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JB
CXR on admission with a PORT...

Need a little help... we obtain a CXR for tip plcmt on all pt's admitted with any type of venous access except for dialysis catheters.  We've had several pt's recently with their port tip malpositioned... we've had IL BC, CL BC & IJ.  Because of this recent increase, one of our MD's has ordered us to stop x-raying his ports.  When we explained why we must continue, he said "I know exactly why you do it... but, I want you to access & use my ports but, do not x-ray them anymore.  How would you handle this?  Is there a written standard/guideline I can refer to?  Also, to compromise with him a little, what's the longest you would go between confirmation CXR's on the same port... in other words, say the pt is admitted every other month.  Would you obtain a CXR on every admission or, would you get a new one every few months?  Thank you in advance for your help.

lynncrni
 Is the chest xray on

 Is the chest xray on admission a written policy? If so, one physician can NOT alter a policy for any patient. He/she must take it back through the committee(s) that created and approved this policy. 

You also do not need to be doing the legwork to find if this physician's desires are reasonable. He must be the one to provide the hospital with the evidence to support his position to get this policy and/or practice changed to his liking 

I would not deal with this physician directly. I would take this up the chain of command, both nursing and medical, and involve risk management. I would not bend to this physician's ridiculous request, especially if this is a written policy. If you have a document to direct this practice, Joint Commission will not allow you to deviate at the request of one doc. 

Stand your ground and get others involved in this decision. 

See the INS Standard of CVAD Malposition. Secondary malposition is a sporadic event. So you must base your decisions on their clinical presentations and signs and symptoms of malposition. What does your policy state about correct tip location? Again, you can not deviate from your written policy. 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

JB
Thanks for your response!! 

Thanks for your response!!  Yes, we do have this in policy "Nurses may access and use CVC/PICC lines on patients admitted with one already in place after chest x-ray placement is confirmed".  We've passed this on up the administrative chain and found they fully support us and the policy.  We seem to be seeing a big increase in malpositioned ports.  Many are in the IL BC... it looks like they're placing these too short to begin with, but, the ones that are placed here at our hospital, have a good post insertion CXR verifying good tip placement.  I have a theory that some are D/T the position of the pt during insertion.  If they're placing these and confirming placement while the pt is in trendelenburg, after the pt sits up, the chest tissue along with the port will drop further down the chest causing the tip to be withdrawn.  I'm not sure what the solution is going to be... maybe they need to be creating the pocket closer to the shoulder?  Thanks again for your reply! 

ErikaA
Facility name?

Which facility do you work at that have as part of practice/ policy?

We have at ours as well but have been asked what facilities outside of our organization have as well..  So reaching out

Thanks

daylily
Having the same problems

How many facilities have in their policy tips of central catheters above the SVC are considered malpositioned and require exchange/replacement, etc?

We are seeing OR inserted implanted ports where the tip is upper svc.  These ports may or may not obtain a blood return.  Random chest x-rays have revealed the tip has moved into the innominate or subclavian and the oncologists are okay with its use and nursing continues to administer chemotherapy.

The 2016 INS standards have several statements but still remain non-commital regarding to use or not to use. "Avoid CVAD tip locations in veins distal to the superior or inferior vena cava (eg, innominate or braciocephalic, subclavian, external, or common iliac veins), as they are associated with higher rates of complications. Although these tip locations may be clinically indicated in rare cases due to anatomical or pathophysiological changes, the goal for tip location should be the CAJ".

Then this..... Manage malposition depending upon the location of the CVAD, the continued need for infusion therapy, and the patient’s acuity.  Collaboration with the licensed independent practitioner.

It would seem that the greatest risk for tips located above the SVC is thromosis and per research a large percentage of these are "clinically silent".

So how to we counter these providers that are not placing these catheters deep within the SVC to CAJ region when they are not "seeing" adverse events related to them other than a patient needing to have peripheral phlebotomy?

lynncrni
 Thrombosis is a big problem

 Thrombosis is a big problem but not the only problem when there is a malpositioned catheter evidenced by no blood return. Anything above the lower SVC is a malpositioned catheter. Your facility must write the detailed policy that is to be followed. INS SOP can not write that policy for each facility. Problems with malpositioned catheters can easily lead to vessel erosion and severe extravasation injuries. See SOP on CVAD malposition - 4 types of malpositioning. primary, secondary, intravascular, and extravascular. We did not create those types. They are found in the literature. I was pleasantly surprised to see the heavy emphasis on blood return in all of the references included. You may have to find those medical articles to educate your physicians about this issue. Also I would refer you to the new INS Policy and Procedure book as this resource has also radically changed as well. See the ones on IV Administration : Continuous Infusion, IV Push, and Intermittent Infusion. Assessment of patency including aspiration for a blood return is included in the Assessment section. As you are doing, benchmarking against other facilities is a good idea, however if no other facility is emphasizing positive blood return, you must be the first. This is not only INS but ONS as well. This is a risk management issue also, as it will protect you, your patient and your facility from increased legal liability when a malpositioned catheter without a blood return was used and it escaped into the chest! 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

daylily
additional comments

Can anyone provide any additional comments r/t this topic?  How often are you having an xray performed?  We could see the same patient into our ER with 24-48 hours?  Currently, if we have a documented history of insertion at our hospital AND a blood return we do not get an x-ray (this goes for all central lines) seen through the ER.  If the device was not inserted at our facility we get an x-ray.  We have radomly found malpositioned catheters or catheters high in the SVC due to lack of blood return and failed alteplase use - then x-ray (tadah?) short catheter.  We can't be the only ones with this issue....

