Radiology techs performing unsupervised bedside PICC procedures
It has been reported to me by a nurse that was performing PICC placement procedure at St Rose Sienna hospital that they currently allow radiology technicians to go perform bedside PICC placement under no direct supervision. These are nonlicensed personal. It clearly states in the Infusion Nursing Society guidelines that only an RN, NP, or physician are sanctioned to perform this invasive procedure. Techicians are not even allowed to start an IV ,aminister medication and such. Each procedure requires the administration of intradermal lidocaine.
Is submitting charges for procedures performed that are not in compliance with CDC & JC standards fraud? With all the focus related to central line blood stream infection and Medicare reimbursement this is a very significant issue. Currently this group has taken a contract at a UHS hospital. The plan is to have one directing RN and two radiology techs to go in and perform the procedures.They will not be working together they will be dividing shifts. I am privledged to this information by the IV PICC team supervisor that just lost her position to these tech's. I practice at SNF's & LTACH's and have seen many pt's that have experienced PICC procedures performed by these tech's....what they describe is medically and professionally incompetent. I have question in relation to documentation. The facilities use electronic documentation and a radiologist's electronic signature is generated on the form. We all kbow that the rads are not following these tachs around the hospital to supervise their procedures. If A tech documents that a physician was present at the bedside during a procedure then that is falsification of documentation. Techs are not licensed so they have no governing body to be accountable for their actions. I have reported this to the JC, Neveda state department of health & humsn resources. I plan to report it to CMS. Does anyone have any support they can offer me. If we allow this to continue, what's to stop this from crossing over into other states. Are all of your positions comprimised? Nurses in general could be replaced by tech's for any number of skilled task. I suppose the universites would have no further need of nursing programs because nurses could be replaced by tech's.
I would appreciate any insight and advise.
Thanks, Margie Hood RN
Whoa, back up, and take a deep breath. You need to learn some more information before you get yourself into trouble. A radiographic technologist may be able to place PICC. This group does have a national certification program, and national guidelines written by their professional organization. This group also has the same amount of formal education as RNs - either a 2 year or 4 year degree. It is true that most states do not require them to take a state board exam and have a state license, but their educational amount is equal to an RN. Their guidelines do state that PIV insertion, medication admin, and PICC insertion is within their scope of practice. I do not believe they have the same knowledge and skill when it comes to pre-insertion assessment and post insertion care and complication management.
Radiology technician is a different group. These are usually the ones who do the patient transports and assist with procedures but do not start PIVs or give meds. It is common slang to refer to both groups as rad techs, but that is not always the same people.
So you need to check very closely to determine which level of personnel you are truly talking about. You also need to assess if this facility has written and approved policies and procedures for this group to do this procedure in this hospital, along with documented comptency. If they do, you will not win this battle. Hold on to your hat, because there are states where respiratory technologist are also placing PICCs at the bedside. I do not see this as competition for nurses. The nursing role is only compromised when there is only an emphasis on the catheter insertion procedure, as if it is simply a task that can be performed by anyone who has acquired the skill. If you omit the whole infusion picture, this is what you get. If the emphasis is on good patient outcomes though, you will include the whole and complete picture of all infusion services including preinsertion assessment of diagnosis, prognosis, medications, anticipated length of therapy, chronic diseases and other compromising factors, methods of infusion, proper principles of infection prevention before, during and after insertion, dressing/stabilization/set/add-on device management, med administration methods, recognition and correct management of any and all complications, etc. This is the nursing component that has been dumped onto the primary care staff nurses without appropriate education and skill assessment. So look at outcomes with many things to determine what the actual problems truly are. The emphasis should be on the scope of infusion nursing practrice, not just catheter insertion. The person performing the insertion may not be the problem. 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
Thanks, Lynn,
The nurse that lost her job told me the tech's told her they could not start PIV's & administer meds. She was also unable to enter them into the hospital opus system because they are not licensed.
