I get the priviledge to orient a nurse trained by IVR doctors to use their IVR kit to place PICCs. I know that it is not safe to use the very long guide wire from kits used by doctors in IVR. I have heard that this particular nurse is resistant to using the RN kits. Is there anything in print that discusses the hazards of blind use of long guide wires to place PICCs at bedside. Thanks, Mary
Check the Infusion Nursing Standards of Practice on VAD Selection and VAD Preparation and Insertion. I can't remember what the statements are but I am sure there are statements pertaining to guidewires. 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, I'll check.
I was trained at a major medical center here inChicago
Thanks for the comment Constance. I do have an additional question for you. Are you taking these IVR trays to the patient bedside? It is my understanding that they are not "bundled" as recommended for bedside use. As nurses working alone at the patient' bedside I have concern about ability to really control such a long wire with a small amount in the patient and always KNOW that it has not gotten contaminated especially in a patient room where space isn't as open as IVR suites are. Thanks again, Mary Penn RN
There are options in PICC insertion trays for shorter wires. You concern is well-taken and I would not want to use these long wires at the bedside since they serve no real benefit and they can easily be contaminated. 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
Like with any product, it’s what you get comfortable with. It was how I was taught and the cost saving advantage is big. The proof is in the practice, no early onset CRBSI at the major medical center where I trained or at the community hospital where I place 1200 PICCs a year at the bedside. Maintaining control of the wire is a must no matter where it’s placed or how long it is. We shouldn’t be cutting PICCs with scissors either, but that’s what almost all manufactures put in the tray and we use them. You need to know why you are doing what you do and monitor your outcomes. No adverse advents with the long wire and it has saved my organization a lot of money. In the end keeping cost down keeps the vascular access nurse at the bedside in a part of the country where vascular access nurses are being cut at alarming numbers.
I can't agree more with you Constance. When we talk about other subjects in medicine, we'd like to say we are evidence based. When we talk about about using long wires to place PICCs, we don't since we already jump to the conclusion that it is not "safe", it causes "contamination"... I have the same experience as you. I was trained by nurses from IR and we have very good control of our guide wires at bed side. We have an extremely hight success rate ( no numbers but needed IR assistance approximately one to two times each month) and low infect rate ( one infection in a year with over 1000 line placement). I bet if we have the money to do a study comparing using long wires by well trained PICC nurses to short wire with other PICC nurses, the result will talk itself. As of now, a lot of nurses are using the long wires but are afraid of talking about it since we are not suppose to...
No organization is telling nurses that they are not suppose to use these long wires for PICC placement at the bedside. I just checked the INS Standards of Practice, which is the legally authoritative document to which you will be held accountable, and there are no statements about the length of the guidewire. If you have a proven track record and were taught by IR, then proceed with what you are doing. However there are numerous situations in numerous facilities and numerous PICC inserters where this would not be the best choice. I would not teach a new person to use these long 130 to 140 cm wires at the bedside because they were not designed for that location and there are risks associated with contamination and insertion into the thorax without fluoroscopy. 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
Lynn,
I was trained using a 80cm galt nitinol wire, when after assessing the H&P I anticipate the possibilty of difficulty upon catheter advancement. I prefer catheters with beveled tips, so I do not trim my catheter.When I advance the catheter I have approximatley 15cm of wire extending from the end of the catheter (the hub end). although I do not free wire, It seems that the blunt end of a trimmed catheter would have a greater potential for vessel damage than the floppy delicate tip of the nitinol. I have place a great number of PICC's, and I find using the nitinol enhances my success rate, I have never had a negative outcome related to traumatic insertion, and I am generally able to advance the catheter on the first pass. I believe all that retracting and advancing of a catheter, time and again, "destroying the vein" during a catheter placement is avoidable when using a flexible, yet sturdy wire. I would not care to use a wire any longer than 80cm due to the possibilty of contamination, but I do like to have enough wire extending my catheter to know I have control of my wire.
Margie Hood RN
How far do you typically insert your wire? How are you sure to maintain standards in keeping the wire peripheral?
What standards is it to say the wire has to be peripheral? I just make sure my accessing wire doesn't go beyond subclavian and I load my long wire in the catheter after I trim the catheter to the measured length. When I have to exchange a catheter, I insert the wire all the way to where the catheter tip is and remain it there while threading the new catheter. The wire thus goes into SVC obviously.
