What criteria do you use to determine if a patient needs a PICC vs a peripheral IV. Our guidelines are rather vague and top level management is questioning the amount of piccs we are placing. Thank you, Laura
We have both inclusion and exclusion criteria based on the published Infusion Nursing Standards of Practice. Length of therapy, infusate are main factors to consider, along with any contraindications such as impaired renal status, thrombus history, pre-existing conditions (i.e trauma, skin infections, etc.)
You can also think of those patients where a subclavian or jugular inserted catheter is not the best choice including respiratory diagnoses, curvatures of spine, increased intracranial pressure, where the reverse Trendelenburg position would be difficult or contraindicated. Also those with a trach have increased cross contamination between the trach and subclavian or jugular insertion sites making a PICC safer. Coagulopathies are safer with a PICC insertion site instead of the other insertion sites. Lynn
I do believe Nurses & physicians are taking advanage of PICC lines. Just because a floor nurse can't start a line (IV) does not mean that the patient needs a PICC line. This is going on in the hospital where I work. The floor nurses will call the physicians and get orders for PICC line insertion. This just drives me crazy. PICC nurses will go and start the line and then everybody is happy. This does take time away from inserting picc's to patient who really meet criteria for a picc line. I'm not sure how to address this problem that has now turned into a major problem.
Which line should be used for the drug Cubicin ML or PICC.
It sounds to me like there are serious skill gaps among the primary care nurses with regard to starting a PIV. A PICC may or may not be right for these patients. I would not place too much blame on these nurses simply because their skills are not great. This just points out the need for more training or , better yet, a full-service 24/7/365 IV Team and not just a PICC team.
You can also teach these nurses when it is no longer appropriate to use a PIV - drug pH, osmolarity, length of therapy, and number of venous access sites. This should trigger an assessment from the PICC team. A list of diagnoses and a list of IV meds that should get PICCs could also generate a pro-active patient assessment from your team.
This happens in our facility as well since there are only 3 IV/PICC nurses on during the day. of course in my opinion this is awful. We recently had a pt with a K+ of 6.7 and no one could get an access until my co-worker got here. Hospitals need IV nurses 24 hours a day. What we do is evaluate each case and we have the authority to not place the PICC. We call the MD and tell them why and also tell them if the situation changes we will be happy to place the line. Of course the pt must have suitable veins to meet the prescribed course of therapy and the infusate must be safe to give in a peripheral vein (eg TPN and cont vesicant chemo need CVC) We have placed PICCs for a few days if the pt does not have good vessels we have placed power PICCs for surgery ...we hace even placed PICCs just for a CT scan.. WE do evaluate carefully each case and even will suggest alternate CVCs if needed. The PICC team needs to be very educated and take ownership of the process and base your decision on the facts.
The biggest problem with PIVs is everyone waits too long, runs out of veins to use, creates complications and then thinks about a PICC. We do need to be proactive with device selection and then they won't say a PICC isn't appropriate for 3 days when really it should have been used for all 10 days of the patient's stay!
Nancy L. Moureau, BSN, CRNI PICC Excellence, Inc www.piccexcellence.com
I can identify with all these comments. It is clear that many of us are in the same boat and while it's supportive to know you're not alone it's very sad and unfortunate that hospital management does not understand the significance of providing a full service team to the patient. It seems no matter how many letters my patients (or families) write to the CEO or how much positive feedback he gets regarding my services it is not enough to persuade him (generically speaking) to invest in this area. This includes countless proposals and many valid justifications grounded in strong documented evidence. Even though I may not be revenue producing I cannot get across that this service is cost saving in a myriad of ways. This one piece of patient care is so important to the patient not only in the outcome and process but also in the reduction of physical and psychogical trauma incurred by multiple and frequent venipunctures, destruction of veins and interruption or incompletion of therapy. Ask any patient. (I know I'm preaching to the choir).
I strongly believe that as long as nursing grads are churned out of school with no more experience or knowledge about infusion therapy that they have then our responsibility to educate is almost insurmountable when we are not staffed well enough to even serve the patients. Only when there is a full service vascular access team is it possible to screen patients thoroughly ourselves within 48 hours of admission or less, do follow up care, maintain appropriate access in patients, reduce complications, make recommendations and educate-not only the nurses but also the physicians and the patient/families. I get taken by surprise sometimes at what the nurse does not know but then I have to remember that this is what I do so I know what I know while the bedside nurse is responsible for all aspects of care for the patient. They are overwhelmed as well. All the more reason to provide this specialized care in the best way with the expertise of the vascular access nurse and the support and assistance of the bedside nurse.
