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There is a new published study that would help but the system will not allow pasting the link in the message. Do a search on Google scholar using name of primary author Vineet Chopra. Narrow search to 2015 and this should come up first. It is commonly called the MAGIC study. Lynn

We need to start a discussion on where we determine best practices. Let me give an example: Double lumen catheters cause increase DVT's. Here's a study that shows that...blah blah blah. So, our industry makes changes, No one going home on IV antibiotics should have a double lumen. Midlines should be single lumens.....and so on and so on. Does anyone take clinical practice and clinical expertise as the gold standard. I'm not bashing studies...Let me say that again I'm NOT bashing studies. However, if a study says that double lumen Midlines should not be used, hospital managers see that and make it policy...is that better than a vascular access nurse who has put in 8000-10000 lines not seeing an apprciative number of DVTs. Am I saying they don't happen , of course not. But, we fail to give credence to a seasoned clinician with 12 years experience with doing just this work and all the authority goes to the study of 200 sample from John Brown Smith hospital in stumptown USA. Why?

Do we not have faith in our own experts?...So to answer the above statement:...Yes use more Midlines. yes use double lumen Midlines they will come in handy. Do good care and maintenance and the odds will be undoubtedly in your favor. I have put in more than one Midline ,but very rare. If you need more than 2 lines then you need to think TLC. Take this to the meeting....Less peripherals , more Midlines, and only central lines when necessary.

Jack Diemer RN

PS. OK let the mean comments begin!!!!....lol

I thought reimbursement was related to CRBSI, not CLABSI. CLABSI is a statistical term and is not patient specific and will not affect reimbursement (Right??). Midlines can cause CRBSI, however, so I just don't understand this trend to replace a perfectly good DL PICC with two single lumen Midlines.

I also think that Jack's comments about clinician experience is valid. However I would go further to say that before any policy is written, expert opinion, recent published literature and practice/industry standards should be evaluated so that policy reflects all three of these contributors so that individual patients with individual needs can be individually addressed.

 Keith, I can explain your confusion on this issue of CLABSI vs CRBSI. CLABSI is a surveillance defintion. So when we are talking about the analyzed data from a group of patients and the rates of BSI attributed to CVADs, that is CLABSI. When we are talking about the diagnosis and management of a patient with a BSI attributed to any VAD, that is CRBSI. Two very different terms. 

CMS, and payments for treatment, uses the term vascular catheter associated infection - all devices, all types of infection. When this is hopsital acquired, there will be no reimbursement for that treatment as directed by the value based purchasing process and hospital acquired conditions that began in Oct 2008. 

CLABSI rates are submitted to CDC through the NHSN system according to their definitions and processes. This data is then used for various state mandated reporting of hospital acquired infections and for Hospital Compare, a website that reports clinical outcomes in hospitals. 

CMS and CDC serve 2 different purposes and are two different processes. Sad but true. 

Regarding the experience of experts directing VAD choices - this is absolutely necessary. However, the decision can never be exclusively based on the opinion of an individual expert. Instead, that expert opinion must be informed by outcomes of research AND their experience. Jack, your message indicated a high number of catheters inserted and that is great. However it is process data only. You made no mention of data related to the outcomes. You can just go by what you perceive to the few complications. Your perception could easily be wrong. So you must collect outcome data and anlyze it to determine the true outcomes produced by your processes. Documented clinical studies, professional experience and patient preference are the 3 components of evidence based practice and all 3 are required. 

Lynn

 Keith, very good questions. It appears that there is a lot of shortsightness in this decision. They are placing a higher value on public reporting of infection rates than the actual reimbursement for treatment. Additionally, PIV-BSI and midline-BSI are both going under the radar because there is no ICD-9 or ICD-10 code for those infections. So another issue with proper recognition of these are a significant problem. Lynn

Your right Lynn. It really never looked at outcomes AFTER the insertion. It's fine to say you put in alot of lines but unless you follow up on those lines it's hard to make a definitive statement on their success. My only source of information really is the lack of information. I guess my point is that after so many insertions, if there was a CONSISTANT problem...policies would have changed and people in our business would have heard about it. So really, I guess we have to take into account the studies because that is the way data of that sort is collected. Geez Lynn, now I have to worry about all those lines I put in?

Jack Diemer

Well in the perfect world Lynn, I think your right. But in the practical world of hospital Vascular Access teams, you work under budgetary constraints. Unfortunately, budgets don't normally allow for data collectors and analysis of such data. I believe most teams are surviving in a hit and run enviroment. Even large vascular Access teams I mean 20-30 FTE's are not collecting data and determining best practices based on that data. If they were, then peripheral IV's would be a limited use line and Midline catheters would be much more prevelant. Actually it's the opposite. The bigger teams are doing more peripheral IV's then any other line and probably not reporting the missed attempts as they should. So, I disagree with your perception of that "insertion teams" are not adequate. Well, let me say this. I do agree that we should have more teams that evolve their practice based on the evidence they find working at their respective hospitalss. But if that was the case, your Vascular Access teams would be more fluid and changes would be happening more frequently to address problem areas. But, that is simply not the case.

Changes in bad practice happen VERY SLOWLY. So, I'm afraid we are what we are. teams trying to prove our relevence without straining the budget.

Jack