Peripherally inserted central catheter.
(Photo by Pinkfud.)
A few days ago I had what’s called a PICC line installed in my right arm. This isn’t a big deal; it’s just a tube that they run up through one of your big veins to transport things like antibiotics to where they’ll do the most good. There are other ways to do that job — for instance to lie in a hospital bed for a week or so and have a nurse come by and stick a needle in you every now and then. That works just as well, but with the PICC line you can go home and do it yourself.
I wouldn’t even have mentioned it except for a coincidence. There’s a tiny possibility of some kinds of problems, like infections. The day after I got the thing, there was a story in the paper about how widely hospitals varied in the number of serious infections they gave patients who got the procedure. The number they’re all supposed to aim for is zero, but not one of the hospitals in this study made it. Some give their patients hardly any, others more than they like to admit to. (Which is really shameful because this is one of the absolute easiest to prevent problems in medicine. The most important thing the OR people need to do to eliminate them is wash their hands.)
So what I’d like to know, if any of you know the answer, is how many patients do get infected from these procedures. Any of you happen to know anything about that?
This isn’t urgent, by the way. I don’t even know anybody who had such an infection. It’s just curiosity, which is to say it’s a part of my plan for all of us to know everything so we can educate the rest of the world.
Javier says:
Dear Mr Pohl,
I have done a quick search and I found a few figures in the Wikipedia. Probably following the sources more figures could be found. Here is the link:
http://en.wikipedia.org/wiki/Nosocomial_infection
Best regards,
Javier
February 18, 2010, 2:29 amPS. Isn’t the Internet great? if twenty years ago, the first time I read something by Frederik Pohl, anybody had told me that one day I could send a direct message to him, I wouldn’t have believed it. And sorry for the bad English.
Ralan says:
A number of articles came up doing a Google search for “PICC infections.”
One said (while admitting that it was limited and more studies need to be done) that in hospital ratios of infections to PICC insertions are 2-5 per 1000. Outpatient ratios are 0.4/1000. So outpatients are safer.
Another said that there were an estimated 250,000 serious cases of PICC-related infection in the U.S. in 2006, with a mortality rate of 12%-15%. It also said, “The incidence of PICC related infections varies considerably according to the type of catheter, frequency of catheter change, sterile technique during insertion, subsequent care by health care providers as well as patient-related factors such as underlying disease and nature of illness.”
The third one I checked, dated 15 July 2009, told about an 18-month project to “clean up” the insertion process. 77 hospitals and 103 ICUs in Michigan reduced infections by 66%, saving an estimated 2000 lives and $200 million. Which is in line with what you said about remembering to wash their hands. Actually, I wonder why they don’t use sterile gloves, since any procedure involving blood should be treated as a HIV risk.
February 18, 2010, 3:00 amMichael Parker says:
Sorry to hear about the procedure. My father just had a stent put in. He had angioplasty years ago and the resultant scarring may have led to restricted circulation of blood to his leg. It was very painful and prevented him from walking more than a few blocks before having to rest. The reason I bring this up is that after the stent was inserted he was out of the hospital within a day. A couple days later he was taking long hikes with no pain. Considering the length of recovery when he went for his first angioplasty this is quite a feat. Ah, modern technology.
As for infections, I’m not sure about the PICC line but the CDC reports that hospital patients have a 1 in 20 chance of catching an infection during their stay. Half of those infections are estimated to be from improper hand washing. It also estimates that treating those infections costs at least $30 billion a year in the United States. 2 million hospital-related infections occur every year and 250 people die from those infections everyday. The Center for Medicare and Medicaid Services ruled last year that it wouldn’t reimburse hospitals for treating infections that occur during hospital stays.
To prevent infections some hospitals are using electronic badges systems. Hospital staff must wash their hands and then have to pass their hands under a wall-mounted scanner. The scanner uses soap-sniffing technology to ensure that they have washed sufficiently and if they have the badge is activated. Additionally, they have a maximum of 90 seconds to get to a patient after hand washing. A monitor near the bed reads the card and flashes green if those conditions are met. If the doctor goes over the 90 second limit the badge vibrates.
