insulin day | Any day in which a pre‐mixed combination insulin was given. |
| Basal plus nutritional or pre‐mixed insulin day | A composite of the basal plus nutritional day category and the mixed insulin day category described above. This group includes any day in which either a pre‐mixed combination insulin was given OR a day in which both: (a) scheduled, intermediate‐acting or long‐acting and (b) scheduled, rapid‐acting or short‐acting insulin were given. |
| Sliding scale insulin alone day* | Any day when only correctional (as needed) insulin was given. |
Statistical Analysis
Bivariate analyses (chi‐square, and t‐tests) were carried out to compare demographic characteristics of the intervention and control populations. Since there were multiple glucose readings nested within individuals, multilevel mixed‐effects logistic regression was used to evaluate the association between the intervention and outcomes. A 2‐level hierarchical model was developed in which patient‐days were nested within patients; this accounted for the correlation between glycemic control across days for a given patient. Patient‐day was modeled as a random intercept and the log likelihood was estimated using adaptive Gaussian quadrature with 7 integration points. Alpha was set at 0.05, 2‐tailed. The final model was adjusted for gender, age, weight, length‐of‐stay, use of oral diabetes agents, use of sulfonylureas, and use of high‐dose corticosteroids. The use of a nonoral feeding route (eg, tube feeding or parenteral nutrition) was too infrequent to be considered in the adjusted analysis. All analyses were conducted in Stata/IC 10.0 (College Station, TX).
Results
A total of 245 patients provided 1315 patient‐days. Patient demographics are shown in Table 2. The patients' weight, length‐of‐stay, and primary diagnoses were similar across the 3 groups. There was a higher percentage of males in the IG as compared to the HCG.
| IG | CCG | P Value IG vs. CCG | HCG | P Value IG vs. HCG | |
|---|---|---|---|---|---|
| |||||
| Number of patients | 84 | 86 | 75 | ||
| Age, years, mean (SD) | 59.3 (15.3) | 60.4 (15.9) | 0.68 | 59.2 (17.2) | 0.96 |
| Range (n = 245) | 18‐94 | 20‐87 | 24‐92 | ||
| Weight in kg, mean (SD) | 92.2 (29.5) | 89.5 (27.2) | 0.57 | 94.2 (35.4) | 0.69 |
| Range (n = 237) | 40‐198 | 40‐188 | 42‐235 | ||
| Sex, n (%) (n = 245) | 0.17 | 0.04 | |||
| Male | 45 (53.6) | 37 (43.0) | 28 (37.3) | ||
| Female | 39(46.4) | 49 (57.0) | 47 (62.7) | ||
| Length of stay, mean (SD) | 7.6 (3.3) | 7.4 (3.0) | 0.62 | 7.0 (2.5) | 0.14 |
| Range (n = 245) | 4‐15 | 4‐15 | 4‐14 | ||
| Number of diagnoses | 169 | 158 | 160 | ||
| Primary diagnoses, n (%) | 0.56 | 0.10 | |||
| Infections | 40 (23.7) | 45 (28.5) | 49 (30.6) | ||
| Gastrointestinal | 33 (19.5) | 19 (12.0) | 14 (8.8) | ||
| Rheumatologic | 13 (7.7) | 12 (7.6) | 18 (11.2) | ||
| Renal | 14 (8.3) | 10 (6.3) | 16 (10.0) | ||
| Diabetes‐related | 11 (6.5) | 11 (7.0) | 10 (6.2) | ||
| Neurologic | 8 (4.7) | 11 (7.0) | 11 (6.9) | ||
| *Misc/other | 50 (29.6) | 50 (31.6) | 42 (26.3) | ||
Table 3 shows the insulin regimens used in the different groups. The use of basal insulin was similar between groups. Congruent with the goals of the education session and the order set, patients in the IG were more likely to be treated with a combination of basal and nutritional insulin than patients in the other groups. Patients in the HCG were more likely to be treated with a premixed insulin than patients in the other groups. However, even when premixed insulin was categorized as a form of basal plus nutritional insulin and combined into a composite group with the combined basal and nutritional days, this type of regimen remained more common in the IG than in the HCG. The rate of sliding scale insulin use alone (ie, without any scheduled insulin) was similar in the 3 groups.
