Our facility has started putting in the extended dwell catheters (Powerglide) out of shear necessity for a longer catheter. Our facility has chosen not to place Midline catheters in the past and do not have a policy so far although that may change. I am aware that an Extended dwell catheter (8cm or 10cm) may or may not be a midline catheter (depending on whether the tip is at the level of the axilla). I am working on policy that will guide placement of the Extended Dwell catheter (placed mainly due to depth of vein). We currently do not D/C patients with these catheters or have a midline policy.
Questions:
Is an order needed for a longer peripheral catheter or just clear documentation about depth of vein justifiying the catheter length inserted?
If one was to place one of these longer catheter higher in the arm thus defining it as a midline - is an order thus required? If one did not set out to place a midline but only acquire a PIV for acute medical management, is an order required?
Is a consent required for placement of a Midline? What about an Extended Dwell PIV placed out of necessity for vein depth?
I would be grateful for any advice or feedback and any sample policies you may have to help as I try to create these new policies and practices within our facility.
Thank you
You may want to ask these questions of your Risk management and/or legal department. They may have concerns regarding placing a catheter that you do not currently have a policy for care or insertion. They would be the ones to answer your questions about wether an order is needed in your state or facility, and if consent is needed.
There are no national regulations or guidelines that address these questions, and practice varies facility to facilty and state to state.
In some facilities, you do not need a concent to place any catheter, it is part of the hospital care that the patent already consented to, in others, there is a consent needed for every procedure. You need to find out how your facility wants to handle these situations and write your policy accordingly.
Good luck
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
First off you need patient consent to place any IV regardless of type. Informed consent
A midline is a peripheral IV catheter. A peripheral IV may now as far as the new INS Standards and position paper (2011 & 2012) remian in place until complicaitons. CDC is still 72 to 96 hours so I would address that as well in your facility for the consenting process. Personally and this is a personal opinion, PIV's are not placed sterilly and this makes me a little edgy on extended dwell of a PIV done with a non steile but no touch supposed technique. But that is personal issue I have. I am not sure where the INS Standards committee fell on the voting of that one for a non sterile procedure and extended dwell time. Midlines although max barrier is not recommended in CDC or INS is a sterile technique and set up as a sterile procedure. Masks, sterile gloves, fenestrated sterile drape, sterile ultrasound probe sheath and gel, CHG prep. it is a sterile insertion and I fee way more comfortable in that for a longer dwell than a no touch PIV technique done by a staff nurse. It is a personal issue. INS Standards differ from my personal opinions.
Consents are detetmined by state regulations so refer to your risk management, who would know the state regulations. I see this consent as being similiar to a peripheral IV consent since you may place a peripheral IV anywhere along the arm. PIV's are often under blanket consents on admission but I would refer to risk management or legal for guidance. Dwell time is another issue. If you have already changed your dwell time on peripheral IV's to meet the new INS standards than I see no difference in consent for either device since both may now stay in for under 30 days. Should your institution require a consent for a midline I have not found an institution that denied one thus far in four months. The doctors love going back to midlines. They are approving protocol decision-decision making on whether to place a lower or arm arm PIV/midline and leaving it up to the placer. It is a periphral vessel which nursing has always since 1960 (for the most part) had some decision-making power in. I would add lidocaine to the protocol as sometimes it is a good thing. I hate pain by the way and needlesticks. I ran away from home as a child, due to going to the doctor for my polio vaccine. They were IM in the old days and I am old. My dad found me under the basement staircase. I did not get very far and got the shot.
Kathy
I'm sure you have them, but just in case you don't, here are the 2011 CDC guidelines that may help you with your own policy.
http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Frank
As far as I am concerned a powerglide is a midline catheter. greater than 3 inches is usually considered a midline. I undertand the need for extended dwell catheters, they have their place, but are often misused. In the past month, I have been called to assess lines that came from hospitals to extended care facilities. The staff are not aware of these lines. 9 lines that I have assessed were poweglides. I think that they are placed in hospitals for power injection. 8 out of the 9 lines I have seen were kinked within the veil. As I removed them due to inability to flush or aspirate I noticed that they are kinked in one or more places. First of all I think that they are too rigid. The literature states that they soften once placed. I have not seen that. I believe that they are kinkied because they are place too high in the upper are. 8 were placed in the Basilic or Brachial veins. The only catheter that was still functional was one placed in the Cephalic of the upper arm. With arm movement the others became kinked. The memory of these catheters leave a lot to be desired. Once kinked they are no good. Also, I have gone throught the charts and noticed that they are being used for drugs that should not be infused peripherally. One patient was getting three drugs via a powerglide, one which was Vancomycin.
The company I work for requires an order and consent for extended dwell catheters. Also there needs to be a policy in the facility for use of midlines. As far as I know there are no true power injectable midlines on the market, only the Medcomp which is approved for MRI, not CT injections. I have seen some facilities cut a power picc to a midline for use as a power midline. I don't believe that this is a good practice. I would think that if you were going to institute a power glide policy that you would also include it in a midline policy. Some hospitals that I have been on PICC teams don't do midlines, because they are misused. Strong staff education is needed for midlines in hospitals. The doctors also need education on drugs not appropriate for midline use. It's a battle but slowly we are educating NP's and MD's on the use and misuse.
Warren Willard, CRNI, VA-BC