I figure its time to start direct conversation regarding these two systems since our team is looking at both. Each company is trying to rebutt the others statements (which makes it difficult to choose).
What we have been told:
Vasonova - can be used with any non-valved PICC. Relies on doppler flow when a p-wave is not present.
Sapiens - can only be used with a BARD PICC. Relies on Sherlock magnet technology when a p-wave is not present.
Please disclose your affiliation with either of these companies when making a comment.
I have no affiliation with either of those companies. My understanding is that both of your statements are correct for both products. The issue with ECG guidance alone will always be that subset of patients that do not have a p-wave on their ECG. Maybe it is just my family, but it seems like everyone is developing atrial fibrillation these days and they would not have a p wave, among others. The magnet technology has been around for at least 15 years and alone is not sufficient to eliminate the need for a chest xray. The magnet technology will tell you the general location when you hold the external piece over where you think the tip is located. Doppler flow technology, also not a new technology but newly applied in this manner, gives you constant feedback as the catheter is passed through the vessels because it is sensing the blood flow. So if it is goes into a contralateral vein moving against the blood flow, it will give you an indication about that. Bard only makes their technology to be used with their PICCs. This is the marketing strategy they have chosen. I am eager to hear from others with clinical experience about these technologies as well. 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
Disclosure: I am a consultant with Vasonova.
For clarification: Neither Bard Sapiens/Sherlock nor the Vasonova Vascular Positioning System can be used with the closed-ended catheters, namely Groshongs. Both require open-ended catheters, which include Bard PowerPICC Solo and the Navilyst Vaxcel PASV or Xcela catheters. Both are open-ended, and it is the open-ended tips that allows the intravascular ECG stylet to "read" the P wave. VPS also requires that the tip of the catheter extend 1 mm into the bloodstream so that it can send out the Doppler signal and RECEIVE the doppler return signal as it bounces off moving blood cells. It is how fast the doppler signal returns that gives the computer the ability to determine if blood flow is moving towards the stylet which would indicate retrograde flow, or away from the stylet which would indicate antegrade flow (the correct direction). Vasonova's research has found that there are distinct flow characteristics within the central vasculature and within the various parts of the superior vena cava and right atrium to accurately and precisely calculate when the catheter tip is in that lower third of the SVC or at the CAJ.
Sapiens/Sherlock must be used with Bard's Site Rite 6 or their newest version of US machine although I understand they are developing a stand-alone machine if you don't use either of their US machines or you do not want to upgrade from a SR V or have another manufacturer. Also to be used with only their open-ended PICCs.
VPS can be used with any US machine or with any open-ended catheter.
VPS can be used with abnormal P wave patients, but requires some clinician interpretation at this point as there will be no "Blue Bullseye". The blue bullseye will only occur when both vectors: IV ECG and Doppler coincide by the computer algorithm which determines this. With no P wave patients the icons would flash between green and orange; PICC should be left at bottom edge of "green arrow", but there will be training when the clinician gets to this point.
Sherlock alone is purely directional and not accurate with tip location, but you probably already know that.
I hope this clarifies some key points.
Nadine Nakazawa, RN, BS, VA-BC
Nadine,
Thank you for your response. Would you be able to comment on use of VPS with an existing or history of thrombus? I have searched the internet for contraindications, read the 510K statement and have not found this mentioned.
Disclosure: I am a consultant with Vasonova.
VPS would give a Yellow triangle, meaning "no information" if the catheter/stylet tip hits a stenosis or thrombus, just as it would if the catheter tip is against the vessel wall. The stylet needs to be exposed in the bloodstream to detect the doppler signals and IV ECG. If there is partial thrombus or stenosis but a relatively patent vessel, the stylet should get a green arrow indicating good blood flow and you would continue to advance the catheter. You can also view the doppler signal and the height of the doppler rises as the catheter/stylet enter the top of the SVC. The doppler frequency should be spiking well above the mid-mark indicating antegrade flow. If the doppler signal disappears or is dampened down the catheter may be up against a stenosis/thrombus or the vessel wall indicating no or little blood flow. The green arrow will likely disappear and the yellow triangle will appear. You would pull back slowly until the green arrow reappears and then try to re-direct the catheter while maintaining the green arrow.
With current insertion techniques without tip location, if you can't advance beyond a certain point despite all the usual manipulations, then you are stuck and most likely have to remove the catheter. With VPS it would be no different: you would know that you are not at the desired tip location if you still have a lot of excess catheter sticking out, and you go from green arrow to yellow, but not orange (do not enter as in going to the R atrium) and never get a blue bullseye. You could get a CXR to see where you got stuck if that information would be helpful, but most likely will not help with another insertion.
I hope this answers your question. Stenosis is stenosis, stuck is stuck, the bain of our work.
Nadine Nakazawa, RN, BS, VA-BC
So Nadine, it sounds to me like the dopplar technology provides significantly more information than the magnet-based technology. 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
I'm trialing Sapiens right now. I've had very good luck with the system. To some, the ECG interpretation could be a challenge. I'd be interested in trialing the vasanova also, just to get an idea of how it works. I think some people would be able to understand a bullseye rather than ECG. They are both probably very good systems, and neither one is going to be 100% accurate all the time. That said, I do like the idea that the vasanova can be used with other lines. Once you're locked into bard...that's it baby.
Mike
Nadine,
Thank you for your response. Would you comment on the statement that as nurses we cannot insert wires, therefore, inserting a catheter with a wire extending beyond the tip is out of our scope.
We have been told so much from both sides.......
No affiliation with Bard Access or Vasonova - just to clarify
I am curious as to where you have heard this or where is this written. Nurses work with wires all the time. Is this something from your state board of nursing? 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
Does anyone know if either of these are billable? If so, would the billable amount outweight the revenue generated by a CXR?
