Forum topic

This concept of respiratory therapist placing PICCs was not new to me. I have heard about it for many years. I was not impressed with that presentation because I wanted more comparison between the different models. I firmly believe that nurses are the most appropriate professionals to place all VADs, but I can also understand why these other professionals have come to be. When nurses complain about putting in PICCs on an urgent basis, or after their usual hours, this is actually serving to discourage the hospital from placing this responsibility with nurses. Nurses have the most holistic approach to patient assessment and the most knowledge about technologies and infusion therapies. But we also have to appreciate the business side of the whole thing. That means setting up the services to meet patient needs at whatever hour or day it is required. Also, inserting the line is only the first hour. It is nursing that will be doing the management of the catheter and troubleshooting complications. So I believe this must remain a nursing service. 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

Well said Lynn!

To answer your question, this is NOT an isolated thing, all over the country, Respiratory Therapists and Radiology Technologists are placing PICC lines as well as other types of vascular access.  It depends on the state and the rules for thier discipline in that state.  Often, if there is no ruling, it falls back on the ASRT (Assoc for Radiology Technologists) or Resp professional organization which allows this.  So, if you feel strongly that you do not want this in your state, petition your board of nursing to make it a function of nursing only and petition the boards for Resp and Radiology techs to take it out of their scope.

I wanted to respond to IVRN about taking scope of practice of respiratory therapist or Radiology technologist to your nursing state board.  I live and work in Arizona with an advanced technique NURSING vascular access team.   I strongly disagree with non-nursing technologists placing PICCs.  Lynn said it wonderfully.  Several years ago, when the Resp therapy teams were coming into my sister hospitals, I fought it with my adminisitration, but they had no control over those facilities.  I took it to my state board.  Here is what the AZ Board of Nursing said in a nutshell:  "Respiratory therapists and Radiology technologists are not regulated by the Nursing State Board, so we do not have control over any of their practices." If you want them kept out of your facility, keep your outcomes, and be your patient advocate as why nursing needs to keep control of vascular access.  Each patient needs "NURSING ASSESSMENT" for insertion of the line as well as the management and troubleshooting of the catheter. 

Ann Earhart, MSN, ACNS-BC, CRNI

This almost happened here in a smaller community hospital in NH.  One RN only in radiology and no coverage for PICC insertion when I am off, other than the Radiologists....No approval for additional coverage or IV team.  Our dept chair MD suggested our chief tech insert PICC in my absence.  I did a bit of research and found that this occurs  other areas of the country although I do not believe technologists or therapists are inserting central lines in the northeast.  No state licensure require for techs in NH, and their national board states within their scope of practice while working under the supervision of a licensed practioner.  Would that be the radiologist or myself, that was unclear to me.  The board of nursing in NH states PICC insertion is an competenecy but does not define other health professional competenc.It was decided not to take this approach, but I was so suprised that this would be an individual hospital decision.   

"You need to have the other two boards understand the functions include nursing assessments and skills as well as a knowledgbase that they do not have.  They do not understand this now."  (IVRN)

 I totally agree.  However, many nurse clinicians that I have taught over the years, only wanted to learn the skill and did not realize that nursing assessment is part of the procedure whether it be placing short peripherals or PICCs.  Also many clinicians (RNs, Non-Professional Staff, Administrators outside the IV / PICC Teams have absolutely no idea that nursing assessment is very important, and only look at placing any vascular access device as a skill and want to do it as cheaply as possible.  I spend a huge portion of my time educating nurses, MDs, and everybody else that vascular access is not just a skill.

 I also agree with what Lynn Hadaway ("meet patient needs at whatever hour or day it is required"), I think we partially did this to ourselves over the years.  And also what Ann Earhart said "If you want them kept out of your facility, keep your outcomes, and be your patient advocate as why nursing needs to keep control of vascular access."

Timothy Royer, BSN, CRNI

Nurse Manager / Vascular Access

In many Radiology departments across the country, radiologic technologists place PICC lines, it is in their scope of practice under ASRT guidelines.  Your individual hospital policy can override these, if they choose to, or the start board of radiology or nursing would superceed these also. 

