An Improvised Cost-Effective Repair Technique for Management of Broken Luer Connections of Tunneled Dialysis Catheter and Salvage Existing Catheter.

Mechanical problems like break or crack in Luer connectors or hubs, clamps, and tubings are common non-infectious complications of tunneled dialysis catheters (TDC), which may lead to other TDC complications and the need to insert a new catheter. These can be tackled using TDC repair kits or spare parts, which are often not available, resulting in the insertion of a new TDC that increases morbidity, TDC-related procedures, and healthcare costs. We discuss two cases of broken Luer connections of TDC, which were managed by exchanging the broken Luer connector of TDC with the similar Luer connector of a temporary dialysis catheter. Both the repaired TDCs are thereafter functioning well. This improvised technique provides an easy, effective, long-lasting option that salvages the existing TDC and reduces the cost factor.

Central Line-Associated Bloodstream Infection Misclassifications-Rethinking the Centers for Disease Control and Prevention's Central Line-Associated Bloodstream Infection Definition and Its Implications.

Centers for Medicare and Medicaid Services imparts financial penalties for central line-associated bloodstream infections (CLABSIs) and other healthcare-acquired infections. Data for this purpose is obtained from the Centers for Disease Control and Prevention (CDC)'s National Health Safety Network. We present examples of misclassification of bloodstream infections into CLABSI by the CDC's definition and present the financial implications of such misclassification and potential long-term implications.

Central Venous Access Devices for the Delivery of Systemic Anticancer Therapy: An Economic Evaluation.

OBJECTIVES: Patients undergoing long-term anticancer therapy typically require one of 3 venous access devices: Hickman-type device (HICK), peripherally inserted central catheter (PICC), or implantable chest wall port (PORT). Recent evidence has shown PORT is safer and improves patient satisfaction. However, PORT did not show improvement in quality-adjusted life-years and was more expensive. Decisions regarding cost-effectiveness in the United Kingdom are typically informed by a cost-per-quality-adjusted life-year metric. However, this approach is limited in its ability to capture the full range of relevant outcomes, especially in the context of medical devices. This study assessed the potential cost-effectiveness of HICK, PICC, and PORT in routine clinical practice. METHODS: This is a cost-consequence analysis to determine the trade-offs between the following outcomes: complication, infection, noninfection, chemotherapy interruption, unplanned device removals, health utilities, device insertion cost, follow-up cost, and total cost, using data from the Cancer and Venous Access clinical trial. We conducted value of implementation analysis of a PORT service. RESULTS: PORT was superior in terms of overall complication rate compared with both HICK (incidence rate ratio 0.422; 95% CI 0.286-0.622) and PICC (incidence rate ratio 0.295; 95% CI 0.189-0.458) and less likely to lead to an unplanned device removal. There was no difference in chemotherapy interruption or health utilities. Total cost with device in situ was lower on PORT than HICK (-£98.86; 95% CI -189.20 to -8.53) and comparable with PICC -£48.57 (95% CI -164.99 to 67.86). Value of implementation analysis found that PORT was likely to be considered cost-effective within the National Health Service. CONCLUSION: Decision makers should consider including PORT within the suite of venous access devices available within in the National Health Service.

Comparative Effectiveness of 2 Chlorhexidine Gluconate-Containing Dressings in Reducing Central Line-Associated Bloodstream Infections, Hospital Stay, and Costs.

Chlorhexidine gluconate (CHG)-containing dressings are recommended to prevent central line associated bloodstream infections (CLABSIs) and other catheter-related infections. This study compared the effect of 2 CHG dressings on CLABSI, cost of care, and contact dermatitis. A retrospective analysis was conducted using the Premier Healthcare Database of hospitalized patients (n = 53 149) with central venous catheters (CVCs) and receiving either a transparent CHG gel dressing (n = 14 488) or an opaque CHG sponge dressing (n = 38 661) between January 2019 and September 2020. Two cohorts (n = 14 488 each), CHG-Gel and CHG-Sponge, were matched 1:1 using a propensity score method on 33 patient and facility characteristics. CLABSI and contact dermatitis rates, hospital length of stay (LOS), and hospitalization costs were compared using mixed-effect multiple regression. This approach effectively controlled for random clustering effects across hospitals and patients' Diagnosis-Related Group (DRG) classifications. CHG gel dressings were associated with a 41% decrease in CLABSI rates (P = .0008) compared to CHG sponge dressings (0.35%vs 0.60%). A 0.4-day shorter LOS (9.53vs 9.90 days, P = .0001) and a cost saving of $3576 per hospital stay ($40 197 vs $43 774, P = .0179) was observed with CHG gel dressing use. There was no statistically significant difference in contact dermatitis rates (P = .7854) between the CHG-Gel and CHG-Sponge cohorts. The findings of this study suggest that the use of CHG gel dressings may be more effective in reducing the risk of CLABSIs and associated clinical costs compared to CHG sponge dressings in hospitalized patients. Moreover, there appears to be no significant discrepancy in contact dermatitis rates between CHG gel and CHG sponge dressings. Healthcare providers may consider using CHG gel dressings as a standard practice for patients with CVCs to reduce the risk of infections and improve patient outcomes.