Thanks
For inpatients, I am pretty sure that there would not be any reimbursement for use of this technology as most patients are under a capitated fee system. For outpatients, there could be some but I am not certain about how much or what you would need to include in your documentation such as an actual printed record of what you saw on the machine or ECG strip, etc. Such technologies can be added to some of the codes used for billing but there is a certain level of evidence that must be made available for those regulatory decisions.
Also, I would never have thought about your angle on the costs. What amount of net revenue is created from a chest xray? You would need to know that fact before your question could be answered. I would just add that loss of revenue would not be a valid, evidence-based reason to avoid exploring the use of and potentially adapting these technologies. Practice decisions should be based on the published scientific evidence. 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
I want to jump in here with a couple of quick responses.
1) Wires: Wires have been passed into PICC's for years....consider those that are passing the stylet into the PASV catheter by Navilyst or those that have used Navigator. There has not been issues with this as far as I know.
2) Billing: As you know, with Medicare inpatient reimbursement, there is really no financial benefit from getting the CXR anyway as payment is made based on the DRG. For out patients there were some recent changes made with Medicare reimbursement with the CXR. It seems that now the cost for the CXR has been eliminated becasue it has been lumped in with the cost of the catheter insertion, as all catheters, until now, have required CXR verification.
I am a clinical specialist for Teleflex who owns Vasonova
Cheryl Kelley
Cheryl Kelley RN BSN, VA-BC
We have begun using Sapiens at our facility. I had a critical care patient, a large man, that we could never get a good chest film on. The Sapiens was very useful in confirming the tip placement via p wave.
For teams that fly solo, a little hard at the beginning to handle the remotes. Also not for those cowboys out there-requires a little finesse. We like the stiffer stylet in the catheter. Getting a baseline tracing can be a little quirky-which freaks out the critical care nurse in me that wants quick-look paddles to make a comeback.
Need to let the rest of your colleagues in the facility know that you are determined to now be at the CAJ, because if you don't, they start pulling your lines back on your day off.
I would also like a fancier printout-I think they are working on that.
So far, so good.
Genine M Schwinge, ANP-BC, PNP, MSN
Vascular Access Coordinator
John T Mather Memorial Hospital
Port Jefferson, NY
We are looking at both technologies too. For us eliminating the CXR is not a factor but multiple CXR for positioning is. Also we are looking at whether repositioning plays a factor in infection as we aim for zero. My facility is big on BARD and we have the sherlock already. However the bullseye would be easier to interpret (my opinion) I also liked that the Vasonova has a print out that could be placed in the chart, versus just having the ECG with p wave. Although you have to use the BARD PICC beware it is a certain PICC you need to use (this one does cost more). For Vasanova the cost per PICC is @ 120 added to your costs right now. However you can use any PICC and downgrade PICCs.
I have no affiliation with either company and yes each has a statement about why theirs is the best.
Tahitia
I have no affiliation with either company. I currently use Bard Power PICCs and have a Site Rite 6 US with Sherlock. I have been using Sherlock for several years now and do use it to help hit the CAJ/stay out of the right atrium. I correlate the depth of the PICC with movement of the tip. You still have to get a CXR for tip posiiton confirmation but Sherlock can keep you out of the right atrium when you become familiar with it and have learned to read its nuances. I am interested in learning more about Sapiens as we are looking at that system in hopes of eliminating the CXR and placing the tip consistently at the CAJ. With DRG reimbursement, I thought the elimination of the cost of the CXR would have to help the financial bottom line. Has anyone else trialed Sapiens or have any words of wisdom on it or other sytems? Thanks, Jan Fuller RN, BSN
Does anyone know if the Sapiens or Vasonova is approved for use in peds?
Holly Hess
I have no affiliation with either company.
I have been using ECG guidance for several years now and my facility just made the decision to purchase the Vasanova guidance system. There are several reasons we chose Vasanova over Sapiens. The doppler system has sound waves that change as your tip progresses through the vasculature. This means that often you can tell where you are without looking at the console because you hear the difference in the sound waves as you pass different landmarks. The ECG portion of the display is clear and I believe easy to learn. The symbols are clear, easy to interpret, and the bulls eye can be trusted to tell you that you are at the caval atrial junction. The system seems to be less cumbersome to use, can be used with any PICC or any ultrasound system. This gives the user much more flexibility in choice of equipment. I have successfully use it for patients with atrial fib going by the doppler signal. We have used it in the morbidly obese patient since the thickness of the chest does not obscure the signal as in the Sapiens system. A patient with difficult vasculature will still be a difficult picc patient but this system provides a lot of information. We are still in a learning curve but are very happy with our decision.
Can anyone that has used Sapiens for awhile comment on Glenda's statement regarding chest thickness? I didn't think about chest density r/t ECG transmission. Is this true?
Hi all,
From what I have heard, Medcomp is going to have their tip location device ready by year end as well - low cost, good value...if we all can wait before comitting spending lots of $$$, I think we should wait to see all the technology. Maybe Navilyst will have one as well??
The chest wall thickness doesn't affect ECG guidance or doppler sensitivity at all but it can be a negative factor in magnetic guidance systems.
Could I have a sample of PICC policy without CXR requirement please?
Can you know while using the Vasonova that your tip has entered an area of stenosis/DVT? Does the sound change distinctively that you would know that is the reason you cannot advance?
Thanks, Kathleen
Kathleen Wilson, CRNI
You get a very damped doppler sound and an orange negative sign that indicates retrograde or no flow and tells you to stop.
I am a contract preceptor for Bard.
Both systems require p-wave per there ifu's to clear the line without cxr. So using vasanova or sapiens in afib still requires xray. The new sapiens sensor also has a deeper magnet scan depth, i have yet to find a patient it didnt see the picc.
Heath