Forum topic

Just by following this message board it is apparent that there is a growing trend to place midlines instead of PICCS to avoid CLABSI. It seems to me like this is a misguided application in AML patients who will likely be needing vesicant therapy. Midlines are not indicated for intermittent or long-term vesicant infusions.

Yes I do....as a matter of fact I think Midlines will become the dominent access for in-patients in the future. However, when you talk Chemo, I'm not sure a Midline is always the answer. My feeling always was if it can be given through a PIV the it can be given through a Midline...Now can it be given indefinitely, no...Keith is the Oncology nurse here so he would know what drugs can be given and which need to go through a central line. But to digress, say goodbye to the overuse of PIV's . Midlines will be the new go to line in the future. Let's just hope nurses take the time to learn about them.

Jack

 First, let me say that I am a strong proponent of midline catheters. I was a clinical person for the company that introduced the first midline catheter to the US market and I can definitely see their benefit. However, they can not replace a CVAD when a CVAD is truly needed. They can replace unnecessary repeated peripheral sticks. Just like all VADs, use of a midline requires a complete thorough patient assessment of all factors involving the patient, therapy, VAD characterisitics, venue of care, and HCW knowledge, skills, and attitudies. I do not believe that midlines can or should replace all PIVs or that is always appropriate to replace a CVAD with a midline. There are situations when both should be replaced with a midline but there can not be a blanket statement that would allow this for all patients. Also, from the theories and opinions that have been published about using midlines to reduce CLABSI, I believe this is based on questionable thought processes. When a CVAD has been placed unnecessarily then some other choice of VAD should be chosen. Here I am referring to situations where there was multiple PIV attempts without the aide of visualization technology (neither near infrared or ultrasound) and the next immediate choice was some type of CVAD only for a few days and when therapy did not indicate the need for a CVAD. Currently in facilities that have insitituted all basic practices for reduction of CLABSI their rates are already low. The risk does not occur during insertion. It occurs during use of the line and this can happen regardless of where the tip is located - SVC or midline location makes no difference if care during the dwell is not adequate. I have not actually seen any published data directly linking CLABSI reduction to use of midlines but that is what we need to support these statements. The other side of the issue is reporting. CLABSI must be reported to CMS using CDC methodology, however midlines are not included in that requirement. So Hospitalcompare data can not be used to support this claim as there would not be midline infections included. CDC has very strict definitions and a long list of veins for tip location that must be counted in CLABSI data but the midline tip location is NOT included. So in my mind, there is no evidence based answer for this question yet. Lynn

I agree with what you wrote Lynn. Especially the part that care and maintenance has much more to do with line infections than insertions. I wonder if hospitals are favoring Midlines for exactly the reason you stated, they are not counted in the infection data. So, that makes a Midline a great access as far as CLBSI's are concerned. If you were to get an infection it is not reportable. I hate to think this is the reason. My argument for Midlines stems from a real access problem. Your right ,there wil always be a place for PIV's but right now ,what's happening is so many multiple sticks to acquire access. This can only lead to bad things.And, it's only going to get worse. So, I see the Midline as the savior. Not saying that it's a cure all....just a better alternative to 8 peripheral IV sticks.

Jack

Our facility was recently scheduled to begin placing midline catheters, but at the last minute was cancelled by administration. Our nephrologists are always on board with them and recently I have heard from many hospitalists who have shared the same opinion about "preventing CLABSIs" by placing them and I am now wondering if that had something to do with being cancelled... I know a lot of our patient's would benefit greatly from midlines.

A couple points - Lynn is correct and I agree that many hospitals are switching to midlines to not "prevent CLABSI" but to not have to report a blood stream infection from a midline.  YET!  Won't be long and the government will catch on and we will be reporting ALL blood stream infections associated with intravenous lines of any kind. And we should be!  Meticulous care and maintenance of all IV lines is essential - preaching to the choir, I know.

Second thought - someone mentioned that their nephrologists love midlines.  Really?  Can you explain why?  Midlines will destroy arm vessels just as well as PICCs do.  Renal failure patients should have internal jugular lines to preserve the upper extremity vasculature for fistulas and grafts.

 We were also told to hold off on implementing a midline program from our corporate office based on one of our sister hospitals having very bad outcomes with their midline program.  Staff nurses don't understand the limitations and abuse them. The education to prevent this abuse has to be extensive and exhaustive. 

As far as nephrologists being on board with midlines I wonder if they truly understand what is happening.  They believe that the midline is going to reduce venous thrombosis that is being reported with PICCs.  Delivering drugs into the vein that they are wanting to preserve is counterintuitive.  I would NEVER agree to place a midline for PPN.

There are plenty of reports on the successful completioin of therapy with midlines but many of them report a certain percentage of failure and or infiltration. What is an acceptable rate of vein destruction in the upper arm?  The act of puncturing the vein and the catheter residing there for weeks is going to create scar tissue which will impede the vein from becoming a good fisutula in the future.  Nephrologists do not create fistulas so they don't get that concept. A surgeon who makes fisutulas would be against this practice.

The midline manufacturers are the ones selling the idea of reducing clabsi with midlines. 

JMHO

Darilyn 

I have only ever worked in military hospitals, so since CMS and insurance are not major driving forces behind our policies, this issue with CLABSI/PICC/Midline is still so confusing to me. Lynn, you have explained the difference in the terms to me several times, so I think I've got that. What still does not make sense to me is why hospitals care so much about their CLABSI rate when it is the diagnostic code of CRBSI that drives reimbursement. Whether the infection occurs because of a PICC, midline, or PIV, it's still a CRBSI, right? So is the feeling (because there does not seem to be data to suggest either way) that midlines have lower infection rates than PICCs? Has there ever been a head-to-head comparison of this? Isn't it well understood that CLABSI may actually overestimate the incidence of vascular catheter infections because the criteria is easier to meet than that of CRBSI? That's what IDSA says, at least. Shouldn't hospitals actually be interested in lowering their own CRBSI rates in order to maximize reimbursement, which, since it includes all types of intravascular catheters, would require a totally different approach than simply switching out catheters (that aren't really interchangeable to begin with!)? Do hospitals even track their CRBSI rates. I don't think mine does. What am I missing as far as the incentive for hospitals to lower their CLABSI rate? How does it affect the bottom line? I really am looking for education here!

It would appear our nephrologist is requesting a midline in an upper arm vessel (specifically identified by himself) of an extremity that has already had fistulas/grafts (but not in his specified vessel) and we are currently using that extremity for multiple PIV insertions per floor staff. He states he is no longer able to consider that extremity for futher dialysis access as evidenced by his doppler studies. By INS guidelines that is still not recommended, correct?

Oh boy whole post got deleted! Never mind!

Kathleen

Great new study titled: How to Establish an Effective Midline Program: A Case Study of 2 Hospitals.

As I have been noting on this site the need to decrease the number of peripheral IV's and increase the use of Midlines as a safe effective alternative, I found this gem. I would suggest everyone trying to define what a good Vascular Access Team should look like in the future read this because...this is it!!

Good job Nancy Moureau! my only regret is I didn't write it first...lol

Jack