We are waiting for product to be delivered. Our service will be trialing this device soon. We have used the Wand, we are trialing the Powerglide and we are considering looking at the Flexicath. More to come.
Please share with this group your thoughts on these two products. My facility will be trailing the PowerGlide but the product committee will not allow us to trial the Power Wand due to $ and the vendor is not on contract
As vascular access nurses our first responsibility is to the patient. Many of us have fought many battles with doctors, pharmacists, and even other nurses on why it is so important to use the right device for the ordered therapy. This is why I am so puzzled as to why so many are jmping on this bandwagon, manufacturers included. We all have seen countless examples of nurses infusing inappropriate medications through midlines that were originally ordered for "hydration only". Very recently I walked into a patients room that a had a midline placed for hydration, it was clearly lableled no irritants or vesicant both on the device and in the chart, and TPN was running through it! On this forum we have seen team managers of IV teams instructing their staff nurses that they WILL insert midlines even though vancomycin is the prescribed therapy. I have some concerns about this "new" device category.
The standards of practice are very clear that osmolalities of >600 should not be used for midlines. We know there is not nearly the hemodilution at the axilla as at the CA junction, a blood flow difference of over 1500ml per minute in the average adult! Almost all of the injectable contrast agents currently available today have osmo's of well over 600. I am informed by many CT techs that the more vein friendly agents are not used mainly due to cost. What happens when a high pressure CT injection injects a high osmo contrast agent into the hard to see and hard to assess axillary area? A CT extravasation in this area has potentially devastating consequences when compared to a PIV. Another troubling factor is what happens if high pH/low pH has been running through that midline either before or after the power injection. Is the vessel weakened enough to extravasate? Who is responsible?
I am hesitant to use devices that may or may not cause injury when used correctly, especially with the knowledge that in the real world of hospital and outpatient nursing these devices will be used incorrectly. How many floor nurses really know what is appropriate for midline therapy? Medical devices that solve patient centered problems have helped to take the vacular access profession to great heights. My final concern is that a device category that might have been created to take advantage of a current administrative culture could do patient harm and the nurses who should be protecting patient safety first will be involved. I am looking forward to seeing more data on this subject and would really encourage those deciding to trial these products to share their experiences.
I must vehemently disagree with Stephen on his opinion of midlines. As many of you know, I was a part of the clinical and marketing team that introduced the midline concept to the US market in 1989. So this is not a new concept. I firmly believe they fill a much needed place in the world of vascular access. I also do strongly agree that they can be misused and that is a problem. But I refuse to say that this misuse should mean that we never use them. I would encourage you to listen to the presentation on midlines by Mickey Hawes at AVA last week. To say that we cannot use a midline because they could be misused is to say that a nursing staff can not be taught how to use them correctly. I don't believe that for a minute. Wrong clinical decisions means that there has not been education, that there is no infusion nurse to support the staff nurses, that there has not been any competency assessments, that there are no written policies or procedures, and/or that no one is monitoring outcomes and completing that quality improvement circle to correct the problems. And this brings us back to education and accountability. The national standards state that the smallest and shortest VAD that will accomplish the prescribed therapy should be used. So midlines definitely have a place in the world of vascular access!! Lynn
Lynn I think it's great that we disagree because discourse on clinical topics leads to knowledge. I agree there is a place for midlines and I also know there is a great deal of misuse, and a huge lack of IV education in many of our hospitals. If you ask the average floor nurse how much infusion nursing support they get the answer is usually zero(not always but usually!). I was a clinical specialist for a major manufacturer covering the Mid-Atlantic area and usually found the opposite of support. Physicians anf pharmacists telling nurses that irritant and vesicant drugs are fine through a midline. So we have two scenarios, 1) that which should be and 2) that which is. My specific objection is to the power injection of these devices. I find the shortest catheter argument troublesome because it turns a blind eye to the fact that these catheters are misused so often in the clinical environment. If a facility is comfortable with their vascular access education, and they use a contrast agent that meets the INS standards then by all means they should have the freedom to trial. My concern is they are being pressured to trial by administrators who feel that piccs and midlines are interchangeable. We all know they are not.
