Legal Issues: Â PICC Line and Midline Program
  ÂOutline:  1.      State regulations regarding PICC Line or Midline placement2.      Nursing qualifications to place a PICC Line or Midline3.      Nursing competency4.      Policies and Procedures for PICC Lines and Midlines5.      Patient consent for PICC Line or Midline placement   State Regulations regarding PICC Line or Midline placement:  As of 1994, all fifty states either specifically include PICC Line placements within the scope of nurse’s practice, or make no statement either way.  Every state currently has at least one or more nursing based PICC Line insertion programs.  While it is legal for nurses to insert PICC Lines throughout the United State, each state does differ on restrictions and provisions it imposes on placements.  For example: some states allow no PICC Line placement in the home and some states require x-ray verification of PICC Line tip position.  It is important to know what your states policy is regarding PICC Line placement.  The attached table (taken from the 1999 “Bard Access Systems PICC / Midline Training Manual†& the INS Course “Peripherally Inserted Central Catheter (PICC) Midclavicular and Midline Catheters†published in 1999) looks at the position of each State Nursing Board with regard to suturing, lidocaine usage, home placements etc.  In addition, a table of State Board of Nursing addresses is available for those individuals wanting updated information.  With technological changes nurses are investigating the use of modified SeldingerÃ’technique.  As you will see from the tables most states do not restrict the utilization of this technique for those states that do it is best to contact them directly for an opinion.  When addressing a state it is important to identify other states where modified SeldingerÃ’ technique is utilized successfully by nursing and the improved patient outcomes that may result from using this technique.  It is also important to confirm in writing that the modified SeldingerÃ’ technique does not utilize the physician approach of threading a catheter over a guide-wire.   But rather it uses a short stylet (15 cm.) wire to ascertain vein patency ad then utilizes a dilator over the wire (60 cm) to actually thread the PICC Line.  The technique for SeldingerÃ’ versus modified SeldingerÃ’ vary greatly.  Note:  There is no State Board of nursing restrictions on the issue of Registered Nursing placement of Midline catheters.    Nursing qualifications to place a PICC Line or Midline:  INS (Intravenous Nursing Society  (617) 441-3008) is the only organization to reference qualifications for a nurse placing a PICC Line or Midline catheter.  This information has been referenced from the Intravenous Nurses Society Position Paper entitled “Peripherally Inserted Central Catheters (PICCs) and the Intravenous Nursing Society Course entitled “Peripherally Inserted Central Catheter (PICC) Midclavicular and Midline Catheters Assessment and Planning, Care and Maintenance, Complications†ÂRecommended criteria & components of an institutions PICC Line and Midline program
1.      Choose a clinician that is a licensed physician or licensed registered nurse as determined by state regulations2.      Choose a clinician that is educated with demonstrated competency and proficiency in intravenous therapyq       Including the insertion of short peripheral cathetersq       Solid understanding of central venous catheters3.      Provide the registered nurse with an educational program for PICC insertionq       The educational program must include theoretical content and clinical instruction on an anatomical model4.      Ascertain that the nurse has validated initial competency.   There must be an ongoing continuum of competencyq       Establish a program for maintaining clinical competency for device insertionü      Which includes the knowledge and ability to perform the insertion safelyü      Which includes knowledge of care and maintenance strategies5.      Program and clinician qualifications must be consistent with state and federal laws 6.      Documentation of insertions and outcomes analysis must be performed.  Each organization must set up its own requirements for initial qualifications and re-qualification. ÂRecommended Education for Clinicians inserting PICC Lines and Midline Catheters
1. Â Â Â Â Â Documented 1600 hours of clinical practice with I.V. therapy responsibilities during the previous two years
2. Â Â Â Â Â Documented experience in central venous device management
3. Â Â Â Â Â Completion of a course in PICC and extended duration peripherally inserted catheter instruction:
q       The cognitive portion of this program must be completed through
(a) Â Â Â Classroom attendance