Longer length peripheral catheters in sickle cell treatment: a more efficient and cost-effective care pathway.

Patients with sickle cell disease require frequent venous access for red blood cell exchange transfusions to manage their condition. Such frequent access can lead to scar tissue formation, increased pain on insertion, and difficult vascular access for the patients. Previous attempts at achieving successful venous access for patients with difficult venous access has been made with central venous lines, usually femoral lines, which required a large amount of nursing input and resulted in anxiety and pain on insertion for patients. In this article, the author reports on a new pathway with a longer-length peripheral intravenous catheter that reduces the nursing time burden during line insertion, requires less equipment and, crucially, results in a less painful procedure for patients. The increased efficiency of the pathway resulted in a cost saving of £149 per insertion, and patient feedback revealed that the longer-length catheter was preferred over femoral lines.

Using a Comprehensive On-Site Assessment Process to Reduce Central Line-Associated Bloodstream Infection Rates.

Central line-associated bloodstream infection (CLABSI) rates increased substantially in the United States following the emergence of COVID-19 and subsequent surges. The pandemic resulted in hospital capacities being exceeded and crisis standards of care being implemented for sustained periods. As COVID-19 rates in the United States began to stabilize, some facilities did not return to previous CLABSI rates, indicating a change in practices that had a longer-term impact on CLABSI prevention. The authors' large health care system observed similar increases in CLABSI following the emergence of COVID-19, prompting investigation and intervention in the form of a quality improvement project. To identify changes related to ongoing increases in CLABSI, an assessment team conducted standardized on-site assessments at 11 facilities. Site assessments were considered an intervention, as they involved rigorous preassessment investigations and interviews, case reviews, practice observations, on-site staff interviews, and postassessment support for additional interventions. Nine facilities had enough postassessment data to analyze the impact of intervention. The overall CLABSI rate (infections per 1000 line days) at the 9 facilities in the 6 months prior to intervention was 1.42, and the postassessment rate in the 6 months following intervention was 0.44. This indicates the effectiveness of facility-specific investigation followed by targeted performance improvements to reduce the rate of CLABSI.

Characteristics, costs, and outcomes associated with central-line-associated bloodstream infection and hospital-onset bacteremia and fungemia in US hospitals.

OBJECTIVES: To compare characteristics and outcomes associated with central-line-associated bloodstream infections (CLABSIs) and electronic health record-determined hospital-onset bacteremia and fungemia (HOB) cases in hospitalized US adults. METHODS: We conducted a retrospective observational study of patients in 41 acute-care hospitals. CLABSI cases were defined as those reported to the National Healthcare Safety Network (NHSN). HOB was defined as a positive blood culture with an eligible bloodstream organism collected during the hospital-onset period (ie, on or after day 4). We evaluated patient characteristics, other positive cultures (urine, respiratory, or skin and soft-tissue), and microorganisms in a cross-sectional analysis cohort. We explored adjusted patient outcomes [length of stay (LOS), hospital cost, and mortality] in a 1:5 case-matched cohort. RESULTS: The cross-sectional analysis included 403 patients with NHSN-reportable CLABSIs and 1,574 with non-CLABSI HOB. A positive non-bloodstream culture with the same microorganism as in the bloodstream was reported in 9.2% of CLABSI patients and 32.0% of non-CLABSI HOB patients, most commonly urine or respiratory cultures. Coagulase-negative staphylococci and Enterobacteriaceae were the most common microorganisms in CLABSI and non-CLABSI HOB cases, respectively. In case-matched analyses, CLABSIs and non-CLABSI HOB, separately or combined, were associated with significantly longer LOS [difference, 12.1-17.4 days depending on intensive care unit (ICU) status], higher costs (by $25,207-$55,001 per admission), and a >3.5-fold increased risk of mortality in patients with an ICU encounter. CONCLUSIONS: CLABSI and non-CLABSI HOB cases are associated with significant increases in morbidity, mortality, and cost. Our data may help inform prevention and management of bloodstream infections.