Our facility and system is just looking into this product, and concept. As Lynn mentioned, midlines have been around a long time, and have their use in the right person, place, and time. Our questions was the use of this product for contrast. Even though approved for power injection, our worry is the effect on the vein and how long it will last after. Our plan is to evaluate this product on a lspecific population of patients and monitor for outcomes. Our thought is to place on outpatient patients who are coming in for CT and monitor for outcomes. If successful, we can expand to some inpatient and monitor outcomes as we go along.
Very well said Stephen. I have your same concerns. I would encourage anyone who is trialing these devices to do ultrasound examination at intervals or at least completion to observe for asymptomatic venous thrombus. There was a time when we believed it was OK to infuse drugs into the subclavian vein via a mid-clavicular line. I hope we are not repeating history. We need to consider the addage "Don't poo where you eat".
"Finally, the presence of thrombosis was evaluated with compressive US before catheter removal. We observed a similar thrombosis rate for both groups, 12.9 % in SC group and 20% in LC group. Most cases of thrombosis were pericatheter; only 6 of 14 thrombotic events resulted in catheter occlusion, and no embolic events were recorded.
Future investigations are warranted to assess thrombotic and infectious risks for both approaches."
For those who are being coerced into placing these lines against your best judgement, Micki Dawes said it best at AVA, "bacteria don't know how long the catheter is". Catheters don't cause infection, bad practices do.
I am willing to trial these catheters for a few select patients but don't see this practice as a panacea.
Please do NOT confuse the midline tip location with the midclavicular tip location. They are not now and never were the same thing. Midline line tip location is in the upper arm level with the axilla in either the basilic or cephalic vein. Midline is NEVER in the axillary vein. Midclavicular is in the middle of the clavicle in the axillary vein and this tip location is the one with the greatest risk of thrombosis. I would readily admit that we need more outcome data on midline tip locations, but I also strongly believe they should be an accepted type of vascular access. Lynn
We have just begun our trial of the Powerglide. Can anyone shed some light about flushing intervals? I have read that they only require flushing q 24h but the product information states q 12h or per facility policy. Any thoughts?
This catheter is managed just like any other midline catheter. Flush and lock immediately after each infusion. If used for continuous infusion, there is no need for routine flush and certainly no lock that is required. There is no need to flush and lock any catheter other than when it is used for intermittent infusion. If there is no infusion therapy prescribed, remove it immediately. Lynn
I have been working in vascular access since 2006 and have learned a tremendous amount of knowledge coming from the floor as bedside nurse. There have been times when the patient requests a midline for home Vanco and the IV nurse that was refusing to place it was told that she was being a "barrier" to patient care because the patient wanted the midline over the PICC after the education was given about the appropriate device that needed to be placed. This is the same as when the MD orders a midline for vesicants and the IV nurses refuse to place it. It says clearly in our policy that a midline is not supposed to be used for medications with a ph of less than 5 or greater than 9 but our management insists that this is the patients and the MD's right to get the line that they want. What would happen in a court of law if this IV nurse placed the midline for home Vanco and he developed a DVT, compartment syndrome or worse? The management involved insists that we are going against orders if we don't follow them, even if we know that it is the wrong order. Any thoughts or ideas on how to handle this almost daily occurance??? Thanks in advance.
Saw one the other day, seems simpler than the power wand, didn't get to try it though.
Hi Everyone,
We are waiting for product to be delivered. Our service will be trialing this device soon. We have used the Wand, we are trialing the Powerglide and we are considering looking at the Flexicath. More to come.
Dave Bruce
Albany Medical Center
Albany NY
David Bruce RN
Thanks, David. I would love to hear how the trial is going.
Terri Coleman CRNI, VA-BC
Sinai Hospital of Baltimore
T. Coleman
Sinai Hospital
Baltimore, Md.
We also trialed the Powerwand and will be trialing the Powerglide soon.