It is very easy to control a "long" wire at the bedside, simply only pull out what you need, and leave the rest coiled in the plastic coil it comes in. There are no "rules" regarding equipment, it is critical thinking and logic. Do you want to insert a wire when you have no idea of where it is going? In IR, flouro is used, so the inserter can see were the wire is at all times. Also, the wires that are made to go into the central circulation have a floppy tip at the end, so they are atraumatic to the vessel when used properly. If you can't see where the wire is going (with flouro) they you don't want to risk it leaving the vessel you are placing it in, therefore you don't want to advance it more than 15-20cm, before the vessels join to form the axillary vein.
There are still many facilities that don't have a kit and pull each item they need to place a line, every line, not just PICCs. Is it more difficult, yes, but it certainly does not mean you need a kit "labeled" for bedside or nursing use.
Another recommendation---ASK for what you need! Many times the people deciding what to purchase do not understand that the same items are not used in every situation, or do not understand everything that is needed for a procedure. It never hurts to ask, the worst that can happen is you may be told no.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
I agree with you Chris, I too have used your suggestion. Wires also have markings on them so you know how much you are advancing into the patient. I do use an IR tray but I don’t pull everything separately. I use a max barrier kit made by DDI, it has everything in it but the PICC. Medline and Cardinal make these max barrier kits too, they cost from $26-32.00 In the system I work in some of hospitals PICC cost is $300.00 while mine is $125.00. With PICC team dissolving at alarming rates in the Midwest we all need to be looking for ways to save money for our organizations without compromising outcomes.
When I ask interventional radiologists if they would be comfortable inserting long wires without fluoroscopy they all say no. "Great" anectodal results should not drive practice, safety should. If something were to go wrong with these long wires during insertion, I feel you would have an indefensible legal exposure. But each of us has to be comfortable in our own practice.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
I don't know if the interventional radiologist would feel comfortable placing PICC lines without fluoroscopy at bedside at all. What had gone wrong with long wires during insertion so far? I have known a lot of well trained PICC nurses placing PICCs at bedside with long wires. I agree very much that nurses who doesn't feel comfortable with long wires at bedside should not use it.
Emily, I did not ask if they were comfortable placing piccs, I specifically asked about wires. What can go wrong? As a nurse utilizing guidewire technology I am sure you are aware of potential complications, guidewire perforation of great vessels has been reported but admittingly is rare. There is a reason why most IR departments request coagulation studies on patients and will often refuse procedures with an INR above 2.5, and that is with fluoroscopy! I understand wanting to defend your practice as you learned it, very similar to MDs wanting to defend non-emergent CVC placement without ultrasound or suturing lines in place. But the human desire to defend how we learned something should not over-ride your responsibility to the patient. If an untoward event were to happen it would be very easy to line up multitudes of expert witnesses stating why your practice is dangerous and not sanctioned by an overwhelming majority of your peers, in prior years I may even have been one of them. Radiologist's would testify they always use flouro when advancing long wires and nurses would testify that there are bedside kits designed for non-fluoro insertion. You would be hard pressed to find anybody that would testify to the safety of this practice. Most instructions for use on the PICC kit itself say do not advance long wires without the benefit of fluoro! I did a very quick search and found this quote from Case Reports in Critical Care Volume 2011 "Nevertheless, the literature reports cases of guidewire-related perforation of the great vessels including the brachiocephalic and subclavian veins [4]. This important complication occurs when excessive force is applied against resistance when introducing the guidewire, especially if the straight or angle tip wire, rather than J tip style wire, is used. In most instances, bleeding from a small penetrating hole in a vein will stop spontaneously by vasospasm or by external compression of the surrounding tissues [4]. However, serious cases of hemothorax, including fatalities, due to the above complication have been reported [4]. Making a timely diagnosis in such cases requires maintaining a high index of suspicion when there is an unexplained drop in hemoglobiIn or the development of unilateral pleural effusion ipsilateral to a recently placed or attempted central venous catheterization. Treatment of a serious perforation may necessitate the insertion of a chest tube or an emergent thoracotomy..."