| Patient‐days on the following | IG (n = 453) | CCG (n = 471) | P Value IG vs. CCG | HCG (n = 391) | P Value IG vs. HCG |
|---|---|---|---|---|---|
| |||||
| Sliding scale alone, n (%) | 105 (23.2) | 130 (27.6) | 0.12 | 89 (22.8) | 0.89 |
| Basal alone, n (%) | 132 (29.1) | 231 (49.0) | <0.01 | 199 (50.9) | <0.01 |
| Nutritional alone, n (%) | 22 (4.9) | 5 (1.1) | <0.01 | 8 (2.0) | 0.03 |
| Basal plus nutritional, n (%) | 166 (36.6) | 71 (15.1) | <0.01 | 14 (3.6) | <0.01 |
| Pre‐mixed insulin included, n (%) | 27 (6.0) | 32 (6.8) | 0.60 | 78 (20.0) | <0.01 |
| No insulin, n (%) | 1 (<1) | 2 (<1) | 0.59 | 3 (<1) | 0.28 |
| Any basal, n (%) | 325 (71.7) | 334 (70.9) | 0.78 | 291 (74.4) | 0.38 |
| Any nutritional, n (%) | 215 (47.5) | 108 (22.9) | <0.01 | 100 (25.6) | <0.01 |
| Basal plus nutritional or pre‐mixed, n (%) | 193 (42.6) | 103 (21.9) | <0.01 | 92 (23.5) | <0.01 |
| Oral diabetes agents, n (%) | 79 (17.4) | 83 (17.6) | 0.94 | 74 (18.9) | 0.58 |
| Sulfonylureas, n (%) | 40 (8.8) | 63 (13.4) | 0.03 | 37 (9.5) | 0.75 |
| Parenteral nutrition/tube feeds, n (%) | 0 (0) | 18 (3.8) | 8 (2.0) | ||
| High dose corticosteroids, n (%) | 66 (14.6) | 93 (19.8) | 0.04 | 51 (13.0) | 0.52 |
Other relevant measures are also shown in Table 3. The use of oral diabetes agents was similar in the 3 groups. The use of a nonoral feeding route (eg, tube feeding or parenteral nutrition) was infrequent.
A comparison of glycemic control in the three groups is shown in Table 4. In contrast to the CCG, patients in the IG experienced more days within the target glucose range (17% vs. 10.6%, P < 0.01), fewer days with severe hyperglycemia (48.3% vs. 59.2%, P < 0.01), and had a lower day‐weighted average blood glucose (195.9 vs. 212.6, P < 0.01). Compared to the HCG, patients in the IG experienced similar rates of hyperglycemia, but fewer hypoglycemic days (5.1% vs. 9.2%, P = 0.02).
| IG (n = 453) | CCG (n = 471) | P Value IG vs. CCG | HCG (n = 391) | P Value IG vs. HCG | |
|---|---|---|---|---|---|
| |||||
| Patient‐days | |||||
| In range, n (%) | 77 (17.0) | 50 (10.6) | <0.01 | 66 (16.9) | 0.98 |
| Out of range, n (%) | 376 (83.0) | 421 (89.4) | <0.01 | 325 (83.1) | 0.98 |
| Hyperglycemic, n (%) | 289 (63.8) | 310 (65.8) | 0.52 | 248 (63.4) | 0.91 |
| Severely hyperglycemic, n (%) | 219 (48.3) | 279 (59.2) | <0.01 | 176 (45.0) | 0.32 |
| Hypoglycemic, n (%) | 23 (5.1) | 36 (7.6) | 0.11 | 36 (9.2) | 0.02 |
| Severely hypoglycemic, n (%) | 13 (2.9) | 10 (2.1) | 0.47 | 15 (3.8) | 0.44 |
| Day weighted average blood glucose (SD) | 195.9 (66.8) | 212.6 (73.4) | <0.01 | 190.5 (63.1) | 0.25 |
The percentages of patients with severe hyperglycemia in each group are shown in Figure 1 by hospital day. Severe hyperglycemia was common, but there was a trend towards a decrease in the prevalence of severe hyperglycemia with increasing hospital days for all study groups, although it was consistently higher in the CCG than in the IG. Figure 2 shows the types of insulin regimens used by hospital day (composite for all groups). The use of basal plus nutritional insulin (the recommended regimen) increased gradually with increasing hospital days. When taken together, the information in both figures support the hypothesis that the use of the recommended insulin regimen may have contributed to the modest improvements in glycemic control seen in the IG.