Genine M. Schwinge, ANP-BC,PNP
Vascular Access Coordinator
J T Mather Memorial Hospital
Port Jefferson NY
Please share with this group your thoughts on these two products. My facility will be trailing the PowerGlide but the product committee will not allow us to trial the Power Wand due to $ and the vendor is not on contract
Darla Tarvin RN VA-BC
Mercy Clermont Hospital
We are training on the powerglide, and will keep the group updated.
Alfonza J. Riley, RN,RVS
As vascular access nurses our first responsibility is to the patient. Many of us have fought many battles with doctors, pharmacists, and even other nurses on why it is so important to use the right device for the ordered therapy. This is why I am so puzzled as to why so many are jmping on this bandwagon, manufacturers included. We all have seen countless examples of nurses infusing inappropriate medications through midlines that were originally ordered for "hydration only". Very recently I walked into a patients room that a had a midline placed for hydration, it was clearly lableled no irritants or vesicant both on the device and in the chart, and TPN was running through it! On this forum we have seen team managers of IV teams instructing their staff nurses that they WILL insert midlines even though vancomycin is the prescribed therapy. I have some concerns about this "new" device category.
The standards of practice are very clear that osmolalities of >600 should not be used for midlines. We know there is not nearly the hemodilution at the axilla as at the CA junction, a blood flow difference of over 1500ml per minute in the average adult! Almost all of the injectable contrast agents currently available today have osmo's of well over 600. I am informed by many CT techs that the more vein friendly agents are not used mainly due to cost. What happens when a high pressure CT injection injects a high osmo contrast agent into the hard to see and hard to assess axillary area? A CT extravasation in this area has potentially devastating consequences when compared to a PIV. Another troubling factor is what happens if high pH/low pH has been running through that midline either before or after the power injection. Is the vessel weakened enough to extravasate? Who is responsible?
I am hesitant to use devices that may or may not cause injury when used correctly, especially with the knowledge that in the real world of hospital and outpatient nursing these devices will be used incorrectly. How many floor nurses really know what is appropriate for midline therapy? Medical devices that solve patient centered problems have helped to take the vacular access profession to great heights. My final concern is that a device category that might have been created to take advantage of a current administrative culture could do patient harm and the nurses who should be protecting patient safety first will be involved. I am looking forward to seeing more data on this subject and would really encourage those deciding to trial these products to share their experiences.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
I must vehemently disagree with Stephen on his opinion of midlines. As many of you know, I was a part of the clinical and marketing team that introduced the midline concept to the US market in 1989. So this is not a new concept. I firmly believe they fill a much needed place in the world of vascular access. I also do strongly agree that they can be misused and that is a problem. But I refuse to say that this misuse should mean that we never use them. I would encourage you to listen to the presentation on midlines by Mickey Hawes at AVA last week. To say that we cannot use a midline because they could be misused is to say that a nursing staff can not be taught how to use them correctly. I don't believe that for a minute. Wrong clinical decisions means that there has not been education, that there is no infusion nurse to support the staff nurses, that there has not been any competency assessments, that there are no written policies or procedures, and/or that no one is monitoring outcomes and completing that quality improvement circle to correct the problems. And this brings us back to education and accountability. The national standards state that the smallest and shortest VAD that will accomplish the prescribed therapy should be used. So midlines definitely have a place in the world of vascular access!! Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn I think it's great that we disagree because discourse on clinical topics leads to knowledge. I agree there is a place for midlines and I also know there is a great deal of misuse, and a huge lack of IV education in many of our hospitals. If you ask the average floor nurse how much infusion nursing support they get the answer is usually zero(not always but usually!). I was a clinical specialist for a major manufacturer covering the Mid-Atlantic area and usually found the opposite of support. Physicians anf pharmacists telling nurses that irritant and vesicant drugs are fine through a midline. So we have two scenarios, 1) that which should be and 2) that which is. My specific objection is to the power injection of these devices. I find the shortest catheter argument troublesome because it turns a blind eye to the fact that these catheters are misused so often in the clinical environment. If a facility is comfortable with their vascular access education, and they use a contrast agent that meets the INS standards then by all means they should have the freedom to trial. My concern is they are being pressured to trial by administrators who feel that piccs and midlines are interchangeable. We all know they are not.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
Hi everyone,
Our facility and system is just looking into this product, and concept. As Lynn mentioned, midlines have been around a long time, and have their use in the right person, place, and time. Our questions was the use of this product for contrast. Even though approved for power injection, our worry is the effect on the vein and how long it will last after. Our plan is to evaluate this product on a lspecific population of patients and monitor for outcomes. Our thought is to place on outpatient patients who are coming in for CT and monitor for outcomes. If successful, we can expand to some inpatient and monitor outcomes as we go along.