Margie Hood RN
Margie Hood RN
So Lynn,
I was thinking about your comments and my first thoughts are that I've always considered the pt assessment the first part of a PICC procedure. That encompasses pt hx, labs, current physiology, treatment regimen and prognosis. The actual PICC placement is part of the proper nursing process....assessment, plan, intervention.Follow up should be part of the procedure, but unless a facility structures post insertion catheter care and monitoring as part of the IV teams duties it does fall to the staff nurses. I agree many CLABSI problems occur as a result of lack of proper care after the PICC is placed. Much focus should be geared to educating and prophylactic devices such as swab caps and such.
I am aware of RT placing PICC's, but I believe they are licensed. If you do not sit for a board examine and are not licensed than who are you accountable to? As nurses we have to hold a degree and a current license or we are not able to practice.
I heard today from a friend that sits on our state board that now there is a new position in developement: the med pass person. A non- licensed body to pass meds. I only came into infusion nursing in the last ten years. My nursing hx prior to that was 16 yrs of critical care float & PACU. I feel the trends in proper pt care are taking some reckless turns. The line between nursing repsonsibility and privledge is growing fuzzy.
One other thing I would like to address is where the INS standards book states which healthcare professionals are privledged to perform PICC procdures. That information is misleading. I always assumed it was like the infusion Bible. I feel that RT & radiology technologist should be included since that is the case.
I researched after reading your comments the following information is what I found.
The ASRT defines a limited x-ray machine operator as an individual other than a radiologic technologist who performs diagnostic x-ray procedures on selected anatomical sites. Limited x-ray machine operator is the term that replaces other terms including, but not limited to, radiologic technician, x-ray technician and limited permitee.
Adopted by the House of Delegates, Resolution 03-2.02, 2003
The ASRT recognizes that placement and removal of peripherally inserted central catheter is within the scope of practice for radiologic technologist with appropriate clinical and didactic education where state statutes and/or institutional policy permits.
Adopted by the House of Delegates, Resolution 03-3.01, 2003
Margie Hood RN
Correct on the pre-insertion assessment piece.
I am not certain about state licenses for respiratory therapists but I do not think that all states require it.
RE the Infusion Nursing Standards of Practice, please not that this document is written about nursing interventions for nurses. We have not attempted to write statements for what other professionals can or should be doing. There may be a need to change this in the future to include others but right now, this document is written for nursing interventions. It makes no attempt to address the many other professionals performing PICC or other CVAD insertion. I strongly agree that the silos for educating all healthcare professionals must come down. I have seen recently where there are several programs where nurses, physicians, pharmacist and others are being educated together rather than separately. This will become more prevalent and it will be a great way to improve our understanding of others scope of practice and communication between all professionals. 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 have attened some online seminars that were open to nurses, physicians, & other members of the health team. In the online college I attend their is a strong focus on the health team approach to pt care.
I worked at a teaching hospital in NC for the largest part of my career...it was common practice way back then. The interns relied heavily on the the nurses during their first years of practice...they had limited clinical experience. I find many general practiioners lack knowledge related to infusion devices and therapy in general. I get calls on a regular basis asking me to reposition catheters that are at the CAJ and other things that I would expect them to know. Infusion therapy basics should be part of their orientation when they assume practicing privileges at any healthcare facilty. I know it is part of the orientation for newly hired nurses.
Thanks for your comments.
Margie Hood RN
Margie Hood RN
Hello to ALL,
I am a Texas licensed and nationally certified Medical Radiologic Technologist (MRT). I am certified by the American Registry of Radiologic Technologist (ARRT) in radiography and computed tomography. I am PICC trained through PICC Excellence.
I have successfully been placing PICCs for the last three years. We as radiographers have extensive training in anatomy and positioning. We have extensive training in venous and arterial imaging. Also, most of us have training in cross sectional anatomy and are able to visualize veins and arteries under fluoroscopy, ultrasound and cat scan.
The American Society of Radiologic Technologist finds the placement and removal of PICCs within our scope of practice. Many of us x-ray technologists are specially trained to do more that be just button pushers. I would like to mention that my expertise in radiology allows me to find veins under ultrasound quiet easily furthermore , I work hand in hand with nurses and assisst them when they cannot find venous access. After all it is all about the patient and facilitating their care.
We are licensed in most states and have extensive training in all the procedures that we perform. Those of us that are priviledged enough to be trained in PICC placement do extremely good jobs.