In the final adjusted regression model, the intervention had a positive impact on glycemic control (Table 5). Subjects in the IG had a 72% increase in the odds of being in the target glucose range when compared to subjects in the CCG (P = 0.01). In addition, subjects in the IG had a 35% reduction in the odds of being severely hyperglycemic when compared to those in the CCG (P < 0.01). Finally, the odds ratio (OR) for being hypoglycemic among intervention subjects was 0.59 (P = 0.06) when compared to subjects in the CCG and 0.48 (P = 0.01) when compared to subjects in the HCG.
| Adjusted OR* IG vs. CCG | 95% CI | P value IG vs. CCG | Adjusted OR* IG vs. HCG | 95% CI | P Value IG vs. HCG | |
|---|---|---|---|---|---|---|
| ||||||
| In range | 1.72 | 1.16,2.55 | 0.01 | 1.08 | 0.74,1.58 | 0.68 |
| Hyperglycemic | 0.93 | 0.70,1.22 | 0.58 | 0.95 | 0.71,1.28 | 0.74 |
| Severely Hyperglycemic | 0.65 | 0.49,0.85 | <0.01 | 1.10 | 0.82,1.47 | 0.52 |
| Hypoglycemic | 0.59 | 0.34,1.02 | 0.06 | 0.48 | 0.27,0.85 | 0.01 |
| Severely Hypoglycemic | 1.36 | 0.59,3.14 | 0.47 | 0.97 | 0.29,1.44 | 0.28 |
Discussion
In this study, we investigated the effects of a standardized insulin order set, coupled with physician and nurse education, on glycemic control in hyperglycemic hospitalized patients. These interventions were designed to encourage a standardized approach to the treatment of hyperglycemia in hospitalized patients, based on the principles of physiologic insulin use, as described above. Our data suggest that the interventions did, indeed, alter the way insulin was prescribed, as more patients in the IG received a combination of basal plus nutritional insulin (the recommended regimen) than in the other groups. These interventions were associated with improved glycemic outcomes in the IG as compared to the CCG. The IG experienced a higher percentage of days in the target range and a trend toward fewer hypoglycemic days than the CCG. Although the IG experienced a similar percentage of days in the target range, it had significantly fewer hypoglycemic days than the HCG.
It is useful to consider the results of our study in the context of 2 other similar studies performed by Schnipper et al.14 and Maynard et al.15 Although each of these 3 studies have different study designs, they are similar in intent (to test the effects of simple quality improvement interventions on glycemic control in the hospital) and results (all showed significant improvements in some aspect of glycemic control). In our study, and the study by Maynard et al.,15 the interventions also led to decreases in the rates of hypoglycemia, whereas Schnipper et al.14 observed no difference in hypoglycemia. Of interest, in each of the three studies the interventions were associated with an increase in the use of some type of scheduled insulin. In our study and the study from Schnipper et al.14 the baseline use of basal insulin was quite high, and the interventions were associated with a significant increase in the addition of nutritional insulin. In the Maynard et al.15 study, the baseline use of sliding scale insulin alone was prevalent, and the interventions resulted in an increase in the use of basal insulin. The results of these studies, taken together, prompt us to conclude that the interventions employed in these studies are likely to lead to more frequent prescription of scheduled (anticipatory) insulin, and a modest improvement in glycemic control, without an increase (and perhaps with a decrease) in hypoglycemia.
A few of our study results are unexpected, or difficult to explain. In contrast to the other studies discussed above, our interventions did not affect the frequency of the use of sliding‐scale insulin alone (without any scheduled insulin), which was similar in the 3 groups. Although the reason for this is uncertain, we hypothesize that the high baseline use of basal insulin in our institution, and the lack of a hard stop preventing the use of sliding scale insulin alone explain this finding. Also, it is difficult to explain why measures of hyperglycemia were similar between the IG and the HCG despite the fact that the HCG was less often treated with a combination of basal and nutritional insulin and more often treated with mixed insulin.