(b) Â Â Self-study modules
(c) Â Â Â Interactive training techniques
(d) Â Â Combination of 1,2, and 3
Recommended education for the clinician caring for PICC Line and Midline catheters:1.      The nurse should be knowledgeable in the following areas:q       All routine nursing care tasks including: dressing change, tubing/injection cap change, flushing, and blood withdrawal proceduresq       All possible complications associated with the chosen device and the recommended methods to manage those complicationsq       Performance improvement and documentation of outcomesq       The design, indications, contraindications, precautions, for the specific device being used as written in the manufacturer’s literatureq       The methods of infusion through the device including:Ø      Possible flow ratesØ      Pressure ratings of catheterØ      Infusion pressure from the chosen flow control deviceØ      Considerations for manual injections with syringesq       Additional resource people to contact for assistanceØ      Nurse who inserted the deviceØ      Clinical support from manufacturer  Recommended qualifications for clinicians teaching PICC Line or Midline Catheter insertion:1.      Must meet all of the recommendations for clinicians inserting these devices 2.      Documented (5) successful catheter insertions in order to mentor or observe the insertions of another clinical – Precepting Criteria3.      And (25) insertions in order to teach PICC Line or Midline catheter insertion – Teaching Criteria4.      The instructor should have documented understanding of the principles of adult learning and employ these principles in:Ø      Assessing the learner’s needsØ      Program development processesØ      Appropriate teaching and learning strategiesØ      Evaluation processes ÂNursing competency:
 INS (Intravenous Nursing Society) recommends that an institution create a set criteria to evaluate the competency of nurses learning to place PICC Line / Midline catheters.  This process should be ongoing such as a yearly competency of nurses placing PICC Line or Midline catheters.  However, it should be noted that nurses can not be certified in PICC Line or Midline catheter placement or care and maintenance.  The formal definition for certification involves taking a test from an organization or state with a certification board.  However, nurses may be qualified  (deemed competent) for PICC Line or Midline Catheter placement or care and maintenance, in your particular institution.  It has been suggested by some State Boards of Nursing that nurses observe (1) – (3) successful insertions and performs under supervision (3) – (5) successful insertions.  Some State Boards of Nursing require that the employer keep this documentation on file.   For your convenience a template has been developed for clinician competency in the form of a checklist.  Please fill free to utilize this template in creating your own institution competency evaluation form. ÂQualification Requirements for
 PICC Line & Midline Catheter Insertion
 Qualifying training, experience and evaluation:  q       Successfully complete theoretical course with Didactic (with supervised practicum)  q       Successful insertion PICC Line and / or Midline catheter on Peter PICCÃ’ or practice arm   q       Observe ______ successful insertions by a qualified clinician placing PICC Lines or Midline catheters Âq       Be observed placing ______ successful insertions by a qualified preceptor placing PICC Lines and / or Midline catheters (see qualification skills checklist)
   Annual re-qualifying experience and evaluation:  q       Minimum insertion of _____ catheters per year must be completed to maintain competency.  The employee performed _______ PICC Line insertion ________year  and __________Midline insertions _________ year  q       Annual evaluation by qualified preceptor placing PICC Lines and / or Midline catheters.  The clinician is observed successfully placing _______ PICC Lines and or Midline catheters a year in accordance with the qualification skill competency checklist.  q       Review of quality management data of PICC Line and Midline catheters placed during the past year  q       Review of current manufacturer information, literature, guidelines, standards on PICC Line and Midline catheter insertion, care and maintenance, complication management and outcomes  ÂCopy of recorded training competency to be kept in employees personnel file
    Qualification Skills Checklist forPICC Line and / or Midline Insertion    Clinician Name/Title:  _______________         Employee Identification No.  __________ Â
Activity Performedq       Observation q       Preceptq       Annual Competency | Date Activity | Preceptor Name Preceptor Title | Patient MR # | Competency    Yes           No | |