Sorry, I didn't mean to hijack this thread--the last few posts just hit a sore spot with me--it's a long standing problem. If any one has any new ideas to try please share.
Angela- my facility is against an IV team also. I think I might have a plan........we are trying to achieve Magnet Status and pt. satisfaction is a very important part of obtaining that. I would somehow like to add a question to the patient satisfaction questionaire regarding "multiple IV attempts and/or blood draws", hopefully the patients will voice their frustrations and administration might finally address this issue. It's worth a try!
I have followed this thread since it's beginning--In an effort to meet the desperate need for early IV assessment I am trying to simply the process so that even the most novice of non-IV nurses can follow the format--Some might say that I am trying to dumb down the process but the algorythms and evaluation documents I have seen speak at the level of the Physician and/or the professional IV nurse--I need a format that can be followed as soon as the patient enters the hospital system--Frequently this starts in the ED or at the bedside when the new Nurse or Traveller does the initial admission evaluation--I want to develop a document to meet this need--Are there any examples of such a format out there already?--Thanks in advance for your responses
I'm in the same boat, so many patients have been discharged/readmitted with vessels that havent healed, and the obesity adds to the difficulty...I can hardly keep my mouth closed when a 400lb-er can't understand why we can't get access!!!
Listen to this one!!!our critical care MD's want to eliminate critical care subclavian lines and replace with PICCs..They state we have lower complication rates(true) and want to look good when the public has the ability to check out the BSI rates..however we are a 2 person team (1600 lines last year),,and wiped out!! any other hospitals considering this?
Patel's retrospective study concluded: "Using open-ended PICCs in intensive care may be associated with shorter CICC dwell times, reduced CRBSIs, and reduced antibiotic usage."
Results: "Two thousand four hundred seventy-four central vascular catheters were inserted in 1788 critically ill patients (21,919 catheter-days). During the control period, centrally inserted central catheter (CICC) median dwell time was 6.4 days, with a CICC CRBSI rate of 2.3 per 1000 catheter-days and a total CRBSI rate of 1.6. During the third intervention year, CICC median dwell time was 3.2 days (50% reduction; P G 0.001), CICC-related CRBSIs were eliminated, and the total CRBSI rate was 0.3 per 1000 catheter-days (81% reduction; P G 0.001)."
Impact of Peripherally Inserted Central Catheters on Catheter-Related Bloodstream Infections in the Intensive Care Unit
Bhavesh M. Patel, MD, FRCP(C), Corinna J. Dauenhauer, RRT, Mohamed Y. Rady, MD, PhD, FCCM,Joel S. Larson, MD, Tonya R. Benjamin, RN, Daniel J. Johnson, MD, and Richard A. Helmers, MD. J Patient Saf & Volume 3, Number 3, September 2007
This is in response to Cathie's comments below. We use PICC lines almost exclusively for central venous access in our critical care patients. Workload aside, they are the most efficient, safest, most reliable lines for these patients. We have PICC nurse coverage 24/7/365 in a hospital with 150 beds. We do CVOR and are a Level 2 trauma center. What your doctors are proposing sounds right to me - use them to help you talk with the "powers that be" about increasing your staffing. Our PICC nurses don't just do PICCs - they are the hospital's Resource Nurses - they float around and assist as needed, place IVs (not an IV team), perform delegated tasks, respond to codes, do all diabetic teaching, etc. So they wear many hats. There are generally two of them on during 6a-6p, one does the diabetic ed, the other does resource activities as well as places PICCs.
I am pretty new to this forum, and am trying to do the same for the hospital I work at as well. Were you ever able to obtain any of the documents you spoke of for starting an early assessment program? What is your opinion on the best way to implement this program? Thank you for your help.
Tamster, we obtained Magnet status last year. I am in the process of pushing (very hard) for a full service team. I have the support of my immediate supervisor who is the one to request FTEs. However we are on the verge of building a new facility and many requests are being turned down. It is, of course, all about the money and how to use it best. I am frankly glad I don't have to make those decisions because they can't be easy. It is easy to say we need this or that (and we do) but we don't see the big picture. Not everything can be had or done.
Regarding patient satisfaction, you are correct--it is important but in this area it seems not to be enough....almost as if a traumatic venipuncture experience is to be expected and therefore tolerated. I have heard adults talk about their experiences in such a matter of fact way it's as if they don't know it could be different. There has been feed back from all over the state and then some regarding the need for 24 hour IV nurses here but it has not been enough to change the situation. I went through a period when I got comments from patients/parents, I would encourage them to write the COO, CEO, my boss, our nursing exec and anyone else I could think of...it didn't seem to make any difference. I got lots of sympathy and word of encouragement but no additonal staff. I hope that will change to action soon. I am looking at hiring my third FTE (including me) and hope to get approval for more.