I generally do not like to determine my clinical practice by litigation risk, we all assume some risk as liscensed professionals, but in the case of long wires at the bedside, it does not pass the litmus test which is basic to most scopes of practice. Is it reasonable and prudent to do? The answer "that's how I learned it" does not hold up.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
I strongly agree with Stephen. He is correct on all points. The primary way to prevent being named in a lawsuit is to use appropriate risk management strategies. One of those strategies is to use equipment that is appropriate for the specific setting. Catheter instructions state not to use the long wire without fluoro. So you are held accountable to those instructions. Those instructions would be one document to establish the standard of care in a lawsuit. I would be one of those experts locating these instructions and testifying about them, along with other pieces that established the standard of care, which would include the studies like what Stephen cited. Vessel perforation, wire fracture and embolization, thrombosis, cardiac arrthymias are among the possible problems. For this to progress to a lawsuit, the patient must have damages. Actual damages from these events could be severe tissue damage from hematoma or fluid/med extravasation if the vessel perforation was not detected. Severe thrombosis can produce so much edema that nearby nerves are compressed producing complex regional pain syndrome. Wire emboli requires removal. You get the picture. So think in terms of risk management and you will not be in a lawsuit. 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
Stephen, I have hesitated for a few days before I decide to reply to this topic again. I realize that it is not going to change anybody's practice at this point by debating it here. But I feel obligated to reply once again to clarify a few things since this could give some nurses who consider themselves as experienced or even expert in some specialty a wrong impression.
When you are trying to decide the risk of using the long wires, you have to at least take a look at the wire and know what it is before you make the comment. We as PICC nurses are not going to the bedside with a bunch of wires to choose from. The only wire using at bedside PICC placement I have seen so far from this forum is the floppy tip wire, Nitnol or others, 80cm or 135cm. Anybody who had used these long wires or has been using these wires would know that it is absurd to say that the wire could perforate a great vessel if you used it the properly while a catheter with stylet wouldn't which are labeled for bedside use. There was a so called clinical specialist trying to prove the long wire is risky by showing us the end of the wire with hard sharp tip. That was when I realize why should we not recommend this long wire method to everybody since there are people out there having no clinical judgement at all and would insert the sharp tip of the wire to the vessel instead of the floppy tip. The risk of harming patient will always exist if you don't know how to use yourr equipment properly. Same as using ultrasound, if you don't know how to use your ultrasound properly, you could cannulate artery or you could cause nerve damage while with much less risk without using ultrasound although with multiple sticks. But should we go back to blind sticks? The answer is no. Since the use of ultrasound had proved to be safer for the patient and more efficient. Don't you want to know why anybody who had used the long wires wouldn't want to go back to short wire method? Not all of us were trained to use long wires from the begaining but a lot of us decide to use long wires once exposed to it since it has better outcome for the patient. We have higher success rate and less readvancing. There has been no literature about this data since most of the nurses who are using the long wires are so intimidated to even admit that they are doing so just because they would be threaten that he or she can be sued simply because of this. But you would rather have more patient going through malposition and unsuccessful placement but still insist it since it is the text book and you can easily wipe your hands clean when something happens. Practice changes and technology evolves as time goes by toward a more optimal patient care outcome. Something you strongly against today may become the standard of practice tomorrow.
I am thrilled to any new technique as long as it benefits the patients. Comparing to the short wire technique, I don't really know which one is more advanced. If the short wire technique is proved to be more advanced and benefits the patients more, I can change to short wire+stylet tomorrow. That is actually what I have to do when the long wire is not available. But at the same time, if the long wire is proved to be better, I will not recommened you to learn it since I get it if you are frightened already by the idea of using long wires and even refuse to look at it.
One more thing, next time when you talk about long wire, the most commonly seen complication associated with the use of long wire is arrythmia if the nurse can't manage the wire properly instead of perforation of the the vessel or even contamination.
Emily, you are seriously misinformed about one thing. A lawsuit will not be filed just because the long wire is used at the bedside. For a lawsuit to be successful, there must be 4 elements- 1) duty owed to the patient, 2) a breach of that duty, 3) causation, and 4) damages or injury. So just becaue someone did not follow the instructions for use and used such a wire outside of fluoroscopy, the patient must have damages, and those damages must be caused by the actions of the healthcare provider. Those of us who began placing PICCs in the early days (i.e., 1981) can certainly appreciate how far the technology has come and we don't want to go backward. However, the better outcomes with the use of long wires at the bedside are only ancedotal information at best right now. I am not aware of any published study showing better outcomes with this procedure at the bedside. And there are definitely questions of safety. If a patient suffers damages and brings a lawsuit, there are methods to learn what device was actually used regardless of whether the individual states that is what they used or not. 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
Hi Lynn, I appreciate your reply. When there is a lawsuit about long wire used in PICC placement, do we want to find out if it is the individual practitioner's lack of prudent judgement or if it is the using of the long wire made the risk unavoidable? I agree that there are risks associates with the use of long wire. Arrythmia for example can happen quite often if you don't really know where the tip of the wire is and fluoroscopy can prevent it to happen in most cases. That is why, we load our wire in the trimmed PICC catheter with the tip inside before advancing it into the vessel. But perforate a great vessel by the floppy tip wire just sounds so bizzar. If a wire can perforate a great vessel, how is fluoroscopy any help in this situation if someone decide to advance the wire brutally?