Standardized Venous Access Assessment and Safe Chemotherapy Administration to Reduce Adverse Venous Events.

Staff of the ambulatory infusion clinic at a Magnet-designated academic medical center observed the rates of adverse venous events, including infiltration and extravasation. An evidence-based quality improvement project was d.

Cost-utility analysis of different venous access devices in breast cancer patients: a decision-based analysis model.

BACKGROUND: Venous access devices commonly used in clinical practice for long-term chemotherapy of breast cancer include central venous catheters (CVCs), peripherally inserted central venous catheters (PICCs), and implantable venous access ports (IVAPs). CVCs and PICCs are less costly to place but have a higher complication rate than IVAPs. However, there is a lack of cost-utility comparisons among the three devices. The aim of this study was to assess the cost-effectiveness of three catheters for long-term chemotherapy in breast cancer patients. METHODS: This study used propensity score matching (PSM) to establish a retrospective cohort. Decision tree models were used to compare the cost-effectiveness of three different intravenous lines in breast cancer chemotherapy patients. Cost parameters were derived from data extracted from the outpatient and inpatient charging systems, and total costs included costs of placement, maintenance, extraction, and handling of complications; utility parameters were derived from previous cross-sectional survey results of the research group; and complication rates were derived from breast cancer catheterization patient information as well as follow-up information. Quality-adjusted life years (QALYs) were measured for efficacy outcomes. Incremental cost-effectiveness ratios (ICERs) were used to compare the three strategies. To assess uncertainty in model parameters, sensitivity analyses (univariate sensitivity analysis and probabilistic sensitivity analysis) were performed. RESULTS: A total of 10,718 patients (3780 after propensity score matching) were included. IVAPs had the smallest cost-utility ratio, and PICCs had the largest cost-utility ratio when left in place for more than 12 months. The incremental cost-utility ratio of PICC to CVC was $2375.08/QALY, IVAP to PICC was $522.01/QALY, and IVAP to CVC was $612.98/QALY. Incremental cost-effectiveness ratios showed that IVAPs were more effective than CVCs and PICCs. Model regression analysis showed that the IVAP was recommended as the best regimen regardless of the catheter indwelling time (6 months, 12 months or more than 12 months). The reliability and stability of the model were verified by single-factor sensitivity analysis and Monte Carlo simulation (probabilistic sensitivity analysis). CONCLUSION: This study provides economic evidence for the selection of vascular access in breast cancer chemotherapy patients. In the case of limited resources in China, establishing a decision tree model comparing the cost-effectiveness of three vascular access devices for breast cancer chemotherapy patients determined that the IVAP was the most cost-effective regimen.

Educating health professionals in ultrasound guided peripheral intravenous cannulation: A systematic review of teaching methods, competence assessment, and patient outcomes.

BACKGROUND: Peripheral intravenous cannula insertion is the most common invasive healthcare procedure, however failure rates remain unacceptably high, particularly in patients with difficult intravascular access. This leads to treatment delays and increased complication risk, causing poorer outcomes among this patient subset. Ultrasonographic guidance reduces these risks and is therefore becoming a competency required of health professionals. However, there is no consensus on how to design teaching sessions to achieve this competency. METHODS: Systematic review was conducted to identify characteristics of effective teaching sessions for current and training health professions to achieve ultrasound guided peripheral intravenous cannulation competency. Secondary outcomes included defining competency and to assess benefits to patients and healthcare systems. Eligibility for inclusion required description of teaching of ultrasound guided peripheral intravenous cannulation to qualified or training health professionals who went on to perform it in human patients or volunteers with reported outcomes or success rates. Studies were excluded if not accessible in full, not peer-reviewed or presented research that had been presented elsewhere previously. Of the 1085 records identified on review of 6 databases, 35 were included for final review based on eligibility criteria. RESULTS: Almost all (97.1%) used mixed modality teaching comprising of didactic and simulation portions, although time allocated varied widely. A median of 5 proctored procedures was required for competency. Competency was independent of previous experience or staff seniority. Mean reported insertion attempts was 1.7, success rate was 82.5% and first-time success rate was 75.5%. All included studies described improvement in their participants or healthcare system including significantly reduced midline insertion rates, central venous catheter insertion rates and associated bacteremia and sepsis, self-reported cannulation difficulty, specialist input, therapy delays and premature catheter failure rates. Further, there was significantly improved procedural confidence, knowledge and competence. CONCLUSION: Simple teaching interventions can lead to competent ultrasound guided peripheral intravenous cannula insertion by novices, resulting in numerous positive outcomes for patients and healthcare systems.