Wendy Erickson RN
 This has been a topic of

 This has been a topic of discussion here as well.  We have always x-rayed a patient who is seen in the ED or is admitted with a PICC line in place for proper tip location prior to use.  However, I have been unable to find any references that indicate this should be done so we will be stopping the x-rays and will be assessing each line for signs and symptoms of  malposition and other complications prior to use.  If there are any concerns or evidence of malposition on the assessment, then we will request an x-ray.  

Not sure what the point is of x-raying only lines placed outside of your own organization.  Do you believe that only "other" lines can malposition? You may have access to the initial placement film but we all know that ANY line can malposition.

Wendy Erickson RN
Eau Claire WI

lynncrni
 Wendy is right - any CVAD

 Wendy is right - any CVAD can become malpositioned at any time. 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

daylily
Again frequency

 So again, what is the frequency for these xrays?  If the device was inserted at your organization, xray confirms lower SVC placement, the patient gets discharged home and comes back in 2 weeks, 4 weeks, etc.  are you having an xray done as standard operating procedure for EACH visit?  Now, this could be through the ER or a direct admission from the doctors office.  Let's say there is no problem with a blood return on each return to the hospital......just need some clarity on how many times a patient is going to receive an xray when there are no other clinical symptoms.

Wendy Erickson RN
As I stated, we are doing

As I stated, we are doing away with getting x-rays since there is no evidence to support this. But a nurse MUST assess the patient for signs and symptoms of ANY complication including migration of the catheter tip. There is no recommendation anywhere to ever re-xray a patient with a central line after the initial placement confirmation.

Wendy Erickson RN
Eau Claire WI

lynncrni
 Wendy, your statement goes a

 Wendy, your statement goes a tad bit too far. The 2016 INS standards now gives criteria for signs and symptoms of malposition and the diagnostic tests that are used to confirm the problem. It also states that routine chest xray at specific intervals may not identify the problem. So clinical signs and symptoms could easily indicate the need for a repeat chest xray or other test. 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

Wendy Erickson RN
I just didn't state it

I just didn't state it correctly - we DO get an x-ray if our assessment indicates any signs and symptoms of malposition. What we are discontinuing is the automatic x-ray on any patient admitted with a port or PICC already in place.

Wendy Erickson RN
Eau Claire WI

dfritz
Incidence of tip migration

Does anyone have any published references on the incidence of tip migration for cvc's as either an aggregate or for specific types of lines, e.g. PICCs? I see a lot of published case reports, but incidence is hard to come by. Or, in lieu of PUBLISHED sources, have any of you collected data on your own population of patients for any quality type studies where incidence was documented? I am having a hard time concluding that CXRs for all CVC patients coming through our doors justifies radiation exposure and expense. One article I looked at recommended all PICCs and "undocumented" CVCs (assume that meant placed elsewhere). Just trying to come to a sensible conclusion. Definitely would XR if symptoms of migration.

lynncrni
 Check reference list from

 Check reference list from INS SOP CVAD Malposition. I did that lit search, don't remember any with stats but maybe some. I have changed my thoughts on this issue of admission chest X-ray. Since this is such a sporadic occurrence, admission xray may or may not catch it. Could happen during admission and all nurses need to know signs and symptoms of migration and what should be done. We may need some criteria for when it is needed and when it is not. Thinking about the chance that a CVAD may not have been at CAJ on insertion, any changes in external length, etc. 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

dfritz
CXR on admission

Lynn, I'm glad to hear your thoughts . . . that echoes my own thinking. If we could identify risk factors for this, e.g. oncology patients who had had a hard time with chemo and had been vomiting a lot, or a combination of line factors (would softer catheters [silicone--SL tunneled Groshongs] be more at risk vs. "power" catheter) and patient factors, then I would be more inclined to CXR for those at highest risk. But with the lack of data, I'm not convinced this should be a standard practice. Certainly if patient has symptoms, yes, find out what is wrong . . . I would agree with what you've said. I will look at the references as you have suggested.

lynncrni
 There is one situation where

 There is one situation where some may need to do an admission xray - if you know there are contracted services or facilities in your geographical area that are not attempting to place PICCs at the CAJ. I know there are companies still using suboptimal position on purpose. For your list, you should focus on all activities that increase intrathoracic venous pressure. I have never seen anything comparing risk between catheter materials. There is documentation that power injection causes movement of the catheter though. 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

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