I also agree with the fact that there are no published study about the higher one-time-success-rate of PICC placement with long wire. But somebody has to use the long wire to collect data. If we are not allowed to do it this way, how can data be collected at all?
But overall, I appreciate this discussion and would be very thankful if you can give me some information about the literatures about the risks or damages associated with long wire for PICC placement. I would like to know them and prevent them in my own practice if there are potential risks that I am not aware of.
Emiily why is fluoroscopy needed for long wires. Vision real time my friend rather than being blind. Safety ois a number one factor in following IFU's. Ask a interventionalist who will testify against the perptrator if they would perform such an action at the bedside iwth no fluoroscopy.
kathy
Just to add a side note the length of a 135 cm wire is the height of a four foot child being used at bedside with no flluorocopy
kathy
Your comments are quite professional and any prudent nurse should appreciate your patient advocacy and your easily noted expertise. I agree with 100% with your comments.
Thank you
Margie Hood RN
INS Standards has no advice on lonbg wires but manufacturer instructions for use have advice on use of wires that are long outside of fluoroscopy. Teleflex has it laid out the best in their instruction for use as they state anything over 80 cm cannot be placed without fluroroscopy and last I heard no one had fluoroscopy at the bedside. So if you are placing these long wires not under fluoroscopy and the patient suffers an adverse event you are practicing outside of the iinstruictoins for use of the product and that you will be held responsible for regardless of your policy and procedure. The Bard instrucitons state fluoroscopy for the long wires in the instructions for use as well Standard of care is not with the long wires without fluoroscopy.
Anyone using long wires outside of fluoroscopy are subject to instructions for use of a product and standard of care. I would not recommend that anything 80 cm and above be used without fluoroscopy. Nurses using these wires under fluoroscopy is not an issue as long as their practice act allows it. I highly congratualte the Teleflex instructions for nuse in this issue as they are laid out the best
Kathy Kokotis RN BS MBA
Bard
I love an 80cm. galt nitinol. I have not seen anyone use a longer wire outside of SP. I have seen INS guidelines associated with the use of a wire taken out of context to promote sales of certain products. I love the Teleflex catheter. My opion is non-bias, I am not on any vendor payroll, I like to do my own research. I don't like being spoon fed information, although I listen and respect other practitioners opinions. I have used many different types of catheters. I have never seen Teleflex bend the rules.
Margie Hood RN
Just to let you know the 135 cm wire has often been cited at the bedside all over the United States. I realize Margy you have not seen this however there are plenty of practitioners utilizing 80 cm and longer wires without fluoroscopy at the bedside. Doing Seldinger technique at the bedside withour fllouroscopy.
This is an off label practice just as adding a second wire is not in the instructions fo ruse in any PICC product I have ever seen on the market. just as pulling back a PICC and not re-xraying is not in any instructions for use i have ever seen on a PICC line
We have many practices that might be considered not in complicance with instructions for use
Policies and procedures in hospitals should be written in accordance to manufacturer guidelines and INS Standards, CDC Guidelines etc.
I love the magic pull back numbers facilities have for no re x-ray. Have yet to find one of those magic numbers in an IFU or stiff wiring (adding a second wire in an IFU) / instructions for use
Kathy Kokotis RN BS MBA
Bard Access Systems
Just to let you know the 135 cm wire has often been cited at the bedside all over the United States. I realize Margy you have not seen this however there are plenty of practitioners utilizing 80 cm and longer wires without fluoroscopy at the bedside. Doing Seldinger technique at the bedside withour fllouroscopy.
This is an off label practice just as adding a second wire is not in the instructions fo ruse in any PICC product I have ever seen on the market. just as pulling back a PICC and not re-xraying is not in any instructions for use i have ever seen on a PICC line
We have many practices that might be considered not in complicance with instructions for use
Policies and procedures in hospitals should be written in accordance to manufacturer guidelines and INS Standards, CDC Guidelines etc.
I love the magic pull back numbers facilities have for no re x-ray. Have yet to find one of those magic numbers in an IFU or stiff wiring (adding a second wire in an IFU) / instructions for use
Kathy Kokotis RN BS MBA
Bard Access Systems