From the 2022 HVPA National Conference
Daniel Alaiev BBA (NYC Health + Hospitals), Da Wi Shin BE, Mona Krouss MD, Hyung Cho MD, Nessreen Mestari MPA, Joseph Talledo MS, Sigal Israilov MD
Central venous access via peripherally inserted central catheters (PICCs) is commonly required during hospitalizations. PICCs may be single or multiple lumen, having one, two or three access lumens. Compared to multi-lumen PICCs, use of single lumen PICCs have shown to carry a lower rate of deep vein thrombosis and central line-associated bloodstream infection (CLABSI). Multiple lumen PICCs are only indicated when patients require vasopressors, total parenteral nutrition, chemotherapy, or other multiple peripherally-incompatible medications. Despite this, multi-lumen PICCs are still overused, often when clinicians opt for more lumens “just in case.”
Our objective was to increase use of single lumen PICC rather than multi-lumen PICCs at NYC Health + Hospitals, the nation’s largest urban safety net system, by changing default options and adding a non-intrusive informational nudge to the pre-existing electronic health record order panel.
Prior to our intervention, the inpatient consultation order for interventional radiology procedures did not default to any lumen option when ordering a PICC line. We modified the order panel to make single-lumen PICCs the default option. We further discouraged ordering multi-lumen PICCs over single-lumen PICCs by requiring additional clicks to select a higher lumen count (double or triple). Additionally, an informational nudge was added to the top of the order panel summarizing guidelines for choosing multi-lumen PICCs. Our outcome measure was the percentage of single lumen PICCs inserted out of the total number of PICCs. Pre-intervention period (1/2/20 to 5/2/21, 16 months) was compared to the post-intervention period (5/3/21 to 1/28/22, 9 months).
The percentage of single lumen PICCs increased from 44.3% (1236 out of 2792) pre intervention to 69.7% (919 out of 1319) post intervention. The 25.4% increase in single lumen PICC usage was determined to have a statistically significant p-value < 0.001 using binomial regression.
The use of an electronic order panel change alone was successful in increasing single lumen PICC usage in a large urban safety net healthcare system. The intervention was effective by nudging the provider specifically when placing the consultation order for the line insertion. The single lumen option is pre-selected as a default, increasing compliance with this lower risk option. Selecting multiple lumens requires two additional clicks, which grants providers extra time to consider their decision. Finally, the statement of the recommendation coming from the H+H High Value Council, a type of norms nudge, gives a trusted recommendation from local leadership.
This intervention increased patient safety by nudging providers to select lower risk options for central venous access via PICCs.