Our facility is looking into having certain patients change their picc dressings at home. What are your facilities protocols on this? Do any of you currently have a protocol for patients to do this?
Have you ever tried to successful remove a dressing and a stabilization device with one hand? I say it can not be done with significant risk of catheter dislodgment. You might be able to train some family caregivers but I don't think a PICC dressing can be done with one hand. The patient might be able to do other CVAD dressings but not a PICC. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Office Phone 770-358-7861
I would agree, it usually requires two hands or two staff and three hands. What kind of stabilization device do you use? We are evaulating the orange clip and it holds the line so dressing changes go faster and do not move while you are changing, even with just one person.
I would not think of a patient or even family doing the dressing. These are to be done with sterile technique. If the pt is sent home with a PICC line, home health is involved. They may train them to do the infusion, but the dressing changes are always done by a nurse.
So.....are you all ok with a family doing this knowing that sterility is breached?
Gina Ward R.N., VA-BC
I would be concerned about the assessment that occurs during dressing changes. This can't be delegated.
In general, I think it depends on the family caring for the line. My daughter had a Broviac for a year and I did ALL the care for her line. I am a nurse as well. The hospital made sure I had the skill prior to leaving. A home care nurse never stepped foot into my home.
A Broviac exits on the center of the chest while a PICC is placed in one extremity. This leaves only one hand to do the PICC dressing. I agree that some family caregivers could be taught to do the dressing change but not all. Patients are routinely taught to do dressing changes for a tunneled cuffed catheter like a Broviac or Hickman. In fact, there is a device the patient can put on over their neck with a demo catheter which allows for practicing this dressing change procedure, but both hands can easily be used unlike a PICC dressing. Lynn
I had a PICC line for almost 18 months and I can tell you from personal experience it is impossible to change the dressing and maintain sterile technique. As a home infusion provider we do teach family to change dressings if they can prove they are competent. Not a lot of difference in teaching a family member for PICCs than the patients for Hickman dressing changes. We have patients that are located in areas where home health nursing is not available or unreliable and we have taught patients to self-infuse and dressing changes prior to leaviing the hospitall.
Was this a tunnelled line or secured with a statlock?
It was a PICC-so non-tunnelled-originally had sutures but over time they obviously broke. I did not use a stat-lock. The dressing kit that we use has a tape securement but that's all that I used and had no issues with PICC dislodgement.
I have found that even seasoned nurses struggle with a PICC line dressing change. Even after attending in-service education on the subject. They struggle to get the Stat Lock replaced without pulling out the catheter. They contaminate more often than not. Again, it's the Stat Lock that gets them and they don't understand the importance of not pulling out the catheter and not pushing it back in when they do pull it out. Nurses with 5 to 20 years of experience are offended when I asked to observe them during a dressing change after telling me they have done it for years and don't need my observation. After explaining that I like to periodically watch nurses just to get an overall picture of nurse's competence, they reluctantly agree. With 90 % of these very good competent nurses, I quickly find out they can't do a proper PICC line dressing change. I have extreme respect for floor nurses. They do their jobs very well. Much better than I could do. But, this is the reality based on my observations. So, if experienced nurses have so much difficulty, how can we expect a lay person to do it correctly? I'd ask those that are pushing that idea to come and do a mock dressing change on another staff member and count the number of contamination and breaks in technique. They think it's like any other dressing change but we know better. They will pull them out and contaminate them. They are asking for trouble IMHO. Whats the liability for bloodstream infections, reinsertion of a new PICC lines, re-admissions, etc... It's not worth it. Have them come in to a clinic or hospital for the dressing change and make sure the nurse knowbwhat they're doing. Home health, maybe, but how many of them are competent with this procedure? Just my thoughts and experiences. I'm not currently practicing as a PICC Nurse but I'm still a competent professional and still certified (for now anyway) Good luck.
D. Bordner, RN, BSN, MA, VA-BC
If lay caregivers and 90% of "very good competent nurses" can't do a proper PICC dressing change, who do you propose actually do the dressing changes?! It sounds like the problem is education and training. I think it is very realistic to train a competent caregiver in the home to do a PICC dressing change. Especially if that is one of the few tasks you are asking them to do. Encourage them to do a return demonstration and correct any deficiencies. It sounds like you might want a PICC dressing expert to do this training, however, since 90% of floor nurses can't do it correctly! Pretty soon the PICC team will be doing ALL dressing changes! Be careful what you ask for. We nurses cut corners. I think it is a natural, albeit dangerous, response to being over-worked. All we can do as vascular access specialists is apply continuous training and support to our fellow nurses in the facility and family members providing in-home care. If teaching a competent home caregiver how to do a proper PICC dressing change produces a competent return demonstration, I would feel 100% comfortable empowering that caregiver to perform the routine maintenance, especially if it keeps an otherwise healthy patient out of the hospital and reduces their unnecessary, out-of-pocket expenses.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
Keith I strongly disagree with you on your statements about staff nurses doing and CVAD dressings. I think it is extremely possible and much better clinical outcomes for infusion/VA specialists to do the care of the catheter after insertion. In fact, that is the way it was for more than 50 years. then we saw a great shift over to these specialists only be responsible for insertion of PICCs and now other CVADs. When this model of CVAD insertion only, the rest of CVAD care is dumped on overworked, extremely burdened staff nurses, you get the bad outcomes we have seen. My entire career of more than 40 years has been spend working on these teams and I strongly believe they should be accountable for far more than only insertion.
I do agree with you that a PICC dressing or other CVAD dressing can be done by some family caregivers who have mastered the skills along with having the manual dexterity to do it.
