Vascular Access Safety: Annual State of the Practice Report

Vascular access devices are used in an estimated 80–90% of hospitalized patients in the United States. At any given moment, more than 5 million central venous catheters and tens of millions of peripheral IVs are in use across the US healthcare system. Despite their ubiquity, vascular access devices remain a leading source of preventable patient harm — from bloodstream infections to thrombosis, from infiltration injuries to air embolism. This report synthesizes the current evidence base on vascular access safety, providing clinicians, VATs, and quality leaders with the data needed to contextualize their facility’s performance and prioritize improvement efforts.

Section 1: Central Line-Associated Bloodstream Infection (CLABSI)

National Scope

Annual incidence (US): 30,000–41,000 CLABSI events per year across all acute care settings (NHSN 2020 estimates). The range reflects year-to-year variation and measurement differences across reporting methodologies.

Trend: NHSN data from 2008–2019 shows a 50–70% reduction in ICU CLABSI rates following widespread implementation of CLABSI prevention bundles. However, reduction has plateaued since 2015–2017; non-ICU CLABSI has proven more difficult to reduce and now accounts for a larger proportion of total CLABSI events.

CLABSI rates by unit type (NHSN pooled mean rates, most recent published data):

Note: NHSN rates are updated annually. Consult NHSN’s most recent report for current benchmarks.

Attributable Outcomes

• Attributable mortality: 12–25% of patients with CLABSI die as a direct result of the infection (Maki 2006; Pronovost 2011 estimates for ICU-based CLABSI)
• Attributable hospital LOS: +7–21 days per CLABSI event
• Attributable cost: $46,000–$90,000 per event (2011 CDC estimate; inflation-adjusted to 2025 range)
• Total US annual cost: $1.8 billion–$3.7 billion (CDC estimates)

Pathogens and Resistance

Most common CLABSI pathogens (NHSN 2020):

1. Coagulase-negative staphylococci (~30–35%)
2. Enterococcus species (~15%)
3. Candida species (~11%)
4. S. aureus (MSSA + MRSA, ~10%)
5. Gram-negative bacilli (Klebsiella, E. coli, Pseudomonas, ~20–25% combined)

MRSA CLABSI: S. aureus CLABSI attributable mortality is substantially higher than CoNS CLABSI (12–25% vs 5–8%); MRSA cases require infectious disease consultation and extended treatment.

Candidemia: Candida CLABSIs carry 30-day mortality of 25–40%. All candidemia in CVAD patients requires ophthalmology evaluation (endophthalmitis risk), echocardiography (endocarditis), and catheter removal.

Section 2: Peripheral Intravenous Catheter Outcomes

Global IV Catheter Burden

Worldwide annual PIV placement volume: Estimated 2 billion PIV catheters placed per year globally (Alexandrou 2015 international prevalence study). In the US alone, approximately 330 million peripheral IV catheters are placed annually.

Peripheral IV failure rate: 30–50% of peripheral IVs fail before completion of therapy (Wallis 2014, Cochrane review). Failure causes include:

• Phlebitis: 9–20% of PIVs
• Infiltration: 12–23% of PIVs
• Catheter occlusion: 6–14% of PIVs
• Accidental dislodgement: 5–10% of PIVs
• Patient request for removal: variable

Phlebitis

INS benchmark: <5% phlebitis rate for peripheral IV therapy (INS 2021).

Actual reported rates in published studies: 9–20% (range across multiple international prevalence and incidence studies). Most facilities do not achieve the <5% INS benchmark consistently.

Economic impact of phlebitis: Each phlebitis event requiring treatment (antibiotic therapy, extended hospital stay, repeat IV placement) adds an estimated $800–$2,500 to direct costs. With millions of PIVs placed annually in US hospitals, phlebitis represents a significant and underappreciated cost driver.

Phlebitis prevention — highest-evidence interventions:

• Appropriate gauge selection (smallest gauge that meets clinical needs)
• Appropriate site selection (forearm veins preferred; avoid wrist flexion points)
• Adequate medication dilution (particularly antibiotics — vancomycin, potassium, amiodarone)
• Replacing catheter when phlebitis signs appear (Grade 2 or higher on INS VIP scale)
• Infusion of irritant medications through appropriate-size veins (avoid small hand veins for concentrated infusions)

Peripheral IV Infiltration

Reported incidence: 12–23% of PIVs across published studies. Most infiltrations are Grade 1–2 (mild swelling, no tissue damage). Grade 3–4 infiltrations requiring intervention are less common but represent significant patient harm.