In regard to adding that question to your questionnaire, be careful how you word it...you are asking for negative feedback and I'm not sure that will be welcomed.
Angela, rather than soliciting negative feedback from your patients regarding their experience with IV therapy, why not solicit feedback from those patients who have had a PICC inserted as a comparison to their previous experience. Questions such as: Would you choose to have a PICC inserted if you should need IV therapy in the future?
Yes? No?
How did the experience of having a PICC for your IV therapy compare with your past experience with IVs?
Better? Worse? No difference?
Good luck with your intent to become a full service team.
You can also think of those patients where a subclavian or jugular inserted catheter is not the best choice including respiratory diagnoses, curvatures of spine, increased intracranial pressure, where the reverse Trendelenburg position would be difficult or contraindicated. Also those with a trach have increased cross contamination between the trach and subclavian or jugular insertion sites making a PICC safer. Coagulopathies are safer with a PICC insertion site instead of the other insertion sites. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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
I do believe Nurses & physicians are taking advanage of PICC lines. Just because a floor nurse can't start a line (IV) does not mean that the patient needs a PICC line. This is going on in the hospital where I work. The floor nurses will call the physicians and get orders for PICC line insertion. This just drives me crazy. PICC nurses will go and start the line and then everybody is happy. This does take time away from inserting picc's to patient who really meet criteria for a picc line. I'm not sure how to address this problem that has now turned into a major problem.
Which line should be used for the drug Cubicin ML or PICC.
It sounds to me like there are serious skill gaps among the primary care nurses with regard to starting a PIV. A PICC may or may not be right for these patients. I would not place too much blame on these nurses simply because their skills are not great. This just points out the need for more training or , better yet, a full-service 24/7/365 IV Team and not just a PICC team.
You can also teach these nurses when it is no longer appropriate to use a PIV - drug pH, osmolarity, length of therapy, and number of venous access sites. This should trigger an assessment from the PICC team. A list of diagnoses and a list of IV meds that should get PICCs could also generate a pro-active patient assessment from your team.
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
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
This happens in our facility as well since there are only 3 IV/PICC nurses on during the day. of course in my opinion this is awful. We recently had a pt with a K+ of 6.7 and no one could get an access until my co-worker got here. Hospitals need IV nurses 24 hours a day. What we do is evaluate each case and we have the authority to not place the PICC. We call the MD and tell them why and also tell them if the situation changes we will be happy to place the line. Of course the pt must have suitable veins to meet the prescribed course of therapy and the infusate must be safe to give in a peripheral vein (eg TPN and cont vesicant chemo need CVC) We have placed PICCs for a few days if the pt does not have good vessels we have placed power PICCs for surgery ...we hace even placed PICCs just for a CT scan.. WE do evaluate carefully each case and even will suggest alternate CVCs if needed. The PICC team needs to be very educated and take ownership of the process and base your decision on the facts.
The biggest problem with PIVs is everyone waits too long, runs out of veins to use, creates complications and then thinks about a PICC. We do need to be proactive with device selection and then they won't say a PICC isn't appropriate for 3 days when really it should have been used for all 10 days of the patient's stay!
Nancy L. Moureau, BSN, CRNI
PICC Excellence, Inc
www.piccexcellence.com
1-888-194-1951/52
Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com
I can identify with all these comments. It is clear that many of us are in the same boat and while it's supportive to know you're not alone it's very sad and unfortunate that hospital management does not understand the significance of providing a full service team to the patient. It seems no matter how many letters my patients (or families) write to the CEO or how much positive feedback he gets regarding my services it is not enough to persuade him (generically speaking) to invest in this area. This includes countless proposals and many valid justifications grounded in strong documented evidence. Even though I may not be revenue producing I cannot get across that this service is cost saving in a myriad of ways. This one piece of patient care is so important to the patient not only in the outcome and process but also in the reduction of physical and psychogical trauma incurred by multiple and frequent venipunctures, destruction of veins and interruption or incompletion of therapy. Ask any patient. (I know I'm preaching to the choir).
I strongly believe that as long as nursing grads are churned out of school with no more experience or knowledge about infusion therapy that they have then our responsibility to educate is almost insurmountable when we are not staffed well enough to even serve the patients. Only when there is a full service vascular access team is it possible to screen patients thoroughly ourselves within 48 hours of admission or less, do follow up care, maintain appropriate access in patients, reduce complications, make recommendations and educate-not only the nurses but also the physicians and the patient/families. I get taken by surprise sometimes at what the nurse does not know but then I have to remember that this is what I do so I know what I know while the bedside nurse is responsible for all aspects of care for the patient. They are overwhelmed as well. All the more reason to provide this specialized care in the best way with the expertise of the vascular access nurse and the support and assistance of the bedside nurse.