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Competency SkillPICC Line / Midline Catheter Placement  | Satisfactory | Not Satisfactory |
Prior to PICC Line or Midline Catheter insertion the competent clinician will: | Â | Â |
Review patient chart for: q       Physician order (for Midline catheter insertion the physician order is for fluids or a standard peripheral catheter)q       Patient allergiesq       Patient coagulation statusq       Patient contradictions to vascular access placementq       Patient labs and medial history  |  |  |
Explain: q       Procedure to patientq       Catheter management to patientq       Obtain signed consent form (PICC Line only) |  |  |
Identify, Evaluate and Select: q       Appropriate veinq       Appropriate insertion siteq       Location of artery q       Choose appropriate catheter length and gauge size q       Position patient properly q       Correctly measures patient properly for catheter tip location q       (optional) measures arm width |  |  |
Set-Up q       Gathers appropriate equipmentq       Wash Handsq       Set up equipment and sterile field with sterile technique / Utilize universal precautions / Utilize full barrier precautions q       Preflushed catheter / syringes / extension sets etc.  (trimming optional) |  |  |
During PICC Line and Midline Insertion: | Â | Â |
A.     Perform appropriateq       Skin Prep (place tourniquet /change gloves)q       Sterile draping of insertion arm and site |  |  |
Competency SkillPICC Line / Midline Catheter Placement  | Satisfactory | Not Satisfactory |
During PICC Line and Midline Insertion: | Â | Â |
Perform Appropriate:q       Venipuncture / observe flashbackq       Modified SeldingerÃ’ (optional)ü      Use of wireü      Use of Scalpelü      Use of dilatorq       Advance Catheter (check patient positioning of head)q       Remove introducer (dilator)q       Remove guidewireq       Attach hub (GroshongÃ’)q       Ascertain blood returnq       Suture or utilize securing methodq       Apply dressing  |  |  |
Upon Completion of insertion: | Â | Â |
Document in patient medical record: q       Allergiesq       Site limitationsq       Blood coagulation problemsq       Patient complications that occurred during insertionq       Contraindications to usage of line placedq       Patient teaching / Patient consentq       Anesthetic usedq       Catheter gauge size (french), number of lumens, length, suspected tip position (awaiting x-ray), vein and insertion siteq       Describe general sterile insertion and problems encounteredq       Arm circumference (optional)q       Catheter lot number and brandq       Catheter method of securement and dressingq       Blood return and flushingq       Contact Radiology for chest x-ray |  |  |
Provide the patientq       Patient care handbook  and care instruction |  |  |
Provide the nursing staff | Â | Â |
q       Patient status reportq       Instructions:  flush protocol, hot packs, dressing changes |  |  |
Competency SkillPICC Line / Midline Catheter Placement  | Satisfactory | Not Satisfactory |
Upon Completion of insertion: | Â | Â |
Contact Radiology q       Confirm catheter tip position and re-position / re-dress if needed  or send to Interventional Radiology for re-positioning if availableq       Ascertain nursing staff has been contacted and physician regarding catheter tip position and usageq       Document approval from Radiology or Attending Physician to use catheter for infusion |  |  |
For Discontinuation of catheter: | Â | Â |
A. Â Â Â Â Review order for catheter removal | Â | Â |
B. Â Â Â Â Assess need for catheter tip culture and or blood cultures (perform if needed) | Â | Â |
C.     Removal processq       Wash hands / Utilize universal precautionsq       Assess patient and siteq       Speed of removal (slow)  Observe how clinician handles complicationsü      If unable to remove apply heat and waitü      If unable to remove contact physician for possible x-ray or venogram needq       Confirm catheter measurement  |  |  |
D.     Documentation post removalq       Patient complications during removalq       Measurement of catheter length compared to insertion lengthq       Patient toleranceq       Cultures or labs sent for analysis |  |  |
E.      Report to Staff Nurseq       Any complications during removal of catheter  / How to handle complicationsq       Patient tolerance |  |  |
(Information taken from “Nurses and The Law A Guide to Principles and Applications†by Nancy J. Brent published in 1997 by W.B. Saunders)