There are several different mechanisms by which the interventions might have resulted in improved glycemic control in the IG compared to CCG. Our data clearly shows that insulin was prescribed differently in the IG, and the more frequent use of a combination of scheduled basal and nutritional insulin might have contributed to the differences between the groups. However, the effects of our interventions clearly went beyond physician education into the realm of true process improvement and standardization. The standardized order form was designed to prompt physicians to use a basal‐bolus insulin regimen. The order form also created nursing expectations of how insulin should be ordered, and clarified the roles of the different insulins that were prescribed.
On the medication administration record, each insulin was labeled as basal insulin (to be given even when fasting) or nutritional insulin (to be given along with the meal). The nurses caring for the IG also attended an education program that reinforced the role of the nurse in the bedside management of insulin administration. Specifically, nurses were taught to assess the premeal blood glucose and the patient's nutritional situation before giving the nutritional insulin (ie, Does the patient have food available? Will he tolerate eating the food?). In situations where is was not clear if the patient would be able to tolerate the ordered nutrition, the order set empowered the nurse to give the nutritional insulin after the meal, and to reduce the dose to match the patient's actual intake. These interventions resulted in some fundamental improvements in the nursing process of delivering insulin to the patient, and these changes might have resulted in improvements via mechanisms that are difficult to directly measure. Since the same physicians cared for both the IG and the CCG, interventions other than physician education clearly contributed to the observed improvements in the IG.
This study was not a randomized study, and there could be important undetected differences between the groups. However, all of the patients were admitted to the General Medicine Inpatient Services and the comparison of the general patient demographics and primary diagnoses between the groups do not suggest major differences.
Although the improvements in glycemic control seen in this study were statistically significant, they were quantitatively modest. The rates of hyperglycemia seen in this study, on the other hand, are quite remarkable. Both the American Diabetes Association and the American College of Endocrinology have recommended that blood glucoses in hospitalized patients not exceed a maximum value of 180 mg/dL, but the day‐weighted average blood glucose in this study was above that for each group. Even in the IG, over 80% of all patient‐days included at least 1 blood glucose value outside of the target range. These data suggest that better strategies for achieving metabolic control in hospitalized patients are needed.
It is worth mentioning that our interventions were not aggressively enforced. While the use of the order set was mandatory for the IG, it was flexible enough to allow for substantial practice variation, especially with respect to the dose of insulin prescribed. Although the education sessions discussed the specifics of insulin dosing in hospitalized patients, the order form did not offer dosing guidelines. It is possible that our interventions may have had a larger impact if a starting dose of insulin had been specified on the form. Although the insulin order form prompted physicians to act, there were no forced functions. Also, not all house staff attended the education sessions for physicians, and there was no feedback provided to physicians related to how they might improve their adherence to the recommendations presented in the educational module. Therefore, it is likely that more aggressive interventions could have led to greater changes in physician practice.
In conclusion, this study demonstrates that interventions including physician and nurse education and a standardized insulin order set can lead to improvement in glycemic control and patient safety in hospitalized patients treated with subcutaneous insulin. However, the observed improvements are modest, and poor metabolic control remains common, despite these interventions. These data suggest that standardization of the process of ordering and delivering subcutaneous insulin in the hospital may lead to a reduction in both hyperglycemia and hypoglycemia. However, it is clear that the interventions used in this study were not potent enough to achieve the recommended glycemic targets for the majority of patients. Additional research is needed to determine the best strategy for achieving safe and effective metabolic control in hospitalized, hyperglycemic, noncritically ill patients.
Acknowledgements
The authors thank David Conway for his work in data collection and management.
- ,,, et al.Management of diabetes and hyperglycemia in hospitals.Diabetes Care.2004;27:553–591.
- ,,, et al.Intensive insulin therapy in the critically ill patients.N Engl J Med.2001;345:1359–1367.
- ,,, et al.Intensive insulin therapy in the medical ICU.N Engl J Med.2006;354:449–461.
- ,,,.Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures.Ann Thorac Surg.1999;67:352–360; discussion360–352.
- ,,, et al.Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting.J Thorac Cardiovasc Surg.2003;125:1007–1021.
- ,,,,,.Hyperglycemia: an independent marker of in‐hospital mortality in patients with undiagnosed diabetes.J Clin Endocrinol Metab.2002;87:978–982.