But I will never stop advocatting for full service, 24/7 infusion teams who have responsibility and accountabiliy for all CVAD care in acute care hospitals. Lynn
I was responding to the statement that if floor nurses can't be trained to do a proper PICC dressing change, how can you expect a lay person to be trained to do it in the home. It sounds like we both agree that can be done given the proper circumstances.
I appreciate and respect your multitude of years of experience in nursing and vascular access/infusion. I have far fewer, but they have all been in the military/federal government/department of Veterans Affairs. I have never worked in a facility that had a dedicated vascular access team. I know they exist, but not in the federal facilities in which I have worked. The few federal facilities that I have seen that do have a team do not do the follow on care. The team isn't big enough for that. I understand their merits and despite my lack of experience, I understand that PICC line care had always been/should continue to be the purview of a PICC Team/Vascular Access Team. But we don't have one and frankly, despite all of your efforts, white papers, evidence based and fiscal justifications, I don't forsee a time when we will. I work in a clinic that can't even get a "supervisor" position created because there are "enough" senior active duty officers assigned to fulfill the role. Instead we get a "manager" position. What's the difference, one might ask? One signs evals and the other just manages. Congress is trying to shrink the federal government, not grow it.
Nurses take pride in making due with the resources appropriated to them. My 21 year career in the federal government has been one exercise to make due after the next. Unfortunately I am challenged on a near daily basis to do the best for my patients with the very limited resources I am given. This includes training floor nurses on central line care, including PICC dressing changes. I do this training (actually at your encouragement after a post last year about my frustration with under-trained nurses accessing ports. Your advice was to train them...not get a VA Team involved!) at regular intervals and am always available to just-in-time training and questions. We utilize family-based care-givers frequently as a way to counter this shortage. Education, training and return demonstrations is a big part of what I do.
For the reocrd, at ever CNS council meeting I go to, I mention that we need a VA Team. It has become a running joke. The entire hospital is chronically undermanned as government is downsized and existing positions are distributed based on need. We do the best we can, and sometimes we have to tap into resources and ensure proper training when we have no realistic alternative. I don't like the system either, but it's what we're stuck with.
Sorry you disagree with me so strongly. I was just sharing a different perspective.
I think its perfectly fine to disagree on some viewpoints. I would like to sit down and chat with you sometime. Contact me at [email protected]. Thanks.
Angelo M. Aguila, MSN, RN, VA-BC
Vascular Access Nurse[email protected]
Thank you all for reminding me of the importance of constructive discussion. I'm not sure what I said to suggest that I am opposed to disagreement, but I will work harder to be more open-minded.
Sounds like I hit a nerve. Education and training is always good. Again, lets look at the realities of many hospitals. Take the hospital I worked at for example. A 400 bed hospital with 2 part time PICC Nurses. One on staff, 10 hour days, 4 hous on the weekend. We did training once a month rotating the different floors. So we caught the days shift nurses only. The powers that be would not let us make it madatory so it was voluntary training. So maybe 3 or 4 nurses a month are being trained by in-service education. Fiqure in turnover rates and the fact is we had many more nurses not trained than were trained. I would train one on one as much as possible and encourage them to train the other nurses. But I can't force anyone to do it, nor can I force them to come to my in-services. I was a military nurse for 20 years so I know most state side hospitals have large and very good Education and Training Departments. In the civilian sector you do as much as you can with the fewest staff possible. It's more money driven than the military hospitals. Yes, give me the time and I can train a nurse to be an expert at PICC line dressing changes. There are some lay people that could be trained, but you have to look at the overall picture. These dressing changes are extremely important and need to be done by a professional that understands the principles of sterile tecnnique, infection control, and the possible ramifications of dislodging the line. To place that responsibility on the patient or a family member is not a good practice. I'm happy if they can keep them clean and dry and don't pull them out in their sleep. These are my opinions and observations based on sound principles, judgment and guidelines. The great thing about this and other forums is so that professionals can share their thoughts and opinions on various ideas. We don't have to agree. These discusions are how change takes place so any idea is worth debating. I'm glad that we don't all think the same.
This week a darling little woman came in to our facility with orders to change out her PICC. We didn't replace her line, we did perform a sterile dressing change.
Her husband was my hero. As I began to remove her old dressing, I lifted one of the edges without gloves to get a bit of a start on it. Her husband spoke up and said "thank you for washing your hands, now will you please stop and put on some gloves?"
He's probably the reason she has had her dual lumen picc in place without any problems for two years. Families who want to change dressings, who are attentive and caring can certainly be trained to change them.
Keith, on the issue of infusion teams and all of the care and maintenance required for VADs, there are 2 choices that any healthcare facility has. One choice - a primary care or generalist model - is to have all nurses doing all care and maintenance. The other choice is to create an infusion team where the care and maintenance is doing exclusively by this team. There is evidence to support the infusion teams and the improved outcomes they produce. Of course, more evidence is needed, especially on the financial analysis of the actual cost of each choice. Regardless of the hospitals choice, the nurses responsible for all VAD care and maintenace are held to the same standard of care. So using a generealist model could easily be more expensive than an infusion team. I think the costs of educating all staff, competency documentation for all staff, and outcome monitoiring for all staff is greater than the costs of an infusion team. But I don't have a study to support these financial outcomes, so currently it is left to each facility to do their own finanacial analysis. Maybe one day we will have what is needed. Lynn
I worked homecare in 1999, 2000. Back then, we would teach and train as much as the family/caregiver was willing to learn. We typically did a once a week visit to check the line, be sure there were no questions or problems and chg the dressing as well as often draw labs. However, if the family was willing we woud teach them to do a sterile dressing change, in case it needed to be done between visits. In Florida, patients dressings loosen easily. We would teach and observe a return demonstration. Caregivers are very worried about injuring the patient, so they are often great at following step by step instructions and aseptic technique. If they were not did not allow them to do the dressing changes.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC