Discussion

We successfully increased single-lumen PICC use and reduced potentially unnecessary multilumen use across 11 hospitals. This research expands on previous work that employed default nudges, with implementation across a larger, resource-limited setting. ^{Reference Bozaan, Skicki and Brancaccio4,Reference Lam, Volling and Chan9} Although it was not statistically significant, we noted a relative reduction in PICC-related CLABSI rates by 27%; thus, a longer postintervention study period may be needed.

Our 26% increase in single-lumen PICC use was less than the 48% increase reported by Lam et al. ^{Reference Lam, Volling and Chan9} This difference may be attributed to their concurrent local publicity campaign, as they announced within their meetings and rounds within units and teams. Education and awareness campaigns are more effective in smaller settings, possibly creating this significant additive effect. ^{Reference Soong and Shojania11} Although we sent a mass e-mail to executive and clinical leadership, practically, we were unable to speak in person in each of the local units or services across 11 hospitals. Interestingly, when comparing our increase with Bozaan et al ^{Reference Bozaan, Skicki and Brancaccio4} (29%), our results were similar. Their intervention was more robust, including having their vascular-access service team review the appropriateness of indications and escalating to clinical pharmacists when inappropriate. However, their single-lumen PICC use likely reached a ceiling at 94%, and a larger increase may have manifested if their baseline use had been lower.

Significant variation was observed among provider types and provider specialties. Among provider types, we observed lower use of single-lumen PICCs after the intervention among advanced practice providers (APPs; 67.7%) compared to physicians (82.4%–94.6%). This novel finding warrants further study; there may be opportunities to investigate APP attitudes regarding vascular access that explain this difference from physicians. In broader context, previous research regarding overuse among APPs versus physicians is mixed. ^{Reference Roman, Yang, Masciale and Korenstein12–Reference Hughes, Jiang and Duszak14} Among provider specialties, there was a wide range of single-lumen PICC utilization (31.8%–97.7%), with neurology and neurosurgery having the lowest rates. Although there may be a higher need for multiple lumens among certain specialties, this variation may also reflect areas in which education and additional reinforcement could be beneficial. We were unable to obtain preintervention provider type and provider specialty data due to the lack of PICC lumen options on the previous consultation orders. Future investigation on the effect of nudge interventions for reducing overuse on these variables could be beneficial.

Significant variation was noted across individual hospitals. This finding may represent differences in clinician engagement and willingness to change their practice to placing single-lumen PICCs. Larger increases were observed in hospitals with the lowest preintervention single-lumen utilization: Lincoln (18.0%), Jacobi/NCB (16.8%), and Harlem (35.4%). This finding suggests that with appropriate nudging, providers are open to changing their clinical practice.

Implementation within safety net systems remains challenging. Understaffing and high staff turnover are mentioned nearly universally in literature, along with “self-siloing” and delayed uptake of newer practices. ^{Reference Lyles, Handley and Ackerman15} Thus, low-effort, high-impact interventions are critical to improving value within resource-limited settings. Models for prioritization of projects, such as those used by Stinnett-Donnelly et al, ^{Reference Stinnett-Donnelly, Stevens and Hood16} may prove more useful in safety net systems. Our intervention may provide an additional framework for improving value with limited resources.

This study had several limitations. First, this intervention lacked randomization or concurrent control. Second, our analysis did not include other complications of PICCs (eg, thrombosis or occlusion) or alternative intravenous access usage. We also suspect that in rare instances, PICC lines were placed outside of the EHR workflow, with a potentially marginal effect on this intervention. Additionally, our initiative does not address or assess the appropriateness of PICC placement over alternative IV access. Notably, our data relied on accurate documentation in the Lines, Drains, Airways (LDA) section of the chart, and though documentation patterns likely did not change before versus after the intervention, there may be some inaccuracies in the data. Lastly, this intervention occurred during the coronavirus disease 2019 (COVID-19) pandemic, including during surges. Hospital-acquired conditions, such as CLABSIs, increased significantly during this period, which may limit generalizability of our findings to nonpandemic periods. ^{Reference Fakih, Bufalino and Sturm17} However, the positive effect of this intervention across the hospitals remains intact.

This initiative successfully improved single-lumen PICC line usage across a 11-hospital safety net health system. Further study is needed to understand effectiveness of default nudge interventions among different provider types and specialties.