Development and validation of medical adhesive-related skin injury risk assessment scale at peripherally inserted central catheter insertion site in oncology patients.

AIMS AND OBJECTIVES: To construct a risk assessment scale for medical adhesive-related skin injuries (MARSI) at the peripherally inserted central catheter (PICC) insertion site in oncology patients and test its reliability and validity. DESIGN: The STARD 2015 statement guided this study. METHODS: Literature research and a modified Delphi method were adopted in this study. A total of 31 experts participated in two rounds of consultation to build the assessment scale. A convenient sampling method was used to select 195 oncology patients at the PICC clinic from January to June 2022. Inter-rater reliability was used to test the reliability of the scale. Validity was evaluated using the content validity index (CVI) and predictive validity. RESULTS: After the two rounds of consultation, the assessment scale with five dimensions and 13 primary entries and 36 secondary entries was developed, and the expert authority coefficients for both were 0.90. The inter-rater reliability was 0.968. The CVIs of the items ranged from 0.83 to 1.00. The area under the subject's work characteristic curve was 0.757, and the sensitivity and specificity of the scale were 80.0% and 65.6%, respectively, at a cutoff score of 15.5.

Daily point-of-care ultrasound-assessment of central venous catheter-related thrombosis in critically ill patients: a prospective multicenter study.

PURPOSE: Central venous catheter (CVC)-related thrombosis (CRT) is a known complication in critically ill patients. However, its clinical significance remains unclear. The objective of the study was to evaluate the occurrence and evolution of CRT from CVC insertion to removal. METHODS: A prospective multicenter study was conducted in 28 intensive care units (ICUs). Duplex ultrasound was performed daily from CVC insertion until at least 3 days after CVC removal or before patient discharge from the ICU to detect CRT and to follow its progression. CRT diameter and length were measured and diameter > 7 mm was considered extensive. RESULTS: The study included 1262 patients. The incidence of CRT was 16.9% (95% confidence interval 14.8-18.9%). CRT was most commonly found in the internal jugular vein. The median time from CVC insertion to CRT onset was 4 (2-7) days, and 12% of CRTs occurred on the first day and 82% within 7 days of CVC insertion. CRT diameters > 5 mm and > 7 mm were found in 48% and 30% of thromboses. Over a 7-day follow-up, CRT diameter remained stable when the CVC was in place, whereas it gradually decreased after CVC removal. The ICU length of stay was longer in patients with CRT than in those without CRT, and the mortality was not different. CONCLUSION: CRT is a frequent complication. It can occur as soon as the CVC is placed and mostly during the first week following catheterization. Half of the thromboses are small but one-third are extensive. They are often non-progressive and may be resolved after CVC removal.

Assessment of an umbilical venous catheter dwell-time of 8-14 days versus 1-7 days in very low birth weight infacts (UVC - You Will See): a pilot single-center, randomized controlled trial.

