For those of you who are measuring arm circumference on Picc insertion, where are you measuring it...above or below the insertion site and how many cms. We no longer measure because we don't feel it to be very accurate in most cases, but need information to justify this. Is anyone aware of any references one way or the other about this?  Thanks
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Lynn,
We have stopped utilizing arm circumference r/t the reasons stated however I need to find EBP related to it. Not having success with finding it. Could you point me in the right direction
Thank you
Carol Busch
[email protected]
Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse
Show me the evidence supporting routine, repeated measurement of mid arm circumference. It is not in the literature. So why do we need evidence to support getting rid of a specific practice that was never evidence-based in the first place? Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
There is no evidence on measuring or not however it is in protocols and hospitals are following them. To have them changed from the policy, which in reality the measurement is not a conclusive measurement there needs to evidence of why it should be removed. However there is no evidence based practice that shows it is an important assessment of the picc line. So where is all the evidence that started the arm circumference to begin with? I like your point Lynn but this won't remove it from our policy becasue Mosbys states it to be done. I have to find the information why it is inaccurate. I will take this point of view forward. Carol
Thank you Lynn
Carol Busch RN
PICC team
St Elizabeth Medical Center
Lincoln, NE 68510
[email protected]
Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse
The 2006 Infusion Nursing Standards of Practice changed this midarm circumference measurement to be a baseline before insertion and when clinically indicated. This change occurred because there was no evidence to support routine periodic measurement. I would consider this current standard to be evidence-based. This practice, like many other nursing practices, got started based on recommendations from a few speakers, or others recognized as experts. I could make a lengthy list of practices that fall into this category. As you may know, the INS standards are in the revision process now. The first draft has been finalized. They will go out for review to ~100 professionals in a few days. We will consider all comments and finalize the document so it will be released as a supplement to the Jan-Feb 2011 issue of the Journal of Infusion Nursing. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree 100 % that the measurement was inaccurate and that nurses have skills of which to assess the increase in circumference before the measurment might. The revisions will assist with the changes. We are not doing intial measurements either because the team decided that this was not an accurate measurement either as everyone measures in a different area.
I know that when we changed this over a year ago I had the information but unfortunately didn't think I would need it again and know I do.
Thank you for your help Lynn.
Is there anyway that I could a copy of the first draft?
Carol Busch RN
[email protected]
PICC Team
Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse
The first draft of the revised Infusion Nursing Standards of Practice will be sent out to those professionals who have volunteered to serve as reviewers. The job of reviewers is to read the document, provide your written comments and the references to support your comments to the INS office in the month of June. If you wish to serve in this capacity, you can contact the INS office and volunteer. Thanks, Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
We take a baseline circumference measurement at the level of the axilla and document it on the insertion note.
The information has proved to be useful - a patient was transferred to another facility and the practitioners at that facility reported that the patient developed a peripheral thrombus and that they appreciated having the pre-procedure arm circumference measurement.
Prior to PICC insertion we measure Mid-Shaft upper arm.
We do a baseline measurement of circumference at the insertion site. The measuremet is at the insertion site, not at any other specified number of cms.from the AC. We found that other measurements would be not comparable at a later date.
Gwen Irwin
Austin, Texas
I think a lot of nurses do measure the AC. But perphaps instead of asking how many measure the AC, let's ask, what do you do if the AC is 1cm greater than upon insertion or what if it is 5 cm greater?
My thought is that if it is 1 cm greater, most nurses would not do anything.
But if it is 5 cm larger and edema is present, I feel certain that the nruse woudl contact the MD for appropriate interventions. Would not visualizing edema (as with a 5cm increase) be enough to warrant intervention? Why do we need to measure. My point, as I ramble, is that it's pretty easy to see if edema is present or not, thus use what we see to decide our approach.
Cheryl Kelley RN BSN, VA-BC
Michael Drafz
Vascular Access Specialist
Sharp Memorial Hospital San Diego, CA
We do baseline on all PICC's and Midlines.
Then we do measurements every 3 days (3 inches above insertion site) on every PICC. Only IV team is taking care of the lines and are doing the measurements, which I believe is the key. If the floor nurses would do it I think it would become very unreliable data.
Our standard is, that if measurement is 2 cm above baseline we look at the other arm, measure and compare, as well as looking at the all over patient condition (fluid retention ect.) So if the problem seems to be isolated to the PICC arm we suggest a US study to the MD, it is then up to him/her to make the determination. In about 70 % of the times we get the study done, there is a thrombus, but not all of the time.
For us it is worth it, since the floor nurses often are not keyed in to look out for the complications with PICCs and nor do the MD's- unless it is infection.
Michael Drafz RN, CRNI, VA-BC
Clinical Lead Vascular Access Service
Sharp Metropolitan Medical Campus
San Diego, CA
Vickie Teresinski, RN, CRNI
You need to publish your results of this practice because there are no studies supporting a routine or regularly scheduled arm circumference measurement.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
INS does not require routine measurements. This was changed in the 2006 standards. It is calling for baseline before insertion and then measurement only when a problem is suspected. The issue is with regular, scheduled measurement at established intervals. There is no evidence that this is beneficial. There are so many differences in measuring techniques, etc. and that was the reason we took it out. But you should do a baseline before insertion and then compare to what is measured when you suspect a problem.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
I agree with Lynn and Leigh Ann. We were doing weekly measurements after the baseline (because we always did it that way!), but now no longer feel that it is useful. We measure baseline, and then only when we suspect a problem. Even then, this information may or may not be indicative. Usually, but not always, there are other symptoms when a problem has reached the clinical state - such as discomfort.
Sometimes the patients forearm will be swollen and not the upper arm. We will request doppler study then as well, and will find thrombi.
Mari Cordes, BS RN
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center
where is it mentioned in the 2011 SOP? I can't find it anywhere about a baseline measurement other than length of catheter
Cheryl E. Aldo, RN, BS VA-BC
where is it mentioned in the 2011 SOP? I can't find it anywhere about a baseline measurement other than length of catheter
Cheryl E. Aldo, RN, BS VA-BC
I just searched the pdf of the INS SOP using "circumference". In the 2011 edition, mid-arm circumference is defined in the glossary but there are no other statements about it in the document. There was no evidence to support any statements and this is an evidence based document. So we could not make any recommendations about this practice. This started as a means to identify venous thrombosis. I would direct you to SOP # 52 Catheter-Associated Venous Thrombosis however this section focuses more on treatment than prevention or assessment. Your facility will need to decide if this measurement should be a part of your plan of care. See SOP 13 Plan of Care. Lynn
Lynn Hadaway, M.Ed., RN, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861