I wanted to re-vist this question of respiratory therapists inserting PICC lines.  It has been a few years since the last response.  I'm in New York state; is this a standard practice for most states now?

Thank you

 I would not say "most" states but respiratory therapist do insert PICCs in some states like Arizona. At INS this year, there was an abstract presentation about a team that includes Resp Therapists but this team is lead by an RN. This is because of nursing's holistic approach and our ability to do a more indepth, broadly based patient assessment. She stated that her RTs prefer this structure. Lynn

 There is no need for the personal attack on Ann Earheart,MSN,RN,ACNS-BC,CRNI on this forum. I found the comments offensive and hope that  Rich Mitchell will apologize.

I'm sorry I didn't pick that up sooner.  The sort of comment made by RM  is completely unacceptable.  Furthermore, the person under attack has been a valuable and appreciated contributor here.  The comment has been deleted from the forum and I hope deleted from your memories.

Sarah

Sarah Kuykendall, RN - retired

Web Manager

RTs are also placing PICCs in Wisconsin. As a vascular Access Specialist I see no problem this. Vascular access nurses must stop folding their arms and saying things like PICCs are not an emergency or we don’t do them in the ED. Some don’t do them if the INR is high or the patient has low platelets. We as a group have to step back for a minute -these patients need access and who better to do it. ? I have worked with nurses that work harder at looking for a reason to NOT place a PICC than actually placing them.

Then we need to step up and move to placing art-lines and CVCs. Patients need access 24/7 and RTs are in the hospital  24/7 why not work WITH them in a multidisciplinary approach to meet the needs of our patients?

 I still believe it is in the best interest of patient care and central line placement that it remains in the registered nurse expertise area.  Many hospital systems are not willing to have 24 hour service more than nurses not willing to work the night shift.  Many APRN's work the night shift in the hospital system where I work so it is not because nurses are not willing to work nights.  RN's are the gate keepers for IV access in my opinion. Where I work we are not 24 hour due to budget.

I think the multidisciplinary model of care for vascular access is exceptional!  It is not only cost effective, but also patient centric.  Healthcare professionals with the proper training, expertise, experience, and motivation have shown over time to have excellent outcomes.  I am much more concerned with the new resident (it is July) that has very limited knowledge and experience placing lines.  RT's in Arizona are also skillfully placing CVC's and Dialysis catheters.  I think we (nursing) should be less territorial and more amenable to others that share our passion for vascular access.  Nursing continues to push into realms where physicians traditionally practice and we expect them to accept us .... we should consider giving the same respect to other disciplines that are treading on what we perceive as 'our' territory.

We run a combined Cardiac Cath, EP and Interventional Radiology Lab. All our PICC lines are placed by RTs. They undergo extensive training with one of our Interventional Radiologists and have set parameters to there training cycle. We have been up and running in our new building for more than 8 years now an have had wonderful outcomes, exceedingly low infection rate and great patient satisfaction with the service.

Pat Murphy, BA, SN, RN,BC, CCRN

Cardio-Invasive Spaecialties Clinical Coordinator

Virginia

I am going to put myself out on a limb here but will tell you for the most part in Arizona which has the highest usage of RT the acute care CVC has a way higher usage than the PICC. A PICC does take more time to place therefore I am not sure how thorough the assessment decision is made. These teams tend to run 70% acute care CVC and 30% PICC. On the other hand since RN's only place PICC is that why this is a higher usage. I believe this needs to be assessed as a study to see if the patients got the right device. I am not sure what is the truth.

 Constance you are correct about most of what you said, but I have to inject here that see X, do X teach X is yesterday's news regarding education and training for anything but especially for any CVAD insertion. The new editiom of the SHEA Compendium chapter on CLABSI has a new section on implementation strategies. Implementataion science is composed of 4 sections - engage, educate, execute, and evaluate. I wrote the new sections on educate and evaluate. I would encourage you to read that new chapter - a free download. Read more about this on the first entry of our new blog - Infusion Insights at www.hadawayassociates.com. Also our videoconference on July 24 will be discussing the changes and updated information in this new guidelines document. Lynn