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Wendy Erickson RN
ECG Tip Placement "trumps" xray reading?

We are just starting Sherlock 3CG technology and are loving it. However, one of the patients we placed a PICC in using ECG had a chest xray done the following day for other reasons, but the radiologist noted that the tip was in the right atrium and needed to be withdrawn 4 cms. If the PICC nurse assesses the line and there has been no migration in/out, does the ECG trump the radiologist's read of the film? If this is your practice, how/what do you document? Is this included in your protocol/policy? We are suspecting that this will occur frequently and I have contacted our IR docs to get their input, but wanted to see what others are doing in this situation. Thanks in advance!

lynncrni
 Are you certain that the

 Are you certain that the nurse interpreted the P wave correctly? Was it biphasic indicating RA location? Was there an adequate P wave or did the patient have some type of cardiac issue preventing a reliable P wave? Did you place a printed copy of the tracing on the patient's medical record? In my opinion, this is needed to adequately document correct tip location. Without this, it is just the nurses assessment at the time and her/his recollection if there should be any later question. ECG, correctly assessed, is usually considered to be more definitive than a chest xray. The xray interpretation can be very subjective and depends upon the patient position, skills of the rad tech, and quality of the picture. All the responsibilities of the inserter must be included in p&p. And the inserter is held accountable for the outcome of the procedure. Expansion to ECG requires thorough knowledge of how to correctly use the ECG including interpretation of the tracing. your question about one trumping the other is a question that must be decided by the appropriate committess in your hospital and this should also be included in P&P. I hope it does not come to a decision made by a court in a legal case, but that is also possible down the road. 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

Random VAT person
I too have had the problem. 

I too have had the problem.  I gave the radiologist a copy of this form and I have no problem now.  :)

 

http://www.avainfo.org/website/download.asp?id=164428

mary-ivt
Chest x-ray reading "different" than ECG

We have had all kinds of crazy reads.  From the mid brachiocephalic vein to just tipped in the R atrium.  I went down to radiology for the first case and showed the radiologist that the PICC reappeared in the x-ray and ended very distal.  He agreed.  When the radiologist said it was tipped into the R atrium, I always call and ask how much they want it pulled back and ask for more specifics.  The answer is usually, it does not need to be pulled back and that it actually appears to be at the CAJ.  We have been educating that that is exactly what we want.  We are now getting better reads with better communication.

One thing our trainer mentioned to keep in mind for some of the ones that appear several cms in the R atrium.  The wire tends to slide easily.  You are only detecting the wire, not the PICC tip.  We secure our wire after it is trimmed and bent with a piece of our sterile tape to the hub.  This assures that the tip of your wire stays in the tip of your PICC making your ECG reading accurate.

We had a case where one of our nurses was in a little bit of a hurry with a discharge PICC and forgot to tape the wire.  The next day the young adult came in to outpatient IVR with palpitations.  Under fluoroscopy the PICC was visualized well into the R atrium.  Remember the ECG/tip placement is only as accurate as your wire is in the PICC.  Try securing the wire with tape and see if some of your issues don't go away.

We are very happy with our ECG system.  I have a very stong telemetry background and use both afib and especially aflutter to guide my PICC before getting my CXR.  Only once with a very chaotic afib did my PICC end up in the R atrium.  A simple pull back and I was done.  Every other time I have still ended right at the CAJ.  Amazing system. 

Mary Penn RN  Vascular Access Team

St Charles MO

lynncrni
 Do you plan to ever stop

 Do you plan to ever stop doing routine chest xrays on every patient when ECG has been used and is confirmed to be at CAJ? 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

mary-ivt
Stopped using CXR

 I am sorry LYNN.  I failed to be very specific at mentioning that we only did two months of this before we STOPPED getting chest x-rays. We have been using the system for almost a year now.  I do think it was obvious that my mention of afib/fllutter and confidence of our placements even before we get chest x-rays would have indicated we had moved beyond and that my remarks were from our learning phase.  Note the others comments in agreement with my experience with the wave forms.  I think everyone who starts using this system should have a side by side comparison even if just for building their own confidence.  I still take a peek at pt's chest x-ray when I have a chance and especially if I think the peaked p wave is okay but a little odd.  You NEVER QUIT LEARNING.  There are times I still stand at the bedside and try to figure out how I am going to get the PICC to go down.  I have a question for you LYNN.  Is it your job to police and try to demean every thing people that are trying to learn from this site say or do?  When was the last time you actually practiced at the bedside? Quit nitpicking.  That is not what this website is for. 