BACKGROUND: Umbilical venous catheters (UVCs) are used for central vascular access in preterm infants, but controversy exits with regard to the optimum dwell-time. PATIENTS AND METHODS: Prospective, randomized controlled trial at a level III University neonatal intensive care unit (NICU), comparing a UVC dwell-time of 1-7 days (control group) to 8-14 days (intervention group) in very low birth weight (VLBW) infants. PRIMARY OUTCOME PARAMETER: Number of infants requiring additional peripherally inserted central catheters (PICC) after removal of UVC. SECONDARY OUTCOME PARAMETERS: Total number of central lines (CL = UVC and PICCs) until time point of full enteral feeds (130-160 mL/kg/d), total number of intravenous vascular catheters, number of CL-associated complications (infection, thrombosis/emboli, organ injury, secondary CL dislocation), number of X-rays for assessment of CL positioning, and days of therapy (DOT) (teicoplanin) for CL-associated blood stream infections (CLABSI). RESULTS: Of 116 patients screened for eligibility, 63 patients were enrolled - control group: 31 infants, mean gestational age (GA) 280 weeks (standard deviation (SD) 2.6 weeks), mean birth weight (BW) 988.9 g (SD 322.0 g); intervention group: 32 infants, mean GA 285 weeks (SD 3.0 weeks), mean BW 1078.9 g (SD 324.6 g). In the control group, 28 infants required additional PICCs versus 16 in the intervention group (p < 0.001); total number of CLs: control group n = 58 versus intervention group n = 28; p < 0.001, and the total number of venous vascular devices was also significantly higher in the control group (109 versus 61; p = 0.04). No significant differences were seen with regard to CL-associated complications (p = 0.09). The number of X-rays for assessment of correct CL-position significantly lower in the intervention group (144 versus 96; p = 0.03). In the intervention group, length of hospital stay was significantly shorter (88.1 (SD: 35.3 days) versus 68.1 (SD: 32.6 days); p = 0.03) and GA significantly lower at discharge from the hospital (404: SD: 33 weeks) versus 385: SD: 25 weeks; p = 0.02. No differences existed with regard to neonatal morbidities and mortality at 36 weeks gestational age. CONCLUSIONS: A longer UVC dwell-time of up to 14 days significantly decreased the number of painful invasive vascular procedures and radiation exposure, and shortened the length of the hospital stay. The findings of our pilot study should be confirmed in a larger, multi-center RCT with the primary focus on catheter-associated complications.

Difficult removal of totally implantable venous access devices in adult patients: Incidence, risk factors, and management.

BACKGROUND: Totally implantable venous access devices (TIVADs) have played an important role of medical oncology practice. However, operators sometimes encounter considerable difficulty when removing TIVADs. This study aimed to investigate the incidence of difficult TIVAD removal, determine associated risk factors, and investigate interventional radiology (IR) approaches to difficult removal. METHODS: A total of 514 TIVAD removal procedures performed in a single-center between January 2014 and May 2021 were retrospectively analyzed to determine incidence of difficult removal and associated risk factors. IR approaches applied in difficult removal cases were also reviewed. RESULTS: The incidence of difficult removal was 7.4% (38/514). In univariable analysis, indwelling duration, silicone catheter, and subcutaneous leakage of fluid were identified as significant risk factors for difficult removal. Multivariable analysis showed that indwelling duration per year (odds ratio (OR), 1.46; 95% confidence interval (CI), 1.28-1.67; p < 0.01) and subcutaneous leakage of fluid (OR, 6.04; 95% CI, 2.45-14.91; p < 0.01) were significantly associated with difficult removal. In the 38 difficult removal cases, 32 TIVADs could be removed using more dissection and traction than the standard removal method. In the other 6, TIVADs were successfully removed by using several IR techniques, including insertion of a guide wire (n = 1), dissection using an introducer sheath (n = 2), pushing with a dilator (n = 1), and pulling with a snare (n = 2). CONCLUSION: Difficult TIVAD removal is uncommon. However, operators should expect it when removing long indwelling TIVADs and those with subcutaneous leakage. IR approaches to difficult removal are minimally invasive and can be useful.

Assessment of the MAGIC recommendations in context of evolving evidence based on the use of PICC in ICU.

The goal of the 2015 Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) was to define indications and appropriate practices for peripherally inserted central catheters (PICC) use; however, MAGIC recommendations virtually reduced the use of PICC in hospital settings, including critical care. The aim of this review is to present an assessment of the MAGIC guidelines, considering contemporary evidence to date. The validity of the MAGIC recommendations and their applicability to current practice are called into question given important concerns with the methodology for their development (e.g. high volume of clinical scenarios for evaluation) and the supporting evidence used. There is a considerable amount of contemporary evidence not considered in MAGIC that reports on evolving practices, techniques, and technologies targeted to reduce complications associated with central venous access devices (CVADs). Recent evidence dictates that CVADs are necessary in the intensive care unit (ICU), and that PICCs are a safe, reliable, and appropriate type of central lines, which cannot be replaced in several ICU situations. In light of evolving evidence and practice, as well as the methodological concerns identified, the MAGIC guidelines should be revisited. It is also recommended to create a clinical assessment tool that identifies potential uses of specific CVADs, based on patient needs. The choice of the CVAD should be based on unique clinical considerations and current scientific evidence, not on fears informed by antiquated data.

Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO): A new decision tool in the management of the complex vascular access patients.