- ,,, et al.Early postoperative glucose control predicts nosocomial infection rate in diabetic patients.JPEN J Parenter Enteral Nutr.1998;22:77–81.
- ,,,,,.The relation between hyperglycemia and outcomes in 2,471 patients admitted to the hospital with community‐acquired pneumonia.Diabetes Care.2005;28:810–815.
- ,.Glycemic chaos (not glycemic control) still the rule for inpatient care: how do we stop the insanity?J Hosp Med.2006;1:141–144.
- ,,, et al.Evaluation of hospital glycemic control at US Academic Medical Centers.J Hosp Med.2009;4:35–44.
- ,,, et al.Diabetes care in the hospital: is there clinical inertia?J Hosp Med.2006;1:151–160.
- ,,,,.Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital.J Hosp Med.2006;1:145–150.
- ,,, et al.Randomized study of basal‐bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial).Diabetes Care.2007;30:2181–2186.
- ,,,.Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial.J Hosp Med.2009;4:16–27.
- ,,,,.Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm.J Hosp Med.2009;4:3–15.
- ,,, et al.American College of Endocrinology position statement on inpatient diabetes and metabolic control.Endocr Pract.2004;10:77–82.
- Society of Hospital Medicine. Glycemic Control Resource Room. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section= Quality_Improvement_Resource_Rooms3(5 Suppl):17–28.
- ,,,.Subcutaneous insulin order sets and protocols: effective design and implementation strategies.J Hosp Med.2008;3(5 Suppl):29–41.
- ,,,,.Society of Hospital Medicine Glycemic Control Task Force summary: practical recommendations for assessing the impact of glycemic control efforts.J Hosp Med.2008;3(5 Suppl):66–75.
- ,,, et al.Management of diabetes and hyperglycemia in hospitals.Diabetes Care.2004;27:553–591.
- ,,, et al.Intensive insulin therapy in the critically ill patients.N Engl J Med.2001;345:1359–1367.
- ,,, et al.Intensive insulin therapy in the medical ICU.N Engl J Med.2006;354:449–461.
- ,,,.Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures.Ann Thorac Surg.1999;67:352–360; discussion360–352.
- ,,, et al.Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting.J Thorac Cardiovasc Surg.2003;125:1007–1021.
- ,,,,,.Hyperglycemia: an independent marker of in‐hospital mortality in patients with undiagnosed diabetes.J Clin Endocrinol Metab.2002;87:978–982.
- ,,, et al.Early postoperative glucose control predicts nosocomial infection rate in diabetic patients.JPEN J Parenter Enteral Nutr.1998;22:77–81.
- ,,,,,.The relation between hyperglycemia and outcomes in 2,471 patients admitted to the hospital with community‐acquired pneumonia.Diabetes Care.2005;28:810–815.
- ,.Glycemic chaos (not glycemic control) still the rule for inpatient care: how do we stop the insanity?J Hosp Med.2006;1:141–144.
- ,,, et al.Evaluation of hospital glycemic control at US Academic Medical Centers.J Hosp Med.2009;4:35–44.
- ,,, et al.Diabetes care in the hospital: is there clinical inertia?J Hosp Med.2006;1:151–160.
- ,,,,.Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital.J Hosp Med.2006;1:145–150.
- ,,, et al.Randomized study of basal‐bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 trial).Diabetes Care.2007;30:2181–2186.
- ,,,.Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial.J Hosp Med.2009;4:16–27.
- ,,,,.Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm.J Hosp Med.2009;4:3–15.
- ,,, et al.American College of Endocrinology position statement on inpatient diabetes and metabolic control.Endocr Pract.2004;10:77–82.
- Society of Hospital Medicine. Glycemic Control Resource Room. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section= Quality_Improvement_Resource_Rooms3(5 Suppl):17–28.
- ,,,.Subcutaneous insulin order sets and protocols: effective design and implementation strategies.J Hosp Med.2008;3(5 Suppl):29–41.
- ,,,,.Society of Hospital Medicine Glycemic Control Task Force summary: practical recommendations for assessing the impact of glycemic control efforts.J Hosp Med.2008;3(5 Suppl):66–75.
Copyright © 2010 Society of Hospital Medicine