There’s another system that uses Infrared and RFID to monitor the locations and times of hand washing using IR-IF sensors in soap dispensing units. ID badges are scanned as they pass through the hospital, denying them access to certain areas. The hospital can track hand washing to determine if additional training is necessary. Staff members are also alerted in real-time when they forget to wash.
These are relatively new systems but have shown to greatly reduce the spread of infection and they pay for themselves within months. Coincidentally, one of the ways bacteria spread to patients is by hitching a ride on doctor’s ties.
February 18, 2010, 5:12 amAndrew says:
A 2006 study gave infection rates as occurring in about 3% of PICC cases (higher for outpatient over inpatient, which doesn’t seem that surprising). However, once you take account of the amount of time they’re left in place - longer is riskier - the pattern changes a little; you get an average of two infections per thousand days of use for an inpatient PICC, and half that for outpatient ones. (full article)
February 18, 2010, 7:10 amJonathan says:
Though not exactly the stats you’re looking for, this CDC article has a lot of information on central venous catheters (CVCs - of which PICCs are just one type) in general, where infections come from and how they are prevented.
http://www.cdc.gov/MMWR/PREVIEW/MMWRHTML/rr5110a1.htm
Just for perspective that article cites 80,000 annual CVC-related infections in ICUs alone, and 250,000 annually for hospitals generally. However it looks like Hospital/ICU rates are higher than for outpatient, so the context of the installation and the patient’s general health probably have a lot to do with it. Comments I found online by self-identified medical professionals but without particular citations suggested a general infection rate for PICCs of under 1% (all this data from the USA).
February 18, 2010, 8:59 amSteven Saus says:
Agree completely with Andrew’s observation - in my anecdotal experience, the longer a PICC line in, the greater chance of infection.
Something we’ve been stressing at my facility (I work at a hospital, though not directly with PICC line insertion) is the importance of technique while *accessing* the PICC line after insertion. That is, it doesn’t matter how sterile the gloves are when it’s inserted if the next person to access it does not clean the hub sufficiently.
And to answer Ralan’s question, the impermeability of the gloves is the key factor for precautions against blood-borne pathogens, not the sterility of the gloves. PICC lines (again, at least at my facility) are inserted using sterile technique because of the risk of infection.
February 18, 2010, 9:22 amMonica says:
A 2006 study reviewed various devices used for vascular access. They searched and studied papers from 1995 through 2005 on these devices. You’ll be relieved to hear that of all these vascular access devices, PICC lines were apparently the safest. “Point incidence rates of IVD-related BSI were lowest with peripheral intravenous catheters (0.1%, 0.5 per 1000 IVD-days).”
Maki DG, Kluger DM, Crnich CJ.Mayo Clin Proc. 2006 Sep;81(9):1159-71. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies.
February 18, 2010, 10:23 amMonica says:
FYI, here is the link to the Mayo Clinic Proceedings article: http://www.mayoclinicproceedings.com/content/81/9/1159.long
Also, re this comment: “Coincidentally, one of the ways bacteria spread to patients is by hitching a ride on doctor’s ties.” Most doctors don’t wear ties for this reason and also because they are a safety risk- a patient getting out of control or having a seizure can grab a necktie and pull/choke. That’s why you’ll often see doctors wearing bowties, as cheesy as they might look.
Back to the original question, if you are going to be giving yourself drugs through your own PICC line, please make sure you are fastidious about handwashing. As noted above, this is one of the most important things we can do to reduce infections and transmission. You should learn about the proper technique for handwashing. Most people don’t do it for nearly long enough. Recent research shows that much of the benefit actually comes from the scrubbing action, so rubbing for the length of singing “Happy Birthday” twice is what’s recommended now: http://www.cdc.gov/cleanhands/.
February 18, 2010, 10:30 amDon Sakers says:
I had a PICC line for a total of a little over two months. Two weeks of that was in the hospital: since I was getting antibiotics four times a day, they figured the PICC line posed less of an infection risk than multiple injection sites. The rest of the time I was at home. I survived with no infection (beyond the original one in my toe which was the reason for the PICC line to begin with).
They did replace the PICC line about six weeks in; they told me that was their limit for leaving a single one in, again due to increased infection risk.
Of course, my body was swimming in antibiotics, so I’m sure that helped lower the risk of additional infection as well.