Grade 3–4 infiltration (INS scale): Characterized by very pale skin, translucency, skin coolness, >6 inches of edema, deep pitting edema, circulatory impairment, or moderate-to-severe pain. These events require immediate catheter removal, arm elevation, warm or cool compress depending on infusate, and provider notification.

Vesicant extravasation: A subcategory of infiltration in which a vesicant medication enters the surrounding tissue. See Infiltration and Extravasation Guide for complete management protocol. Vesicant extravasation requires immediate antidote therapy and surgical consultation in severe cases.

Section 3: PICC-Specific Safety Data

PICC Adoption Trends

PICC use has increased dramatically since the mid-1990s. Factors driving PICC adoption:

• Avoidance of bedside CVC placement (pneumothorax and arterial injury risk)
• Ability for nurse-led insertion with ultrasound guidance
• Lower CLABSI risk compared to femoral and IJ CVC
• Suitability for outpatient/home infusion therapy

Estimated annual US PICC insertions: 3–5 million per year (estimate based on NHSN central line-day data and published literature).

PICC Complication Rates (Published Literature Summary)

PICC vs CVC CLABSI Comparison

Chopra et al. (2013, Lancet) — the definitive comparative meta-analysis:

• PICC-associated DVT risk: 2.55× higher than non-tunneled CVC (95% CI 1.54–4.23)
• PICC CLABSI risk: Lower than femoral CVC, similar to IJ CVC
• PICC preferred over non-tunneled CVC for patients not critically ill

Inappropriate PICC Use

MAGIC criteria analysis (Chopra 2015): When MAGIC criteria were applied retrospectively to PICC insertions at academic medical centers, 20–30% of PICCs did not meet any appropriate indication. Inappropriate PICC use exposes patients to DVT and CLABSI risk without clinical benefit.

Financial impact of inappropriate PICCs: Each unnecessary PICC represents $200–$800 in procedure cost plus daily catheter-day costs (nursing maintenance, supplies). At a facility inserting 1,000 PICCs per year with 25% inappropriate rate, addressing inappropriate use prevents 250 unnecessary procedures — a potential savings of $50,000–$200,000 in direct costs, plus avoidance of associated complications.

Section 4: Catheter-Associated Thrombosis

Upper Extremity DVT (UEDVT) from CVADs

Background prevalence: Symptomatic UEDVT accounts for approximately 1–4% of all DVT diagnoses. Secondary (catheter-related) UEDVT accounts for 70–80% of UEDVT cases — the vast majority are catheter-related.

Risk factors (published evidence):

1. Catheter-to-vein ratio >45% — the strongest modifiable risk factor
2. Active malignancy — doubles DVT risk
3. Multi-lumen catheter vs single-lumen
4. Tip position in the mid or upper SVC (vs. CAJ)
5. Prior UEDVT in the same extremity
6. Insertion on the left side (longer, more tortuous path; left subclavian angle)

PICC-specific DVT risk vs other CVADs: As noted above (Chopra 2013), PICCs have higher DVT rates than non-tunneled CVCs. For patients with cancer, PICC-associated DVT rates are 5–10% symptomatic (vs 1–3% in non-cancer patients).

Treatment: Per CHEST 2021 guidelines:

• Symptomatic catheter-associated UEDVT: anticoagulate for minimum 3 months or duration of catheter plus 3 months (whichever is longer)
• LMWH preferred in cancer-associated DVT; DOACs acceptable in most other patients
• Catheter removal vs. retention: if catheter is still needed and functional, may continue anticoagulation without removal; remove if catheter is no longer needed

Hemodialysis Catheter Thrombosis

Tunneled dialysis catheters (TDC) have the highest thrombosis rates of all CVADs:

• Catheter dysfunction from thrombosis: 30–50% of TDCs within 6 months
• Fibrin sheath formation occurs within days of insertion in virtually all CVADs
• Alteplase lock (not infusion) is the primary treatment for dysfunctional TDC

Section 5: Air Embolism

Estimated US incidence: Difficult to quantify; likely significantly underreported. Published case series and estimates suggest 0.5–1.0 events per 1,000 CVC insertions; insertion-related events are declining with universal ultrasound guidance adoption.

