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PICC use after nurse insertion
I am trying to establish the standard for using a PICC line after nurse insertion.  Is a specific physician order required before use?  If the facility policy allows, can the doccumentation that the line flushes and aspirates well and that the tip is in the lower 1/3 SVC sufice? Thanks, Keith NM
The process that I have seen

The process that I have seen work and strongly recommend is:

1. a firm policy stating where the tip should be located and that a chest xray is always performed.

2. assessment of the chest xray by either the nurse inserting (preferred), radiologist, or primary physician.

3. adequate communication of that specific anatomic tip location to the primary care staff - "line in good position" or "it is ok to use" is NOT sufficient

4. if the stated anatomical location is what your policy states, proceed with using the line. I see no need for a separate physician's order stating that the line can be used.



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

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Our facility requires an
Our facility requires an order from a physician or radiologist that the line can be used.  The policy is based on the position that nurses (inserter of PICC or not) are not qualified to "read" the CXR and dictate care as a result of the reading.  It is viewed as a diagnostic interpretation that can only be performed by a physician.  They, the physicians, argue that nurses are perfoming outside their scope of practice.  Our criteria for catheter use is the same as yours, but we have to get a physician order stating the catheter is ok to use.  I feel comfortable reading my own CXR but I feel even more secure (legally) that a physician has also read it and given his blessing.  Two eyes are better than one and in the event of catheter migration, etc., I wouldn't want to be left with doubt about my initial read.
Your problem may be a turf

Your problem may be a turf issue or political battle. "Reading" the xray is medical practice and that is ***not*** what nurses can or should do. However, nurses placing PICCs can and do assess for catheter tip location. Please note this is not reading the xray for pathology etc. A radiologist will be doing the final reading, but waiting for their report will usually delay the initiation of infusion therapy - not good for moving paitents through the system. AVA now has a position paper supporting nurses doing this.  


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

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Angela Lee
I look at the CXR with a

I look at the CXR with a radiologist and do not clear it for use until we both agree on the tip location.  Our procedure form has a space for the radiologist name, a space for tip location documentation and also a check off to use or not use.  I clear the line myself but only with the radiologist's blessing on the tip location.    No MD order.

Interestingly enough, there are occasions when the radiologist does not see what I see until I point it out.

We do not require an "OK to

We do not require an "OK to use" order.  Our policy states the tip must be anywhere in the SVC to be considered a central line  Then we, the IV nurses acting as the liasson, call the floor and give them a verbal OK after the radiologist gives us their SVC reading.  If it is malpositioned or short, we deal with that on a case by case basis, sometimes using it anyway (with the intensivist's or primary doctor's order, but not the radiologist), or sometimes pulling it back to midline, if type of therapy permits.  If it's looped, contralateral or up the IJ, time permits and the patient is able, I have them sit up for a couple hours or get up and walk around and then repeat the xray.  If it's late, I have them sleep on it and get an early AM xray.  You'd be surprised how many spontaneously fall into place.  And there are some cases that have to go to Radiology for an over the wire exchange or new insertion altogether. Angela, I have also had the experience of disagreeing with the radiologist, but it's usually over a poor quality film, and usually get a repeat.  Rarely, I get a second rad to confirm (or deny!).  Sort of sneaky, but it's for the patient's welfare!  Good luck with your policy writing.  Janet Brown-Wise 

Only an IV RN can approve

Only an IV RN can approve our PICC lines for use, and we write an order in the chart.  This is written in our policies, and we write SAFE reports when this procedure is not followed.  Not even the patient's house officer, attending, nor any other physician can clear our PICC lines for use (too many errors, too many times).

Until we're officially able to use our own tip location readings, we need a reading from radiologist first - but they often change their reading because of our input.   

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

In the past, we required an

In the past, we required an "OK to use" order. Some of the nurses would use the Radiologists' name which would lead to unhappy Rads...we don't like unhappy Radiologists:)  

So we developed a PICC insertion order set that includes all the necessary things for PICCs including goal of tip position=distal SVC. There is a statement that reflects PICC may be used once tip position is verified by Radiologist and PICC Nurse gives clearance to use.

So basically, the order for post-placement CXR is there and even Ok to do Doppler Ultrasound to r/o thrombosis if swelling occurs. Not to mention the order for Alteplase 2mg IV to de-clot PICC prn, MRx1.

 Saves a lot of time & headaches for both nurse & docs.

Raquel M. Hoag, RN, BSN, CRNI

Fremont, California 


Raquel M. Hoag, BSN, RN, PHN, VA-BC

Gwen Irwin
We have been assessing the

We have been assessing the tip location and releasing the PICC for use for about 3 years.  We have on our pre-printed orders a blank for who assessed the tip location in the SVC.  We have policy in place that allows us to do this.

 Gwen Irwin

Austin, Texas

T. Nauman RN, CRNI  IV

T. Nauman RN, CRNI  IV Educator SHMC Eugene, OR

Our PICC nurses have been assessing for PICC tip position for about 8 years.  We have to have tip assessment training(the course we've taken is given by Jamie Santolucito RN and Dr. Verhey(sp?)...then, usually, two of us look at the x-ray before we release it for use.  The Oregon State Board of Nursing lists this as a nursing function (with special training).  Our policy states that the PICC tip must be in the SVC and can be released by the PICC nurse...the tip placement must be verified by the radiologist within 24 hours.   We have no statement saying "o.k. to use"  or "released for use" on the order sheet...just an orange sticker that is filled out any time any central line is placed...with a line for location of tip and our signature.

T. Nauman RN, CRNI

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