 ÂWho Should Obtain the Consent?  1.      Physician who is doing the procedure2.      Clinician (Nurse) who is doing the procedure3.      Key:  Who is performing the procedure and documenting the consent in the patent medical records and could testify as to what was said to the patient     Information to be Provided During Consent:  1.      Patient diagnosis2.      Type of treatment or procedure or medication3.      Explanation of procedure or treatment or medication and its intended purpose4.      Hoped for benefits from the proposed treatment, procedure or medication (with no guarantees to outcomes!)5.      Material risks, if any of the treatment, procedure or medication6.      Alternative treatments, if any7.      Prognosis if the recommended care, procedure, treatment, or medication are refused   Documentation of Informed Consent:  1.      Blanket consent forms are the type of consents signed on patient admittance which is not treatment specific.  It arguably gives a health care provider unbridled authority and discretion to provide whatever treatment is decided upon by the provider.  These are not recommended for treatment specific procedures.  It is up to your institution to determine if PICC Line and Midline insertion require a treatment specific consent.2.      Battery Consents protect health care providers against allegations of battery and include information specific to a particular procedure or treatment.  They are different from treatment specific consent forms, which are detailed.3.      Treatment Specific Consents are written and are very detailed in description of the procedure, complications and alternatives.  These are often used for the placement of central lines (PICC Lines). Â
PICC Â LINE Â INSERTION Â INFORMED Â NURSING Â CONSENT
AND Â AGREEMENT Â FOR Â TREATMENT
ÂI agree to have a Peripherally Inserted Central Catheter (PICC) placed in my arm.
ÂThe catheter insertion procedure, care, maintenance and, complications have been explained to me and I understand them.
ÂI understand that this is not the only way I can receive my medication. I understand that my health care team has determined that the PICC line would be the safest and most effective means of giving my medication at this time.
ÂAlternative vascular access device options ________________________________________________ Â of giving my
medication have been explained to me and I have chosen this one.
ÂI realize this procedure will be performed only by a nurse who has been specially
trained and certified to insert PICC lines. Â
ÂMy catheter will be inserted by ____________________________.
ÂI realize that this is an invasive procedure and has certain risks such as catheter or air embolism, arterial puncture, infection, irregular heartbeat and venous thrombosis.
ÂI understand that while the catheter will be placed in my upper arm the end of the
catheter will come to rest in an area near my heart.
ÂI have the right to voice any questions I may have about this procedure and I expect knowledgeable answers.  I also understand that (Institution Name) has specific policies relating to the care which will be given to me and include provisions for termination of services at my request, the request of  physician, and/or at the decision of the agency.
ÂI agree to abide by the terms of these policies in all respects.
 Â__________________________                          _________________________
Patient Signature                                                                              Date
Â__________________________ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â __________________________
Witness                                                                                              Date
 Policy and ProcedurePICC Line (Peripherally Inserted Central Catheter)
  Policy:  Product Description and Indications:  q       The Per-Q-CathÃ’ PICC Line and the GroshongÃ’ PICC Line is indicated for short or long term peripheral access to the central venous system for intravenous therapy and blood sampling.  q       The Per-Q-CathÃ’ Midline and GroshongÃ’ Midline catheters are indicated for short term or long term peripheral access to the peripheral system for selected intravenous therapies and blood sampling (see contraindications)q       For blood therapy it is recommended that a 4 French or larger catheter be used.q       PICC Line and Midline catheters are made from specially formulated and processed medical grade materials for reliable long (greater than 30 days) and short (less than 30 days) vascular accessq       PICC Line catheters are an effective vascular access device in adults, children and infants.  q       Patient’s who may benefit from a PICC Line are mid to long term IV therapy.  These patients include (but are not limited to): chronic disease, have limited venous access, receive vesicant / irritant drugs, need antibiotic therapy, etc.  q       PICC lines have been an accepted technology since 1975, with extensive published research.  