Note: Not all x-ray technologist should be performing PICCs, just like not all RN's should be. There has to be specialized training and the PICC specialist should be a competent.
Note: After successfull insertion of PICCs by x-ray technologists we are able to break sterile technique and take our own chest x-ray. Just a thought who would you say has more experience in looking at chest x-rays a nurse or an x-ray technologist?
I would like to thank Lynn Hadaway, she has incredible knowledge and insight on the profession of x-ray technology.
I, along with the nurses that I work with on a daily basis share a great working relationship and mutual respect. I would like to see nurse and x-ray technologist work closer together. Both professions have so much to offer the other.
Hello,
I am a CT tech and on a vascular access team and have been doing PICCs and Extended Dwell Catheters for the last few years. We use PICC Excellence for continuing education. My facility wants me to find other techs and facilities that have multimodality PICC teams. So I am reaching out to you and anyone else whom can help me. And if so, could you please share with me your policies at your facility governing Techs doing PICCs.
Thank you
Joseph W Naebers
I don't understand this notion that just any "TRAINED" person can "PUT IN" a PICC
Kathy K. seems to have had the most exposure to this situation around the country perhaps she could comment on this disturbing development in healthcare
When a Radiology or Respiratory Technologist inserts a PICC have they completed any pre insertion assessment?
How do they know the appropriateness of the device based on HX [Mastectomy, Fistula or past CVC experience] previous XR evaluation, Labs or the planned teatment regimen?
Robbin George RN VA-BC
The answer to that question depends upon who did their education and training and what it included. The same can be said for nurses. I have seen some radiology nurses who have no knowledge of assessment, site selection etc. They only use the chosen arm because it was most convenient for their table and set-up. So our silo practices must come down. We have to begin thinking of ways we can improve the flow of patients through our systems by having the most appropriate person do the task. That may or may not be a nurse, depends upon the situation. Some hospitals simply refuse to give this role to nurses of any background or experience level. Those nurses trained only by a radiology physician do not have the same level or amount of knowledge as other infusion nurses. 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 totally agree with you. I have talked to a few rad tech's I know and for the most part that they don't have the knowledge to perform a pre-insertion assessment or to dertermine PICC placement is in the pt's best interest. What's more they do not know how to what to do if there is a procedural complication.
Last year I trained some nurses that came to my state from Ca. These nurses told me they tried this practice in Ca. and their nurses were able to stop it. It really makes a difference for nurses communicate with their state when federal law permits what a prudent nurse feels is unsafe practice.
Margie Hood RN
Margie Hood RN
the same way you do, we interview, we read the h&p, please do not be so negative. i welcome you to see our outcomes
Rich Mitchell RRT
Technicians is a growing trend and will continue to move forward. In fact there will be multiple changes to healthcare over the next five years that will knock your socks off. First off these are licensed individuals in 48/50 states for reespiratory theapy and last I read 46/50 states for radiology technologists. They pass a certificastion test given by their professional organization in order to apply for licensure. I highly respect Mr. Ramieriz in the Banner System for his program of respiratory therapy practitioners placing vascular access devices as well as his published outcomes which will be found in JVAD 2011.
Healthcare of the future will involve 24/7 service as I have mentioned in the past and continue to discuss. The placement of a PICC or any other central line will need to be done 24/7. I will leave a caveat to that 24/7. Due to sepsis bundle that 24/7 in the future will be difficult unless that individual is on site as one cannot wait for someone to be called in to place a central line for sepsis bundle. Not all facilities have ultrasound trained physicians to drop central lines and ultrasound will become mandatory inthe next five years.
I actually have been speaking of the medication tech for the last three years so I am not surprised to see that a state board is looking into this. Healthcare is expensive and labor is expensive. The future holds labor reductions in the healthcare field or labor shifts. With electronic medication delivery we will be able to shift this labor to non licensed personnel who take qualification courses to give IV and oral medications. These positions will be supervised by RN's.