lynncrni
 I am sorry if you consider

 I am sorry if you consider my comment to be nitpicking. and your message was definitely not clear about what you wrote regarding ignoring orders to reposition a PICC. I was simply pointing out the realities of life in healthcare when things go wrong. I definitely do not think my message was written in a demaning manner and I am sorry if you read it that way. 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

mary-ivt
Stopped using CXR

 Excuse me Lynn.  There is nothing in anything I have written on the matter of ECG guidance that said that I ignore radiologists orders.  Please reread my comments.  I said I have talked to them, discussed it, mentioned that they said no repositioning needed. I also mentioned that I charted a note of discussion if I was concerned that the radiologist might not go back and reedit his read.  I also never said that my x-ray reads said to pull back.  I don't always have time to go back and recheck edits, but I do thorougly chart.

If you wanted to clarify if we were still doing chest x-rays why not just ask, "Are you still doing chest x-rays?"  That is the way you talk to adult learners.  Not "do you plan to ever stop doing chest x-rays".  Maybe you need a refresher course in education with a focus on adult learners. 

Random VAT person
I agree with Mary,   I use my

I agree with Mary,   I use my ECG system even in afib and aflutter for placement.    Of course we always verify only with the chest xray but so far all of them have been at CAJ.  Great system.

Saharris
Saline Not Wire

If I am not mistaken I believe it is the saline that carries the electrical signal in the intracavitary lead not the wire?

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

lynncrni
 I don't think so based on my

 I don't think so based on my interpretation of the Bard IFU. 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

Saharris
Saline

Right out of the Bard IFU.

"At this point, the catheter may need to be flushed to stabilize the waveform. If necessary, attach saline-filled syringe. Flush catheter with saline and wait for intravascular ECG waveform to stabilize."

It is the sodium ions that carry the electrical signal from the SA Node not the wire. Maybe Kathy Kokotis could she's some light?

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

lynncrni
 I read that as a possibility

 I read that as a possibility but not a requirement. There are studies that do use only saline without a wire. With the Bard and Teleflex devices, I am pretty sure they are relying on the wire for the signals with the saline to augment if necessary. 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

Wanda Warren RN
Bard Sherlock

I found this on one of Bard's web pages. "It operates by detecting the slight magnetic fields generated by the pre-loaded stylet in Bard Access Systems' PICC kits marked with "

Saharris
Saline

Having placed multiple catheters using this technology I will say this, if you place the PICC "dry" you will not get a waveform. It won't work. The Sherlock will work, the ECG will not.

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

jill nolte
hmm

Our Bard trainer explained the saline column is the "third lead" that produces the wave form. 

Wendy Erickson RN
Update: Interestingly enough

Update: Interestingly enough (and not surprising) was that an xray the following day showed the tip at the junction, and we had not repositioned it at all.
My question is to those of you using ECG guidance and who are NO LONGER doing chest films immediately following the insertion. What do you do in situations like this where the radiologist reads an xray and indicates the tip is "malpositioned"? Do your radiologists report the location of the tip (in right atrium), but don't say what to do about it, i.e. pull back 4 cm? Do you then make the determination of what to do based on your assessment of the line? Does anyone know of any research about this specific situation?

Wendy Erickson RN
Eau Claire WI

nancymoureau
Update: Interestingly enough

Hello Wendy and all,

This is a great question and discussion on what to do if and how to deal with a one dimensional xray that is open to interpretation and varying interpretations by different radiologists.

The issues:

1. Arm movement 1-4cm change in position,

2. Varying interpretations by radiologists at different times

3. Does real time positioning provide enough legal protection to assume no repositioning is needed when xrays are intermittently performed?

4. Will we be able to check position intermittently without extensive wires and set ups??

I see the discussions have touched on how the electrical impulses are conducted. In fact the electrical impulses do move through a wire AND through the saline column. The website www.romedex.com also provides some good discussion on how the SA node transmits the signal. Multiple new devices will be on the market in the next year or so that solely use saline. The paper Glenda Dennis and I published on EKG and application to PICCs/CVCs describes that process. The original pacerview was a connection to the catheter, a needle into a rubber catheter cap and an alligator clamp. the whole system is rather easy, we in our need for machines and technology have made it very expensive when only a monitor, a couple leads and connectors are needed to see the internal EKG rhythm and maximum p wave. Read Mauro Pittiruti's articles for clarification.