Contraindications:  q       The device is contraindicated whenever: ·        The presence of device related infection, device related bacteremia, or device related septicemia is known or suspected ·        The patient’s body size is insufficient to accommodate the size of the inserted device ·        The patient is known or suspected to be allergic to materials contained in the device ·        Past irradiation of prospective insertion site ·        Previous episodes of venous thrombosis or vascular surgical procedures at the prospective placement site ·        Local tissue factors that will prevent proper device stabilization and/or accessq       Midline catheter placement is contraindicated for patients requiring any of the following: ·        Solutions with final glucose concentrations above 10 percent ·        Solutions with protein concentrations above 5 percent ·        Continuous infusion of vesicantsWarnings:  q       Polyurethane Per-Q-CathÃ’ (only) ·        Use of ointments can cause failure of the device ·        Use of alcohol or acetone based solutions should not be used to clean the polyurethane Per-Q-CathÃ’ catheter or skin site as the catheter may be adversely affected.  Providone Iodine is the recommended antiseptic solution to be usedq       Intended for single patient use.  Do not reuse.  Any device that has been contaminated by blood should not be reused or resterilizedq       Providone-iodine is the suggested antiseptic to use.  Acetone and tincture of iodine should not be used.  10% acetone / 70% isopropyl alcohol swabsticks used for dressing changes may be used for silicone Per-Q-CathÃ’ and GroshongÃ’ PICC and Midline cathetersq       After use thus product may be a biohazard.  Handle and discard with universal and blood / body fluid precautions in mind (state, federal, local laws and regulations and accepted medical practice)   Qualification for Insertion:  q       A licensed physician or a registered nurse who has demonstrated competency and have been educated in advanced intravenous therapy may insert a PICC Line or Midline catheterq       PICC Line and Midline catheters are commonly inserted into (but not limited to) the basilic, cephalic, median cubital veins of the antecubital area and upper arm.  Care and maintenance shall be performed by persons knowledgeable of the risks involved and qualified in the proceduresq       The tip of the PICC Line resides in the superior vena cava.  The tip of the midline lies in the peripheral vein system below the axillary veinq       A physician’s order is needed for PICC insertion.  q       Tip verification is required by radiographic confirmation prior to initiation of infusion therapy (PICC Line only)q       For Bard Access Systems products:  Per-Q-Cath PICC / Midline or Groshong PICC / Midline information, literature or video (insertion & maintenance techniques) may be obtained by contacting (800)-443-3385  Precautions:  q       Follow universal precautions when inserting and maintaining cathetersq       Follow all contraindications, warnings, cautions, precautions, and instructions for all infusates specified by the manufacturerq       Use aseptic technique whenever the catheter lumen is opened or connected to other devicesq       The fluid level in the catheter will drop if the connector is held above the level of the patient’s heart and opened to air.  To prevent a drop in the fluid level (and thus air entry) while changing injection caps, hold the connector below the level of the patient’s heart before removing the injection cap.  Procedure:  1.      Prior to beginning the placement procedure, do the following:q       Examine the package carefully before opening to confirm its integrity and that the expiration date has not been passed.  Do not use package if it is damaged, opened or the expiration date has passed.  Inspect kit for inclusion of all componentsq       Flush the catheter with sterile normal saline or heparinized saline prior to use.   2.      To avert device damage and /or patient injury during placement:q       Avoid accidental device contact with sharp instruments and mechanical damage to the catheter material.  Use only smooth edged atraumatic clamps or forcepsq       Avoid perforating, tearing, or fracturing the catheter when using a styletq       Do not use catheter if there is any evidence of mechanical damage or leakingq       Avoid sharp or acute angles during implantation which could compromise the patency of the catheter lumen(s)q       Do no place suture around the catheter as sutures may damage the catheter or compromise catheter patency.  GroshongÃ’ catheters (only) the provided suture wings will secure the catheter without compromising catheter patencyq       Do not cut sylet  3.      After placement, observe the following precautions to avoid device damage and / or patient injuryq       Do not use the device if there is any evidence of mechanical damage, or leaking.  Damage to the catheter may lead to rupture, fragmentation and possible embolism and surgical removal.  If the GroshongÃ’ catheter is damaged, it should be clamped with an atraumatic clamp, or kinked closed if a clamp is unavailable, until the catheter can be replaced or repaired. q       Use only leur lock connections for accessories and components used in conjunction with this deviceq       If signs of extravasation exist discontinue injections.  Begin appropriate medical intervention immediatelyq       Infusion pressure greater than 25 psi (172 kPa) may damage blood vessels and viscus and is not recommendedq       Do not use a syringe smaller than a 10 cc (smaller syringes generate more pressure than larger syringes).  A two-pound weight of equivalent force on the barrel of a 3-cc syringe generates in excess of 45 PSI.  The same two-pound weight on the barrel of a 10-cc syringe generates less than 7 PSI of pressure.q       Do not infuse against resistance.  Follow standard institution policy / procedure to clear a blocked catheter q       Published data indicates that a PICC Line may be damaged by the use of high pressure injectors in Radiologyq       Caution should be used when taking blood pressures on the arm of a patient with a PICC Line or Midline catheter in place as that could damage the catheterq       Caution should also be used by taking peripheral phlebotomies at or above the insertion site of a PICC Line or Midline as that could damage the catheter  Possible Complications: Âair embolism | Bleeding | Brachial plexus injury | Cardiac arrhythmia | cardiac tamponade |
Catheter erosion through the skin | Catheter embolism | Catheter occlusion | Catheter related sepsis | endocarditis |
Exit site infection | exit site necrosis | Extravasation | Fibrin sheath formation | hematoma |
Intolerance reaction to implantable device | Laceration of vessels or viscus | Perforation of vessels or viscus | Phlebitis | spontaneous catheter malposition or retraction |
Thrombo-embolism | Vessel thrombosis | vessel erosion | Risks normally associated with local or general anesthesia, surgery and post operative recovery | Â |
Technique for GroshongÃ’ single lumen PICC Lines and Midline catheters – Safety ExcaliburÃ’ Introducer  | Technique for GroshongÃ’ dual lumen PICC Line and Midline catheters & All Per-Q-CathÃ’ products Safety ExcaliburÃ’ Introducer | |
q       Remove introducer needle cover | q       Remove Introducer needle cover | |
q       Stabilize vein below intended access site with non dominant had  (unless using Site RiteÃ’ which is in non dominant hand) | q       Stabilize vein below intended access site with non dominant had  (unless using Site RiteÃ’) | |
q       Grip only the introducer flashback chamber during the insertion | q       Grip only the introducer flashback chamber during insertion.  Do not apply excessive pressure to the T-handles (peel apart sheath) | |
q       Perform venipuncture using shallow technique 15 – 30 degree angle.  For Site RiteÃ’ place introducer into needle guide and perform venipuncture.   Use needle guide angle to guide needle puncture. | q       Perform venipuncture using shallow technique 15 – 30 degree angle.  For Site RiteÃ’ place peel away sheath (if available) into needle guide and perform venipuncture.   Use needle guide angle to guide needle puncture. | |
q       After confirmation of blood return, lower introducer angle and advance approximately ¼ to ½ inches further to ensure positive cannulation of the vein.  For Site RiteÃ’ after confirmation of blood return pull needle from introducer. | After confirmation of blood return, lower peel apart sheath angle and advance approximately ¼ to ½ inches further to ensure positive cannulation of the vein.  For Site RiteÃ’ after confirmation of blood return pull needle from peel apart sheath . | |
q       Holding the needle stationary, advance the introducer into the vessel by pushing forward.  Stabilize introducer, release tourniquet | q       Holding the needle stationary, advance the peel apart sheath into the vessel by pushing forward.  Stabilize introducer, release tourniquet | |
q       Support the introducer to avoid displacement.  Apply slight pressure to the vessel above the insertion site to minimize blood flow.   Release the tourniquet.  Withdraw the needle from the introducer.  | Support the peel apart sheath to avoid displacement.  Apply slight pressure to the vessel above the insertion site to minimize blood flow.   Release the tourniquet.  Withdraw the needle from the peel apart sheath. | |
