Forum topic

 In a discussion below about parafilm, Glenda Dennis says it has been useful for wrapping the hubs of these lines. We tried parafilm on a PICC we had high suspicion of tampering and it worked very well.  The bedside nurses felt a measure of safety using the parafilm. Ultimately our patient left AMA but we were able to deliver IV antibiotics while she was inpatient.  

This is a topic that I must confess I have never done a literature review on, nor have I ever looked for best practice guidance. I keep getting hung up on my gut feeling. I feel that a known or unknown IV drug user is going to use whether there is a line in their vein or not. Is there data suggesting that having a PICC line or any line for that matter is independently responsible for increasing illicit IV drug use? I guess the argument is that if the patient has a line and there is a high concern for tampering, than perhaps the patient is putting the line at increased risk for contamination. But couldn't this happen with anyone, even a patient not previously known to be a user? Do we routinely screen all candidates for outpatient PICCs prior to insertion to make sure they do not have a recent history of IV drug use? Do we only wear gloves when we care for patients with HIV? No, we treat all patients with a universal approach to protect ourselves because we don't know. I feel that if the patient needs the line for an indicated therapy, they should get it regardless of a concern that they might tamper with it. I would be sure to include education by looking this patient in the eye and telling him, "This line must not be used for anything other than these antibiotics. If you do, you will contaminate it and you could become infected. The infection could be very difficult to treat and we may have to remove the line. If we remove the line, we may not be able to treat your osteomyelitis. This could be fatal. If you must use, I would encourage you to find another route." I am sure that there is a population that will get a line placed and then elope, abandoning the purpose of the line and instead using it for drugs to their demise. In this case it is hard to say if they would have died from their primary infection or their secondary line sepsis faster. All in all, a holistic assessment is crucial, but I would be very reluctant to deny a patient an appropriate device to treat a potentially progressive condition out of fear that they might use it for illicit drugs.

 One of the facilities I work with have tried to keep the pt inpatient for the entire time of the antibiotic regimen but it is costly and they were caught on several occasions with visitors bringing in illegal drugs for them to infuse.  It is a big problem with the IVDU population and one of our docs has just had us place the PICC and if they miss 2 doses of IV meds in the treatment room he sends the police to pick up the patient and he has us pull the line.  Just some ideas, Christy 

I am not as concerned about the infecting the line as I am concerned about giving the patient a direct line to over dose with. Many of our heroin abusers have long ago used all their veins and now only "skin pop" their heroin. Sending a KNOWN IV drug abuser home with an open line for them to inject into at the same dosage as they used for skin popping could lead to an acute over dose.
In our area the home health agency's will not take patients with PICC lines and known recent IV drug habits. These patients either stay here in our acute care facility or go to a SNF for the remainder of their therapy. Unfortunately the majority of these patients leave AMA prior to finishing their treatment.
Because of the high rate of these patients leaving AMA we usually keep a peripheral in them for the first several days until their withdrawals are complete...and if they agree to stay in house or go to a SNF...then we put the PICC in to finish the antibiotics

This is a very interesting string. We are struggling with many of the same concerns. Does anyone know of actual laws, case laws, individual cases or even specific written policies that address the question of sending IVDU patients home or to SNFs with a PICC?

Speak with your case managers and social workers,  medicare/medicaid has stringgent requirements for discharging these patients to home. usually they will be sent to a sub-acute facility for the course of treatment. The private insurance companies usually follow similar guidelines.

Funny this shows up in today's forum. I have received a request on a patient that is currently in-house with a dx of endocarditis. In his late 50's. admitted IVDU-was crushing oxycodone and injecting it-even told the ED docs the last time he injected (which was just a few hours before he came in). He now needs 6 weeks of nafcillin. So the case is coming to us as a home infusion provider. I can't find any nursing agency that's willing to take him on and the question is coming up can we teach him how to administer and have him come in weekly for PICC dressing changes and labs. He is currently on oxycodone for pain control in-house and I'm guessing will be sent home with a script. He's a functioning addict as he owns a business that supports several employees and doesn't want to "be confined" to complete course of antibiotics but I still have concerns. What is our liability if he uses the PICC to inject and either develops a bacteremia or worse case scenario overdoses? Any advice would be greatly appreciated!!