In answer to the original question, documentation and validation is needed to protect the hospital. We need a system that can recheck easily and inexpensively, anytime there is a question. Just my thoughts!

Oh, and by the way PICC Excellence will have an EKG training program designed for PICC/CVC application released in the next week or so. Check out our other 19 educational programs.

Warm regards to all,

Nancy Moureau

[email protected]

www.piccexcellence,.com

Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com

nancymoureau
Update: Interestingly enough

Hello Wendy and all,

This is a great question and discussion on what to do if and how to deal with a one dimensional xray that is open to interpretation and varying interpretations by different radiologists.

The issues:

1. Arm movement 1-4cm change in position,

2. Varying interpretations by radiologists at different times

3. Does real time positioning provide enough legal protection to assume no repositioning is needed when xrays are intermittently performed?

4. Will we be able to check position intermittently without extensive wires and set ups??

I see the discussions have touched on how the electrical impulses are conducted. In fact the electrical impulses do move through a wire AND through the saline column. The website www.romedex.com also provides some good discussion on how the SA node transmits the signal. Multiple new devices will be on the market in the next year or so that solely use saline. The paper Glenda Dennis and I published on EKG and application to PICCs/CVCs describes that process. The original pacerview was a connection to the catheter, a needle into a rubber catheter cap and an alligator clamp. the whole system is rather easy, we in our need for machines and technology have made it very expensive when only a monitor, a couple leads and connectors are needed to see the internal EKG rhythm and maximum p wave. Read Mauro Pittiruti's articles for clarification.

In answer to the original question, documentation and validation is needed to protect the hospital. We need a system that can recheck easily and inexpensively, anytime there is a question. Just my thoughts!

Oh, and by the way PICC Excellence will have an EKG training program designed for PICC/CVC application released in the next week or so. Check out our other 19 educational programs.

Warm regards to all,

Nancy Moureau

[email protected]

www.piccexcellence,.com

Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com

mary-ivt
Malpositioned? PICCs

 Wendy,

I sorry I didn't make it clear that we were no longer using CXRs.  We presented to our clinical performance committee after 2 months of side by side evaluations and it was unanimously accepted.   I kept data for a while longer on pt's that had ordered CXRs for other reasons and still check them from time to time, especially if I get an odd looking peaked p wave.  The next day's CXR was fine. It's still a learning experience.  It was during the transition time that I had discussions and more education with our radiologists.  When the radiologist would indicated a malposition I would call and ask more specific questions about location and then how much to pull back.  They would tell me none needed and I would chart which doctor I talked to and what was said just in case s/he didn't make an addiontal note.  We had discussions about the CAJ being right where I wanted it.  Most of the time our radiologists are usually pretty vague.  "Overlying the SVC" etc.  Some of our interventional radiologists that I worked with education on PICC location are now placing the PICCs they do place at the CAJ now.   We do the vast majority of the PICCs at our facility but the radiologists move to 2 other hospitals in the system that regularly transfer pt's to us so I see their notes.  I placed a PICC on one very ill pt in the ICU that had a bunch of CXRs afterwards over the course of approx 2 weeks.  Just for my own interest I followed the reports. When the PICC was mentioned at all something different was said every time, yet I saw the tip at approximately the exact same place each time.

Our little team has had no calls from radiology or doctors complaining about PICC placements since we have stopped.  Before that we had 3 problems with PICCs that appeared acceptable on initial CXRs.  One patient was asymptomatic yet a week later when a CT of chest and abdomen was done the PICC was clearly in his right ventricle,  Another pt started having ectopy.  No one contacted us.  The patient actually had an EP study in the cath lab for the doc to see the tip just past the valve into the right ventricle.  That was really sad.  All the docs discussed the CXR that the radiologist read as low SVC on a pt that had slightly increased ectopy that the surgeon thought was caused by the removal of his baclofen pump from his thoracic spine due to infection.  The cardiologist wasn't sure and asked me to pull back 3 cm.  I wasn't going to re x-ray but as soon as I left the room the pt started having long runs of V-tach. I ordered a STAT CXR and now could see the tip dangling in the lower part of the right atrium and pulled back another 4 cm.  The ectopy went immediately away.  We have not had any such problems since our ECG guidance except for the one I mentioned over not securing the wire. 

I hope this helps.

Mary Penn RN  Vascular Access Team

Saint Charles MO

 

 

 

Glenda Dennis
Thank you Nancy for your

Thank you Nancy for your comment.  I still use my Pacerview for several things such as checking the placement of a PICC tip in a patient that comes to our hospital after PICC placement in another facility, as well as verifying tip placement before power injecting a PICC.  I read the EKG from a saline column in the picc.  This means we can save the patient the radiation of a scout scan before power injecting contrast. 

That said, my choice of guidance systems is the VasoNova which uses doppler technology along with EKG.  This device is approved by the FDA which means that when I have confirmed with a blue bulls eye that the tip is in the caval atrial junction, any subsequent reading by a radiologist saying otherwise is not cause for repositioning.  I usually check the cxr myself just to see what he saw but I write a note by any order to reposition that the order is noted and I sign it.  Then I ignore the order. 

Any time that I have followed the order to pull back has always resulted in the PICC being too short in subsequent cxr so I don't do it anymore.

 

lynncrni
 Good comments, but my only

 Good comments, but my only concern is stating that you ignore a physician's order. The fact that the order was noted and no action was taken would be a huge red flag to a plaintiff's attorney. By thinking of a hypothetical situation, there could be a lot of legal trouble for the nurse. Let's say the tip was at the CAJ (ECG tracing); radiology said to pull it back by 3 cms. Nurse thinks this would put the tip in a suboptimal position in the SVC so does not retract PICC. Then patient has pericardial effusion with tamponade, cardiac arrest, lack of O2 lead to brain damage, etc. The fact that no repositioning occurred and the nurse ignored the order will be a huge issue that could cause the nurse to loose the case. I can understand your frustration with dealing with physicians who will not listen and try to understand your position, but I would strongly warn against any action that would allow any nurse to ignore an order. Each case would need to go up the chain of command for resolution but it can not be ignored. 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

PICC VAT rn
Hi we use Sapiens 3CG also. 

Hi we use Sapiens 3CG also.  We initially had that problem especially in ICU when a patient would recieve a routine xray and we had a few say it was in the RA.  Our medical director spoke with the radiologists and explained to them the technology that we are using.  They decided that they were going to read picc placement as picc stable - clinically correlate.  That pretty much means check the ECL and as long as the line has not migrated in then the 3CG placement trumps the cxr.  We have not had any issues in over a year and a half since they started doing that.  If we need an xray for picc placement (afib/paced) then they know to read actual tip because the reason for xray is picc placement.

 

PICC VAT rn
Hi we use Sapiens 3CG also. 

Hi we use Sapiens 3CG also.  We initially had that problem especially in ICU when a patient would recieve a routine xray and we had a few say it was in the RA.  Our medical director spoke with the radiologists and explained to them the technology that we are using.  They decided that they were going to read picc placement as picc stable - clinically correlate.  That pretty much means check the ECL and as long as the line has not migrated in then the 3CG placement trumps the cxr.  We have not had any issues in over a year and a half since they started doing that.  If we need an xray for picc placement (afib/paced) then they know to read actual tip because the reason for xray is picc placement.

 

jackik1
documentation for Sherlock 3CG

We have been using Sherlock 3CG for a while and just recently stopped getting Xray's when PICC's are placed appropriately with the 3CG technology.  My question is what about outpatient PICC's or lines placed in the hospital prior to being discharged with IV therapy.  In our area of North Texas at this time this technology is rather new using 3CG if we sent a copy of the waveform I am not sure they would understand what it is.  .  Does anyone get a chest xray for outpatient placements regardless and do you get a chest xray prior to sending the patient to a skilled nursing facility or home health.  As it stands now if we place a line and we know the patient is going to be discharged home with the line, we automatically get a chest xray on placement.  My concern is if the patient is discharged a few days later, how do we know that the tip is still correctly placed?  I had this concern prior to using 3CG also.  I am wondering if we need to get an xray immediately prior to discharge? 

Another question, we have been putting a copy of the 3CG waveform in the chart.  Is anyone using any other form of documentation?  Thanks

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