Hi everyone! I'm pretty new to the forum, so forgive me, I'll try to be brief. My department has been training a new PICC RN (not a new grad), for the past four months. We are a small community hospital averaging 15-20 PICCs per month, so we don't do a lot of business, however, his success rate still is quite low (40-50% with ultrasound). He has had two patients comment on the "amount of pain" caused by the attempt, and his critical judgement has been a little questionable (pulling a PICC without checking with anyone, etc). Because our volume is so low, I want to continue to give him the benefit of the doubt and continue to work with him, but the low success rate continues to concern me. Any trainers out there willing to give some advice? Thanks.
Patrice Smith, RN
There are many things you can do to help a new PICC nurse along. If he has only been at it for 4 months, based on your frequency of placements, he has done less than 80 PICCs. The learning curve for ultrasound in steep, in some cases, it takes 30-50 attempts at placement before confidence is obtained. Is he working alone? Perhaps paring him with one of your more successful RNs to coach him during placement would be better. It can be difficult to evaluate and determine areas of improvement unless the procedure is observed. Sometimes coaching "at the moment" is most effective. Perhaps a clinical specialist from your catheter company can come in, observe and do some bedside coaching for him--sometimes a fresh perspective is helpful.
Good luck.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
Jeffery Fizer RN, BSN
Patty,
Like Chris says, there can be a long learning curve with ultrasound.
About the painful insertions -
1 - check his technique for instilling lidocaine. Many nurses haven't done a subdermal or even subQ injection in years.
2 - When you miss the first attempt, sometimes nurses forget to re-lido when they move to a different spot. I know it seems basic but I have seen this a lot.
3 - Does he know how to identify nerves on ultrasound?
Aslo, sometimes nurses need a second round of education. Especialy if they are new to PICCs. After placing some lines, it is common for a nurse to have a whole new set of issues/questions.
As Chris suggested, contact your PICC company and see if they can follow up. Anyone can do a class, but if they have a real commitment to you they will help.
thanks,
Mike Brazunas RN
Clinical Specialist
Angiodynamics.
[email protected]
I am a founding member of our PICC service and have taken on the role of primary trainer for new members. I have had some really successful "students" and have had two that never got the hang of PICC insertions. I have had Bard send out one of their clinical trainers on a couple of occassions, which helps me by getting them started while I place the orders for the day. What is the average time that someone should be expected to be under mentorship? My successful "students" have become very competant in about 60-80 hours. If it takes longer than that will they ever succeed? We have an average of 8-10 PICCs per 10hr day for 1 nurse if we get into a situation where more PICCs are ordered then we may get assistance from another nurse in our department. We work out of radiology and we are also responsible for interventiaonl special procedures, CT, U/S. What is a reasonable cut off to say sorry this is not going to work out?
Karrie
Although it has not been formally studied, the conventional wisdom is that US PICC insertion could require up to 50 insertions to master the technique. So it is not a matter of clinical hours worked but actual insertions performed.
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 would watch the specific errors:
If they are BASIC (infection control, pre-assessment, vein selection, etc) then this might not be a good match for this nurse for patient safety unless you can successfully reinforce these concepts.
If the errors are specific to insertion (lidocaine, tourniquet, use of U/S, introducer insertion, wire insertion) then you can work on the specifics of insertion. Causing pain would be another concern: was it the nerve or was it his technique? I have witnessed a few "rough" nurses with treatments other than PICCs and reminded them that there is a human being under those drapes.
If they are more advanced problems (can't get the catheter to advance around the corner, for example) then he may just need more experience.
Attitude: if he is open to suggestions and adapts to what is being instructed, then you may want to to continue to give him more experience to develop the "feel" of insertion. If he knows it all already (!!!!!) then you may have to reconsider if he is the right person for this position.