In the last decade, different standardized protocols have been developed for a systematic ultrasound venous assessment before central venous catheterization: RaCeVA (Rapid Central Vein Assessment), RaPeVA (Rapid Peripheral Vein Assessment), and RaFeVA (Rapid Femoral Vein Assessment). Such protocols were designed to locate the ideal puncture site to minimize insertion-related complications. Recently, subcutaneous tunneling of non-cuffed central venous access devices at bedside has also grown in acceptance. The main rationale for tunneling is to relocate the exit site based on patient factors and concerns for dislodgement. The tool we describe (RAVESTO-Rapid Assessment of Vascular Exit Site and Tunneling Options) defines the different options of subcutaneous tunneling and their indications in different clinical situations in patients with complex vascular access.

Health Education and Nursing Needs of Breast Cancer Patients With Totally Implantable Venous Access Ports at Different Stages.

Context: The totally implantable venous access port (TIVAP) is an intravenous-infusion device, with a lower complication rate than other such devices. If patients fail to maintain the catheter, however, complications can still occur. Patients' needs may vary by the period of the port's use. Objective: The study intended to explore the differences in the needs of breast-cancer (BC) patients with TIVAPs for health education and nursing care at different periods of the port's use and to determine the kinds of targeted health education that can improve patients' quality of life. Design: The research team designed a questionnaire that the participants completed. Setting: The study took place at the Breast Center at the Fourth Hospital of Hebei Medical University in Shijiazhuang, China. Participants: Participants were 442 BC patients at the hospital between March and June 2020, who had TIVAPs at different stages. Groups: The study included three groups: (1) the preoperative group-participants in the preoperative period prior to the TIVAP implantation after they had signed a consent; (2) the chemotherapy group-participants in the chemotherapy period during the TIVAP's use for chemotherapy-agent transfusion, and (3) the maintenance group-participants in the maintenance period during which the TIVAD was in place but wasn't being used. Outcome Measures: The research team analyzed the results from the questionnaires, categorizing them as: (1) methods of knowledge acquisition, (2) methods of distribution of knowledge, (3) needs of participants in the different groups, and (4) distribution of symptoms among the groups. Results: Compared to other methods, the nursing staff was the main source that participants used to access the TIVAP-related information at different periods: preoperative group (79.6%), chemotherapy group (90.7%), and maintenance group (90.2%).The differences between the periods were statistically significant (P = .00). A traditional mode of education-the medical staff's explanations-was the most common in all groups: preoperative group (79.6%), chemotherapy group (83.3%), and (3) maintenance group (80.7%). Patients wanted new modes of receiving information: talks, a poster, and a medical system. TIVAP patients paid different amounts of attention to educational contents at the different stages (χ2 = 29.816, P = .00). Conclusions: BC patients' needs for health education and nursing vary at different stages when using TIVAPs. Nurses are the main source of knowledge about TIVAP in different periods for BC patients, and the nurses should obtain multidisciplinary health knowledge to enhance the benefits of the education for patients. The current education for patient is traditional, and hospitals need to implement new modes of education such as medical systems and network platforms, lectures, and posters for health education.

Barriers and facilitators for implementing peripherally inserted central catheter (PICC) appropriateness guidelines: A longitudinal survey study from 34 Michigan hospitals.

Peripherally inserted central catheters (PICCs) are prevalent devices for medium-to-long-term intravenous therapy but are often associated with morbid and potentially lethal complications. This multi-center study sought to identify barriers and facilitators of implementing evidence-based appropriateness criteria to improve PICC safety and patient outcomes in a pay-for-performance model. Participating hospitals received an online toolkit with five recommendations: establishing a vascular access committee; implementing a clinical decision tool for PICC appropriateness; avoiding short-term PICC use (≤5 days); increasing use of single-lumen PICCs; and avoiding PICC placement in patients with chronic kidney disease. Longitudinal online surveys conducted biannually October 2014-November 2018 tracked implementation efforts. A total of 306 unique surveys from 34 hospitals were completed. The proportion of hospitals with a dedicated committee overseeing PICC appropriateness increased from 53% to 97%. Overall, 94% of hospitals implemented an initiative to reduce short-term and multi-lumen PICC use, and 91% integrated kidney function into PICC placement decisions. Barriers to implementation included: achieving agreement from diverse disciplines, competing hospital priorities, and delays in modifying electronic systems to enable appropriate PICC ordering. Provision of quarterly benchmarking reports, a decision algorithm, access to an online toolkit, and presence of local champion support were cited as crucial in improving practice. Structured quality improvement efforts including a multidisciplinary vascular access committee, clear targets, local champions, and support from an online education toolkit have led to sustained PICC appropriateness and improved patient safety.