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carolsrn
PICC placement at home
I would like to hear from anyone whose home infusion organization or nursing agency is still placing PICCs in the patient's home. I am particularly interested in whether you are using ultrasound and if you utilize full barrier precautions.  If so, what brand insertion kit are you using?  Will appreciate input. 
Chris Cavanaugh
It is a standard of care to

It is a standard of care to use ultrasound, MST and maximum barrier precautions to place PICCs, even in a home setting.  Many infusion companies and homecare agencies are placing PICCs using both.  There are kits that have everything you need to place the line, and inexpensive portable (in a suitcase) ultrasound machines available.

 

Chris Cavanaugh, CRNI

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

lynncrni
Then is a mobile xray

Then is a mobile xray service available?

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

Chris Cavanaugh
To reply to the question

To reply to the question regarding mobile x-ray, home patients have two choices, they can go into a hospital or free standing radiology center as an outpatient to have their chest x-ray done and read, or mobile x-ray can come to the home, for a truly homebound patient.   

Chris Cavanaugh, CRNI

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

roger
We do offer this service.
We do offer this service. Standard kits are used always with ultrasound much in the same way as in the hospital with Max barrier precautions observed. Then mobile X-ray is waiting in the wings as we are doing the procedure and the film is processed curbside. This procedure is not really encouraged because you never know what you're getting yourself into in patient's homes (home health nurses can attest to this) especially when trying to do a sterile procedure (i.e. cats jumping around, filthy environment, etc...) We have gone into patient's homes and turn right around because of environments not suitable for the procedure.
Glenda Dennis
This would be a good place
This would be a good place to use ECG guided PICC placement.  A portable ECG machine would be much easier to use than portable x-ray, and you would be certain of the tip placement.
lynncrni
Good idea, but the national

Good idea, but the national standards and instructions for use have not changed to state that this ECG technology alone can be used for tip location. I think this will change over time but we need more published outcome studies. So you still need a chest xray, if only for legal purposes when using ECG guidance. One other thought is that ECG guidance is not a common competency among many nurses yet. This would require adequate competency to be documented. 

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

Robbin George
Lynn--I hope the powers at
Lynn--I hope the powers at AVA read your comment and are preparing a forum focused on ECG guidance for those of us who find the concept interesting and would like to become more versed on the subject--It is clearly an advanced practice that requires a hands on competency   

Robbin George RN VA-BC

Karen Day
Karen Day's picture
I too am interested in
I too am interested in learning more about the ECG concept, but I fear it has a lot of limitations.  What about patients who are in atrial fib or in some type of block, is it true that this would not be able to be used in these situations and thus would require a chest X-Ray.  Also, for in-patient settings, your patient must be on a monitor in order to use these ecg devices - for those who are not, are we going to have to have an additional charge to monitor these patients for an hour or perform EKG during picc insertion and if so, would the cost of that be cheaper than the Chest XRay.  I know that you could use a portable monitor, but in this day and age, nothing is "free" at a hospital - whenever they can find a way to tack on a charge they will.  If nothing else, the charge for a picc insertion will increase to offset the cost of the ecg device, wires (if applicable) and portable monitor/monitoring.  I think this is a great concept, and through vascular access nurses input the device will eventually be valuable to all, but we need to critique it strongly in order to achieve the outcome we so desire.
PMRMD
Regarding the concerns of

Regarding the concerns of Karen Day, R.N. :

Karen - ECG guidance actually has few limitations and will work in the majority of patients in which you wish to place a PICC:

Since it requires an SA nodal signal, it requires a sinus rhythm. It does not work in atrial fibrillation or atrial flutter. It will not work in patients who are pacemaker dependent.  It will work in patients who have a demand pacemaker for slow rhythms (assuming their current sinus rhythm is faster than the demand rate).

As for "blocks" :

AV BLOCKS : ECG guidance will not work in the setting of third degree AV block ("complete heart block") if  the patient is pacemaker dependent or does not have a sinus rhythm. It will work in the more common first degree (very common) and second degree (much less common) AV block as long as the rhythm originates in the SA node (which it usually does). AV block may affect the PR interval (the time  it takes for the initiating signal to travel from the SA node and start depolarizing the ventricles) but not the shape of the P wave (which represents the actual depolarization of the atrial muscle and occurs above the level of the AV node) which is what you use in ECG guidance.

BUNDLE BRANCH BLOCKS : Since bundle branch blocks occur below the level of the atria and AV node, they will affect the shape of the QRS but not the P wave (or PR interval) . They will not affect ECG guidance.

Glad you asked? While the above may seem confusing, the bottom line is that ECG guidance will work in the vast majority of your patients. ECG guidance is far more accurate than chest x-ray or Navigational systems / surface landmarks, correlating up to 100% of the time with echocardiographic tip location (as opposed to 60-80% with the other methods). (SEE http://www.pacerview.com/index_files/ECG_GUIDANCE_FOR_CVC_PLACEMENT_IN_THE_LITERATURE.htm). If you have other technical questions or concerns, you can email [email protected].  

As for the monitor, some hospital administrators are finding that the cost and time savings ECG guidance offers, as well as the improved patient care (expedited procedures, less radiation, etc...) as well as the benefits of freeing up their radiology technicians and radiologists to do other things, may make the donation of a dedicated monitor financially feasible. (Imagine if you save $70-$100/ line, it wouldn't take many lines to pay off a monitor.)  While not thought of as an ECG monitor, many 12 lead ECG machines have a screen that can be used for real time display and are widely available in hospitals as well.

Glenda Dennis
ECG placement does have some

ECG placement does have some limitations.  You cannot use it in patients with atrial fib/flutter or AV block.  You would have to use a portable ECG machine.  It doesn't matter if it is a 3 lead or 5 lead system.  You also need a very inexpensive pacerview with grabbers in order to get the signal from the guidewire.  The cost is significantly cheaper than a chest x-ray.  The pacerview is a one time cost of under $200.00 and the grabber is a one time use item at about $15.00 each.  You can look for these items on the pacerview website.  (I am not a vendor) 

I took this technique with documentation of correlation of ECG with the CXR to our physician committee's and was approved to use it in our hospital.  I usually check for subsequent chest x-rays for the inpatients and find the technique very accurate.

MarkCVL
Know that the AVA Scientific
Know that the AVA Scientific Meeting, Sept 15-17 will be addressing this issue in a multi-presenter session.  Studies with new compelling data will be presented.  Hope to see you there!
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