Highest-risk scenarios:

• CVC/PICC insertion during dilator exchange
• Catheter hub disconnection (accidental)
• Tubing changes with catheter unclamped
• PICC/CVC removal (most underappreciated risk)

PICC removal air embolism: Air can enter the tunnel tract after catheter removal through the fibrin sheath track. Prevention: supine or Trendelenburg position, Valsalva maneuver at moment of catheter tip exit, occlusive dressing for minimum 30–60 minutes post-removal.

Mortality: Estimated 20–50% mortality in severe air embolism (large volume, immediate entry to pulmonary circulation or coronary vessels). Fatal cases have been reported from as little as 20–50 mL air in high-risk patients (left heart defect with patent foramen ovale creating right-to-left shunt).

Section 6: Regulatory and Benchmark Landscape

CMS and HAC Reporting

CLABSI is a Centers for Medicare and Medicaid Services (CMS) Hospital-Acquired Condition (HAC):

• CLABSI events in Medicare patients trigger payment reduction
• CLABSI is one of the HAC measures used in the Hospital-Acquired Condition Reduction Program (HACRP), which penalizes the worst-performing quartile of hospitals
• CLABSI rates are publicly reported on CMS Care Compare (formerly Hospital Compare)

Leapfrog Group

The Leapfrog Group collects and publicly reports CLABSI rates and other HAI metrics as part of its hospital safety grade. CLABSI performance is a component of the Leapfrog Hospital Safety Grade (A–F letter grades).

TJC National Patient Safety Goals (NPSG)

NPSG.07.04.01 (Reduce healthcare-associated infections): Requires compliance with current CDC or WHO hand hygiene guidelines. CLABSI prevention bundles are TJC expected practice for any hospital with central line access.

CMS Central Line Catheter Bundle Requirement

CMS Conditions of Participation (CoP) require hospitals to implement a central line bundle for the insertion and maintenance of central lines. Compliance is verified through accreditation surveys (TJC, DNV, HFAP).

Section 7: Quality Improvement Targets for 2026

Based on current national data, facilities should prioritize the following for 2026 quality improvement initiatives:

1. Non-ICU CLABSI reduction: ICU CLABSIs have declined; non-ICU (ward-based) CLABSI now represents a larger proportion of total events and requires focused maintenance bundle implementation outside the ICU setting

2. PICC appropriateness programs: Implement MAGIC-criteria-based appropriateness review to reduce inappropriate PICC insertions by 20–30%

3. Peripheral IV quality standardization: PIV failure rates remain high (30–50%); ultrasound guidance protocols for difficult-access patients, extended-length catheter use, and DIVA screening can reduce failure rates significantly

4. Catheter-to-vein ratio documentation: Mandatory documentation of catheter-to-vein ratio at each PICC insertion is the highest-yield DVT prevention intervention currently underimplemented

5. Air embolism prevention at catheter removal: PICC removal air embolism prevention protocols (supine/Trendelenburg + Valsalva + occlusive dressing) are not universally implemented despite clear evidence and clinical recommendations

Related Resources

Prevention frameworks:

• CLABSI Prevention Framework
• VAD Competency and Credentialing Checklist

Clinical guides:

• CLABSI Definition and Epidemiology
• Catheter Thrombosis Guide
• Air Embolism Prevention Guide
• Infiltration and Extravasation Guide

References

1. Dudeck MA, et al. (2015). National Healthcare Safety Network report, data summary for 2013. Am J Infect Control, 43(3):206–221.
2. O’Grady NP, et al. (2011). CDC Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR, 60(RR-1).
3. Pronovost P, et al. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med, 355(26):2725–2732.
4. Chopra V, et al. (2013). Risk of venous thromboembolism associated with peripherally inserted central catheters. Lancet, 382(9889):311–325.
5. Alexandrou E, et al. (2015). International prevalence of the use of peripheral intravenous catheters. J Hosp Med, 10(8):530–533.
6. Wallis MC, et al. (2014). Risk factors for peripheral intravenous catheter failure: a multivariate analysis. Infect Control Hosp Epidemiol, 35(1):63–68.
7. Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice. J Infus Nurs, 44(Suppl 1).
8. Maki DG, et al. (2006). The risk of bloodstream infection in adults with different intravascular devices: a systematic review. Mayo Clin Proc, 81(9):1159–1171.