So I have noticed that we are having some picc line migration in patients that have had picc lines in for an extended period of time. My question is at what point do I need to worry or have a new xray to determine placement? I honestly think that it might be due to the stat lock device. Many of the nurses are not very comfortable using it. We are a small hospital, so it is not really feasible for the picc nurses to do all the dsg changes. Any suggestions?
Migration is just the catheter tip moving to a different location. Dislodgement is the entire catheter moving into or out of the vein. It sounds like you are talking about dislodgement and not migration. The nurses who are doing the actual dressing change procedure must be doing it correctly, regardless of what product you are using. So either the staff nurses learn to do it correctly or you limit the number of nurses who change the dressing. I would vote for limiting the number of nurses who perform the procedure because we get greater efficiency and reliability with a high level of skills. I just gave a presentation about this at the recent INS fall conference. Teams and teamwork are now heavily recognized as producing better outcomes with numerous aspects of patient care. I think you nurses who insert PICCs should focus on a broader scope of their services to include infusion therapy and not simply the technical task of inserting catheters. This level of quality does not increase costs but saves cost. Lynn
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 have found that when inexperienced nurses are left to perform dressing changes the outcomes are not good. We were forced to try that several times and every single time we did our infection rate shot up and we were replacing PICCs like crazy b/c the nurses were pulling them out a few cms at a time with dressing changes as well as doing an inadequate dressing change. If the nurse pulls it out by 2-3 cms with each dsg change you will most likely be out of the SVC by the third dsg change ,assuming you were in the low SVC. That may vary some depending upon the length of the pts SVC. I agree with Lynn the best thing to do is to take over the dsg changes of the lines you place OR you will be forced to educate all those that perform the dsg changes. You will not only need to stress the proper technique...you must tell them why it is so critical to prevent any dislodgment. You will probably find the average nurse does not know why. The stat loc is really not that difficult to use and in my opinion is worth its weight in gold, again I think the answer is education. Unfortunately, I have seen nurses not realize that they have to change this at a minimum of at least every seven days. Just saw a home care patient come in with a stat loc that had been in place for 3 weeks..it was still sticking but the patient had a problem there b/c it was not changed
Have you had statlock reps/clinicians come in and do thorough inservicing? Sounds like it might help. Virtually every complaint we got about statlock was from nurses who were using or removing it incorrectly. Brendan at Dartmouth described a similar experience.
I agree with Lynn and MaryAnn about PICC nurses doing the PICC dressing changes. Or, since it's just you and Dave right now, how about training a small group of staff members who would be responsible for it? Their training would include rationale for best practices around central line care/maintenance.
We teach the staff RNs to measure (outside the dressing) and document exposed catheter length every shift. Since they probably won't be able to see the cm hash marks, they measure from insertion site (or center of antimicrobial disc) to where the catheter meets the trifurcation or bifurcation (monofurcation? a-furcation for single lumen??) This measurement is a little more than 1cm greater than the true "zero" on powerpicc/Solo powerpicc.
If their measurement is greater than 2cm from original documented exposed catheter length, they are to contact an IV RNs to help them evaluate. Usually 2cm doesn't make a big difference, but if the tip of the catheter wasn't originally deep in SVC it could make enough of a difference to warrant replacing the catheter, especially if the tip is pointing irritants/vesicants right at the tunica intima of the opposite vein wall. A radiologist could look at the original chest film and with the migration amount you provide could tell you the expected tip location with that amount of migration.
Of course, if you're not getting blood return and/or having to use cathflo frequently, a repeat xray is definitely warranted.
Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center