So what does this mean for the RN. My suggestion is education and the need for four year degrees and above. They cannot take away your RN but they can write future job descriptions to include four year degree and above. I am already seeing this take place. The nursing shortage is gone and we will face the labor shifts that have happened in all other industries to downsize or use lower cost labor. Start to work on expanding hours and review what services you can add. Integration of technicians to an RN team are entirely possible and that would be a blending process. This blending process is what is taking place in Arizona where respriatory and RN are working side by side. Cases where blending did not take place the respiratiory therapy has taken over completeley the process. I prefer belending because this brings to the table the RN expertise in assessment and the RT expertise in pulmonary and sepsis bundles. I have learned so much from the RT's about sepsis bundles and want to credit Banner Del Webb Director Brian for his extensive knowledge in this area of pulmonary. My knowledge in this area is a result of communicaiton with respiratory therapy and by no means am I an expert in the pulmonary aspect.
My advice:
Obtain more education
Monitor your outcomes for proof of your expertise
Offer more hours of servce or more service or both of these
Look at how to make the process better with integration of other disciplines rather than fight progress
Now that I have stirred controversy I leave you with one thought I love nursing but the world changes and as a nurse I will change with the world to make it better. In 1998, most RN's thought ultrasound guidance to place a PICC was crazy and the radiloists told me an RN could never sucessfully use ultrasound as it was difficult and they were not trained. Well IR is not placing the majority of PICC line anymore. Lesson to be learned in this progression of PICC placement from an MD in the IR to an RN with ultrasound. Progress moves forward and we must move with it or be eliminated.
Kathy Kokotis or Kathy K's opinion
Bard Access Systems - PICC Busienss Analyst
Radiology technologists are NOT unlicensed personnel. They are licensed by the state just like RNs are. Their scope of practice includes placing and removing PICC lines, since 1999 via the national ASRT guidelines. The state board of Radiology and the hospital policies can superceed these scope of practice guidelines, but if there is no statement saying they cannot place PICCs, then they can.
I am a member of the ARIN board, Assoc of Radiologic and Imaging Nursing, so if you have a question about radiology practice, I may be able to help you or find a resource for you.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
Your interpretation of the 2016 INS Standards of Practice is not correct. This document does NOT state who can or can not do any procedure. In fact, it states, "Recognize the overlap between professional groups and that no single professiona can claim exclusive ownership of any skill, activity, or tasks.", page S13. Also, radiographic technologists are either licensed in their state or their state requires a certification from theirr professional organization. These rad techs have an 2 or 4 year college degree just like an RN. If the facility is following their state rules and regulations, and there is policies and procedures allowing rad techs or respiratory techs to place a PICC, then they can do it. You should contact the American Society of Radiographic Technologists, and you can probably find support for rad techs doing PICC insertion on their website. It has been there for many years.
The outcomes produced is a separate issue, but that is not directly tied to the licensure of the person performing the procedure. We must stop being territorial over procedures or tasks and practice interprofessional collaboration. Please read INS Standards 3 and 5. 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
If anyone is a Radiology Tech placing PICC lines in Texas, please let me know. I would like to know what the policies are at other facilities.
We have been trained both techs and nurses to do PICCs and obtain continuing education through PICC Excellence. We also have regular meetings to discuss issues and learn from each other. We have had great success with our program, pre-assessment, and evaluation for the need for PICCs.
I would like to find other multimodality PICC teams in and out of my state to connect with.
Thanks
Joseph W Naebers
hello Mss.Hood
i dont know about your state rules, but in our hospital in saudi arabia, we as interventional radiology technologists have a hospital privilege to do PICC lines, bedside or conventional using the c-arm. in saudi arabia most of hospitals have nurses to do this procedure and they do not need to go through privilege committee because this is a core business for their profession, unlike us.
neverthe less, is ASRT "Cardiac Interventional and Vascular Interventional Technology Practice Standard" , in page 7 , you can find that the PICC is in the scopr of practice for interventional radiology technologists
in france there is a published paper regarding radiology technologists training to do this procedure.
all in all , Like most of interventional radiology procedure. Picc line insertion is a shared procedure among several profession in healthcare that depends on the organization, convenience, and in Saudi Arabia also on the privilege.
Ibraheem Aljediea
Johns Hopkins aramco Healthcare
Saudi Arabia