My facility is trying to institute a catheter exchange practice and policy. The following are the comments and concerns from some of the team members who are writting the policy:
1. Alice Cenanno originally wrote a catheter exchange policy as an over the wire policy in 2003. She revised it in 2007 and removed the over the wire techniques. It was stated that she changed the policy related to the manufacturers unwillingness to provide written support for this procedure.
2. The 2006 INS standards referenced catheter exchanges by an "over the wire technique," but did not state the RNs should perform this procedure. The 2011 INS standards no longer references an over the wire exchange.
3. The INS standard 55 that the exchange with be performed under organizational policies and procedures, and/ or practice guidelines and according to manufacturers directions for use.
4. It was stated that using a guidewire is a "dangerous act" r/t drug precipitation or other occlusion
5. It was also stated that not everyone who places a PICC should be allowed to exchange a catheter.
We would like to do catheter exchanges, there seems to be conflict about what nurses at the bed side should exactly be doing.
And if anyone knows Alice Cenanno, I would love to talk to her.
Matt Gibson RN, CRNI, VA-BC
Catheter manufacturers do not offer any instructions about this procedure because they do not supply the guidewire for this procedure. It must come from a different source, so they can not write instructions for another manufacturer.
Anything included in the Infusion Nursing Standards of Practice would be considered to be procedures performed by nurses who have met the criteria listed in that standard. The 2011 SOP does not mention the specific "over-the-wire" procedure because there are at least 2 different procedures that can be used - over a wire and through an introduer. The SOP is not a procedure document and must avoid all references to specific step=by-step procedures.
As with any procedure, including CVAD insertion, there will always be risks. If you are doing this procedure at the bedside, you would need to pay attention to the length of the wire, adequate cleaning of the external old catheter (it can never be made sterile again for this procedure), and repeating the chest xray for tip location of the new catheter. Unfortunately neither exchange procedure was included in the INS P&P book and I do not have an explanation for that.
For any nurse qualified to insert PICCs, I think they should also have the competency of catheter exchange at the bedside. This procedure should be documented in the same manner that competency for insertion was documented. Yes, there will always be the risk of breaking off anything that might be adhered to the catheter wall when you drive the guidewire into the lumen. This is why you will need to do a risk vs benefit assessment before each procedure specific for each patient. 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
As usual Lynn has nailed it. There is very little for me to add. I have observed IV-Thereapy.net for almost two years now and have not jumped in to any forum, here's a shot. There is not always a manufacturers Instructions For Use (IFU) or an algorithm for licensed professionals to follow. In our era of Evidenced Based Practice (EBP) some have jumped in the deep end without their life-jacket(floaties) and a double-blind study to keep them afloat. In other words, there is a reason we are licensed, not because we are the fastest at looking up the latest study on "X", but because, in our free time, we have already read that study and can apply it to the unique patient situation in front of us. It is ALWAYS a matter of risk/benefit. It is not always possible to competency validate a person on over-the-wire or through-the-introducer exchanges because they are not that common, but when the decision comes down to either of those options being best for the patient, than a licensed vascular access expert should be able to apply previous knowledge to the situation presented.
Dictionary.com definition of "algorithm": a set of rules for solving a problem in a FINITE number of steps, as for finding the greatest common divisor.
Works for most patients, but not all... people, and their situations, are unique.
Dictionary.com definition of "license": exceptional freedom allowed in a special situation.
Be ready to back why you did what you did, patient first.
Mickey
Michelle L. Hawes, RN, MSN, CRNI, VA-BC
Chief Executive Officer
Vascular Access Specialists, LLC
Indianapolis, IN
317-888-0303
Mickey and Lynn hit the nail.....I've been doing exchanges since 2004 without incident and was taught by my mentor. He documented compantencies and that was it.....I would say I have at least 1500 exchanges in 8.5 years without incident. Should I look for a study with a 300 sample size to tell me it's ok to do this? You should not be inserting PICC lines if you have to rely on only what others have done. Know what you can do and make sure you have someone who has done thousands of these with you and jump in. Set the trend. don't just follow.
jack Diemer