Ann Earhart, RN, MSN, ACNS-BC, CRNI
Vascular/Infusion Clinical Nurse Specialist
Banner Health
Phoenix, AZ
Very well said Stephen. I have your same concerns. I would encourage anyone who is trialing these devices to do ultrasound examination at intervals or at least completion to observe for asymptomatic venous thrombus. There was a time when we believed it was OK to infuse drugs into the subclavian vein via a mid-clavicular line. I hope we are not repeating history. We need to consider the addage "Don't poo where you eat".
I found this study that did look at thrombosis.
http://jacobiem.org/wp-content/uploads/2012/09/Long-vs-Short-IV-catheters-AEM-2012.pdf
"Finally, the presence of thrombosis was evaluated with
compressive US before catheter removal. We observed a
similar thrombosis rate for both groups, 12.9 % in SC group
and 20% in LC group. Most cases of thrombosis were
pericatheter; only 6 of 14 thrombotic events resulted in
catheter occlusion, and no embolic events were recorded.
Future investigations are warranted to assess thrombotic and
infectious risks for both approaches."
For those who are being coerced into placing these lines against your best judgement, Micki Dawes said it best at AVA, "bacteria don't know how long the catheter is". Catheters don't cause infection, bad practices do.
I am willing to trial these catheters for a few select patients but don't see this practice as a panacea.
D. Cole
Please do NOT confuse the midline tip location with the midclavicular tip location. They are not now and never were the same thing. Midline line tip location is in the upper arm level with the axilla in either the basilic or cephalic vein. Midline is NEVER in the axillary vein. Midclavicular is in the middle of the clavicle in the axillary vein and this tip location is the one with the greatest risk of thrombosis. I would readily admit that we need more outcome data on midline tip locations, but I also strongly believe they should be an accepted type of vascular access. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
We have just begun our trial of the Powerglide. Can anyone shed some light about flushing intervals? I have read that they only require flushing q 24h but the product information states q 12h or per facility policy. Any thoughts?
This catheter is managed just like any other midline catheter. Flush and lock immediately after each infusion. If used for continuous infusion, there is no need for routine flush and certainly no lock that is required. There is no need to flush and lock any catheter other than when it is used for intermittent infusion. If there is no infusion therapy prescribed, remove it immediately. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I have been working in vascular access since 2006 and have learned a tremendous amount of knowledge coming from the floor as bedside nurse. There have been times when the patient requests a midline for home Vanco and the IV nurse that was refusing to place it was told that she was being a "barrier" to patient care because the patient wanted the midline over the PICC after the education was given about the appropriate device that needed to be placed. This is the same as when the MD orders a midline for vesicants and the IV nurses refuse to place it. It says clearly in our policy that a midline is not supposed to be used for medications with a ph of less than 5 or greater than 9 but our management insists that this is the patients and the MD's right to get the line that they want. What would happen in a court of law if this IV nurse placed the midline for home Vanco and he developed a DVT, compartment syndrome or worse? The management involved insists that we are going against orders if we don't follow them, even if we know that it is the wrong order. Any thoughts or ideas on how to handle this almost daily occurance??? Thanks in advance.
Christin Dillon BSN, RN VA-BC