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Although rates of complications with midlines were low, significant variation in both the nature and types of adverse events across hospitals was observed. Importantly, midlines appear to be more often associated with minor than major complications, with low rates of DVT and bloodstream infection noted across hospitals. These observations are congruent with recent studies and suggest that midlines might be a ‘safer’ alternative to PICCs with respect to these outcomes.8 9 Given their lower rate of potentially lethal events such as DVT and CLABSI, midlines appear to have an important place for hospitalised patients, especially for those who need short-term venous access. Compared with prior studies that found substantially greater rates of complications,16 our data suggest that the complication profile of midlines has improved perhaps due to newer catheter materials or ultrasound to guide insertion.
Third, while we did not find an association between hospital-level and patient-level factors related to midline use or outcome, it is possible that we were underpowered for this effect given the pilot nature of this study. Importantly, midlines appear to be more often associated with minor than major complications, with low rates of DVT and bloodstream infection noted across hospitals.
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The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): Results From a Multispecialty Panel Using the RAND/UCLA Appropriateness Method
Use of peripherally inserted central catheters (PICCs) has grown substantially in recent years. Increasing use has led to the realization that PICCs are associated with important complications, including thrombosis and infection. Moreover, some PICCs may not be placed for clinically valid reasons. Defining appropriate indications for insertion, maintenance, and care of PICCs is thus important for patient safety. An international panel was convened that applied the RAND/UCLA Appropriateness Method to develop criteria for use of PICCs. After systematic reviews of the literature, scenarios related to PICC use, care, and maintenance were developed according to patient population (for example, general hospitalized, critically ill, cancer, kidney disease), indication for insertion (infusion of peripherally compatible infusates vs. vesicants), and duration of use (≤5 days, 6 to 14 days, 15 to 30 days, or ≥31 days). Within each scenario, appropriateness of PICC use was compared with that of other venous access devices. After review of 665 scenarios, 253 (38%) were rated as appropriate, 124 (19%) as neutral/uncertain, and 288 (43%) as inappropriate. For peripherally compatible infusions, PICC use was rated as inappropriate when the proposed duration of use was 5 or fewer days. Midline catheters and ultrasonography-guided peripheral intravenous catheters were preferred to PICCs for use between 6 and 14 days. In critically ill patients, nontunneled central venous catheters were preferred over PICCs when 14 or fewer days of use were likely. In patients with cancer, PICCs were rated as appropriate for irritant or vesicant infusion, regardless of duration. The panel of experts used a validated method to develop appropriate indications for PICC use across patient populations. These criteria can be used to improve care, inform quality improvement efforts, and advance the safety of medical patients.
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