Interestingly, while I was in the hospital I had to wear a red warning label on my left arm, and I was under strict orders to prevent anyone from taking blood pressure, blood samples, or anything else from that arm. I guess they were worried about contaminating or collapsing the PICC line. Several times I had to speak up to stop people from trying a procedure on my PICCed arm.
February 18, 2010, 2:24 pmKirk says:
I don’t know the answer to your question, but it seems like the hospital could sterilize the PICC fairly easily by putting it in an autoclave, before handing it to the patient.
February 18, 2010, 4:23 pmACW says:
My first child had a PICC line in at seven days old, but it infiltrated and was pouring antibiotics into her foot instead of a vein. Ten years later, said child is healthy as a horse.
February 18, 2010, 9:41 pmI think if you have gone a few hours without the surrounding tissue swelling (indicating the line having been misplaced) or problems at the insertion site (redness, irritation)… you should be good to go.
I’d agree with previous comments: watch your medical providers like a hawk. Treat the insertion site gingerly and don’t hesitate to pipe up if anyone who isn’t freshly scrubbed tries to access it.
Marc says:
I managed to locate a reliable source of information (UK NHS) on how various PICC complications are managed and what procedures are involved, should they occur. A handy guide on what symptoms to look for.
http://www.wales.nhs.uk/sites3/documents/357/ComplicationmanagmentofPICCs.pdf
Also, stats on complications and a detailed study by the ICS.
http://journal.ics.ac.uk/pdf/1002095.pdf
Best wishes
February 19, 2010, 8:02 amJenonymous says:
Steve Gilliard (famous liberal blogger, alas, now dead)is now in his current state partly due to having such a line installed.
Basically, they can send a mainline of infection to the heart, which is what happened in his case (as well as a possible infection from a saline tube that was put in one of his neck veins).
His PICC was getting infected constantly, and in the end it weakened him to the point that he got a second heart valve infection (after getting surgery for his first) and that did him in, alas.
RIP, Gilly.
February 19, 2010, 11:14 amJohn Boland says:
Our household’s experience with these things doesn’t point to hospital infection. In fact, the picc line
is a way of getting you out of the hospital and away from infections (though, of course,
there is the risk when they put it in that someone is careless).
But use of the thing at home has to be meticulous. We did it every eight hours for five weeks
to infuse antibiotics. Each time, the port had to be sterilized, the line flushed, and remembering
to take each step in the right order while sleep-deprived was a challenge.
I hope it’s working well with you. Most hospitals will send a nurse around now and then to make sure you’re doing it right.
February 26, 2010, 11:32 amKirk says:
Fred’s comment about washing hands reminds me of an interview with Dr. Atul Gawande that I saw on Democracy Now! back in January. He wrote a book titled ‘The Checklist Manifesto’, in which he promotes the use of checklists in hospitals to minimize errors made in medical procedures. He got the idea from Boeing. The first flights of the B-17 ended in several crashes. The problem was that the new aircraft was much more complex than what the pilots had flown previously, and omission of one or two pre-flight procedures resulted in the crashes. Boeing came up with the idea of a checklist - a list of pre-flight details to check before takeoff, and the crashes ended. Similarly, modern medicine is so complex, that doctors cannot keep all the information in their head. Checklists for various medical procedures were tried out in a number of hospitals, and resulted in dramatic reductions in malpractice and death. ‘Wash your hands’ was a simple step on the list.
February 27, 2010, 3:06 pmWilliam Young says:
Much like Mr. Sakers above, I had a PICC line for about two months (around ten years ago) for regular antibiotic treatment. Other than it taking a while to get into the habit of making sure nothing whacked the insertion point (since it really hurt to do so, but nowhere near as painful as when the line was initially installed), the only problem I had with it was a very slight infection that cropped up at the insertion point a couple of days before they removed it.
The removal had nothing to do with the infection, though; it was purely random chance. And random lucky chance at that, since it allowed the line to slide out of my arm that much more easily.
March 6, 2010, 3:57 pmTully says:
FWIW: When I was managing an IV cinic we installed about 200 PICC lines. The only infection case we had was in an AIDS patient who was already severely immuno-compromised. They made it past that — in part thanks to having that PICC line — but died from other complications of AIDS. (This was the early \’90s.)
March 13, 2010, 2:16 pm