Sorry, I didn't mean to hijack this thread--the last few posts just hit a sore spot with me--it's a long standing problem. If any one has any new ideas to try please share.
I have followed this thread since it's beginning--In an effort to meet the desperate need for early IV assessment I am trying to simply the process so that even the most novice of non-IV nurses can follow the format--Some might say that I am trying to dumb down the process but the algorythms and evaluation documents I have seen speak at the level of the Physician and/or the professional IV nurse--I need a format that can be followed as soon as the patient enters the hospital system--Frequently this starts in the ED or at the bedside when the new Nurse or Traveller does the initial admission evaluation--I want to develop a document to meet this need--Are there any examples of such a format out there already?--Thanks in advance for your responses
Robbin George RN VA-BC
Listen to this one!!!our critical care MD's want to eliminate critical care subclavian lines and replace with PICCs..They state we have lower complication rates(true) and want to look good when the public has the ability to check out the BSI rates..however we are a 2 person team (1600 lines last year),,and wiped out!! any other hospitals considering this?
Cathie
Patel's retrospective study concluded: "Using open-ended PICCs in intensive care may be associated with shorter CICC dwell times, reduced CRBSIs, and reduced antibiotic usage."
Results: "Two thousand four hundred seventy-four central vascular catheters were inserted in 1788 critically ill patients (21,919 catheter-days). During the control period, centrally inserted central catheter (CICC) median dwell time was 6.4 days, with a CICC CRBSI rate of 2.3 per 1000 catheter-days and a total CRBSI rate of 1.6. During the third intervention year, CICC median dwell time was 3.2 days (50% reduction; P G 0.001), CICC-related CRBSIs were eliminated, and the total CRBSI rate was 0.3 per 1000 catheter-days (81% reduction; P G 0.001)."
Impact of Peripherally Inserted Central Catheters on Catheter-Related Bloodstream Infections in the Intensive Care Unit
Bhavesh M. Patel, MD, FRCP(C), Corinna J. Dauenhauer, RRT, Mohamed Y. Rady, MD, PhD, FCCM,Joel S. Larson, MD, Tonya R. Benjamin, RN, Daniel J. Johnson, MD, and Richard A. Helmers, MD. J Patient Saf & Volume 3, Number 3, September 2007
Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada
Daphne Broadhurst
Desjardins Pharmacy
Ottawa, Canada
Wendy Erickson RN
Eau Claire WI
HI,
I am pretty new to this forum, and am trying to do the same for the hospital I work at as well. Were you ever able to obtain any of the documents you spoke of for starting an early assessment program? What is your opinion on the best way to implement this program? Thank you for your help.
Stephanie
Tamster, we obtained Magnet status last year. I am in the process of pushing (very hard) for a full service team. I have the support of my immediate supervisor who is the one to request FTEs. However we are on the verge of building a new facility and many requests are being turned down. It is, of course, all about the money and how to use it best. I am frankly glad I don't have to make those decisions because they can't be easy. It is easy to say we need this or that (and we do) but we don't see the big picture. Not everything can be had or done.
Regarding patient satisfaction, you are correct--it is important but in this area it seems not to be enough....almost as if a traumatic venipuncture experience is to be expected and therefore tolerated. I have heard adults talk about their experiences in such a matter of fact way it's as if they don't know it could be different. There has been feed back from all over the state and then some regarding the need for 24 hour IV nurses here but it has not been enough to change the situation. I went through a period when I got comments from patients/parents, I would encourage them to write the COO, CEO, my boss, our nursing exec and anyone else I could think of...it didn't seem to make any difference. I got lots of sympathy and word of encouragement but no additonal staff. I hope that will change to action soon. I am looking at hiring my third FTE (including me) and hope to get approval for more.
In regard to adding that question to your questionnaire, be careful how you word it...you are asking for negative feedback and I'm not sure that will be welcomed.
Good Luck to you.
Angela, rather than soliciting negative feedback from your patients regarding their experience with IV therapy, why not solicit feedback from those patients who have had a PICC inserted as a comparison to their previous experience. Questions such as:
Would you choose to have a PICC inserted if you should need IV therapy in the future?
Yes? No?
How did the experience of having a PICC for your IV therapy compare with your past experience with IVs?
Better? Worse? No difference?
Good luck with your intent to become a full service team.
Anita Brown RN CRNI
Director of Nursing
MediLink Homecare, Inc.
Anita Brown RN CRNI
Director of Nursing
MediLink Homecare, Inc.