At our hospital we are reviewing the need for a doctors order when a midline
is requested. Historically we have always needed an order from the doctor for a
midline. This would be for patients that will be recieving a non-vesicant drug for up
to four weeks. It is not for a failed PICC. Any imput would be appreciated, including
evidence based pracitice info as well .
Thank you ,
Maureen RN, CRNI
There are additional criteria to determine who is a successful candidate for a midline, not just vesicants. pH should be between 5 and 9 and osmolarity should be less than 600 mOsm/Liter. I have seen 2 apporaches to the use of midlines. First is that this is a nursing decision (made by the infusion nurse) as to when a midline is required and no additional physician order is needed. This is based on the fact that the midline remains in peripheral veins and does not enter the thorax or central venous system. The other approach was to sent a letter to all physicians asking for their standing order for a midline based on infusion nurses assessment. If they signed and returned the letter, the infusion nurse wrote a verbal order and placed a midline. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Would there be a risk for legal implications against the hospital without a physicians standing order?
That would depend on how your policy and procedure is written. If your hospital chooses to make this a nursing decision, I do not think there would be an increased liability to not require a physician order. This would be based on the fact that it is a peripheral catheter and remains totally inside peripheral veins of the upper extremity in adults. Also you need criteria for who is and is not a candidate for a midline. I do not think that primary care staff nurses should be given this decision, however an infusion nurse with the specialized knowledge and skill can decide when a midline may be in the patients best interest. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Do you require a consent form the pt/family/POA for a midline? I would think not because it is a form of a PIV, however, if available would this be best practice? I would think that to be consistent with each and every insertion that whatever you decide, to consent or not should be done on 100% of you patients, not just those who can consent for themselves or happen to have their NOK with them. Thoughts?
You are correct. The policy on a written informed consent must be clear and understood by all so that it can be applied in the same manner to every patient. Any deviation from this written policy could easily result in problems with a Joint Commission survey as this is one of the factors they look for. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
We use midlines only under very stringent rules......and very rarely. When we did place them we did not require a physician's order since they are a peripheral IV. Now, on those rare occasions when a midline may be the patient's best option, we discuss with the physician because we think it's very important that all who have an interest in that patient's line be aware that it is not a central line. Riskier (in my opinion) to place a midline than a PICC. For us it's generally a short peripheral or a PICC.