Another Sample Consent

Micro-Introducer Technique for PICC Insertion

 A Sample Policy with Competency Checklist  1.           Follow institutional policy and procedure for PICC insertion up to the venipuncture.2.           Perform venipuncture with the peripheral IV catheter or thin walled percutaneous needle.3.           Remove the tourniquet through the sterile barrier.4.           If an peripheral IV catheter is used, remove the stylet from the peripheral IV catheter.5.           Insert the floppy-tipped guidewire through the peripheral IV catheter or percutaneous needle and advance to approximately the level of the axilla maintaining at least 15-20 cm of the guidewire external to the insertion site.   Caution:   The practitioner must be aware of the position of the guidewire at all times.   Failure to adequately secure the guidewire or over insertion of the guidewire could result in guidewire embolization.6.           Remove the peripheral IV catheter or percutaneous needle by retracting it off the guidewire.   If using a percutaneous needle to access the vein, caution must be emphasized:   At no time should the guidewire be retracted through the needle as this could result in embolization of the guidewire.7.           Perform a small superficial skin nick utilizing a #11 scalpel directly above the wire.   Caution must be emphasized:   The sharp side of the scalpel must never come in contact with the wire.   The skin nick is performed with the sharp side of the scalpel positioned away from the guidewire.8.           Advance the introducer-dilator assembly over the wire, through the skin and into the vein.   Applying traction to the skin and utilizing a twisting motion of the introducer-dilator assembly may facilitate advancement.   If unable to advance, enlarge the skin nick slightly and reattempt.   If resistance is still encountered, retract introducer-dilator assembly off the guidewire, separate the introducer sheath from the dilator and attempt to advance the dilator alone over the guidewire and into the vessel.   Advance the dilator completely into the vessel, then withdraw the dilator from the vein and off the guidewire.   Reassemble the introducer-dilator assembly and reattempt advancement into the vein.   Upon successful insertion of the introducer-dilator assembly, the guidewire may be bent over the hub of the introducer to prevent guidewire embolization.9.           Remove the guidewire and dilator, maintaining intravascular position of the introducer.10.   Insert PICC or midline catheter as per institutional policy and procedure.                        NAME:______________________________DATE OBSERVED:__________________  




1.Verify physician order for insertion of peripherally inserted central catheter    
2.Performs patient assessment    
3.Explains procedure to patient including potential complications and obtains verbal informed consent    
4.Performs pre-insertion measurement    
5.Masks everyone in room including patient    
6.Performs thorough hand wash utilizing antimicrobial skin cleanser x 60 seconds as per institutional protocol.    
7.Preps proposed insertion site as per as per institutional protocol    
8.Applies tourniquet    
9.Dons sterile gown and sterile gloves    
10.Applies sterile barriers    
11.Administers intradermal anesthetic agent as per institutional protocol    
12.Performs successful venipuncture utilizing percutaneous needle or peripheral IV catheter.   Removes tourniquet maintaining sterile technique    
13.Removes introducer needle-style if venipuncture performed utilizing peripheral IV catheter    
14.   Inserts floppy-tip of guidewire through peripheral IV catheter or percutaneous needle and advances to approximately the level of the axilla, demonstrating caution t avoid entering the thorax with the guidewire    
15.Removes the peripheral IV catheter or percutaneous needle by retracting it off the guidewire.*If using a percutaneous needle, it must be emphasized that at no time should the wire be retracted through the needle as this could result in embolization of the wire.    
16.Demonstrated adequate securement of the wire at all times    
17.Performs skin nick utilizing #11 blade    
18.Advances the micro-introducer and dilator sheath over the wire into the vessel utilizing a twisting motion and counter traction (this will facilitate advancement of the dilator sheath and introducer assembly)    
19.If resistance is encountered when attempting to advance dilator sheath and introducer assembly, demonstrates appropriate troubleshooting technqiues:a                 Enlarge skin nickb               Separates dilator sheath and introducer assembly and attempts insertion with dilator sheath onlyc                 Re-attempts insertion of dilator sheath and introducer assembly    
20.Removes guidewire and dilator sheath maintaining intravascular position of peel-away introducer    
21.Proceed with PICC insertion as per institutional protocol    


 Evaluator Name:____________________________________  Evaluator Signature:_________________________________Date:_________________