q       Apply pressure with nondominant hand over cannulated vein at tip of cannula to control bleeding and minimize blood exposure  | q       Apply pressure with nondominant hand over cannulated vein at tip of cannula to control bleeding and minimize blood exposure | |
q       Insert the catheter through introducer (may use smooth non-grooved pick-ups to advance the catheter).  Advance the catheter slowly.  For central placement (PICC only) when the tip has advanced to the shoulder, have the patient turn head (chin on shoulder) towards the insertion side to prevent possible cannulation into the jugular vein. | q       Insert the catheter through peel apart sheath (may use smooth non-groved pick-ups to advance the catheter).  Advance the catheter slowly.  For central placement (PICC only) when the tip has advanced to the shoulder, have the patient turn head (chin on shoulder) towards the insertion side to prevent possible cannulation into the jugular vein.    For peel apart sheath you may remove the sheath after the catheter tip has been advanced 10 cm | |
q       Continue advancing catheter to measured point for PICC Line or Midline tip position.  Catheter depth markings are in centimeters.  (Arm at 90 degree angle)  If difficulty is encountered, moving arm to shoulder height may ease passage. Warning:  for PICC Line avoid positioning the catheter tip in the right atrium. | q       Continue advancing catheter to measured point for PICC Line or Midline tip position.  Catheter depth markings are in centimeters. (Arm at 90 degree angle)  If difficulty is encountered, moving arm to shoulder height may ease passage. Warning:  for PICC Line avoid positioning the catheter tip in the right atrium | |
q       Stabilize the catheter position by applying pressure to the vein distal to the introducer.  Withdraw the introducer from the vein.  Slide the introducer catheter to the end of the PICC Line or Midline.  Remove the suture wing from the delivery card.  Squeeze the suture wing together so that it splits open.  Place the wing around the catheter near the venipuncture site.  Caution Note:  To minimize the risk of embolization the suture wing must be secured in place   | q       Stabilize the catheter position by applying pressure to the vein distal to the split apart sheath.    Withdraw the split apart sheath from the vein and away from the site.  Split the sheath and peel it away from the catheter.q       For GroshongÃ’ only: Remove the suture wing from the delivery card.  Squeeze the suture wing together so that it splits open.  Place the wing around the catheter near the venipuncture site.  If the “Y†adapter of the dual lumen catheter is at the insertion site, the suture wing will not be needed  Caution Note:  To minimize the risk of embolization the suture wing must be secured in place | |
q       Stabilize the catheter position by applying light pressure to the vein distal to the insertion site.  Slowly remove the stylet.  Caution:  Never use force to remove the stylet.  Resistance can damage the catheter.  If resistance or bunching of the catheter is observed, stop stylet withdrawal and allow the catheter to return to normal shape.  Withdraw both the catheter and stylet together approximately 2 cm and reattempt stylet removal.  Repeat this procedure until the stylet is easily removed. | q       Per-Q-CathÃ’ only – Disconnect the T-Lock form the catheter leur connector.  Stabilize the catheter position by applying light pressure to the vein distal to the insertion site.  Slowly remove the T-Lock and styletq       GroshongÃ’ dual lumen – Stabilize the catheter position by applying light pressure to the vein distal to the insertion site.  Slowly remove the stylet.  q       All catheters - Caution:  Never use force to remove the stylet.  Resistance can damage the catheter.  If resistance or bunching of the catheter is observed, stop stylet withdrawal and allow the catheter to return to normal shape.  Withdraw both the catheter and stylet together approximately 2 cm and reattempt stylet removal.  Repeat this procedure until the stylet is easily removed. | |
q       Modification of catheter length for single lumen Groshong Catheters – Using a sharp scalpel or sterile scissors carefully cut the catheter leaving at least 4 cm – 7 cm of the catheter for connector attachment.  Insect the cut surface to assure there is no loose materialq       Attach connector to single lumen catheter – Retrieve the oversleeve portion of the connector and advance it over the end of the catheter.  If you feel some resistance while advancing, gently twist back and forth or spin to ease its passage over the catheter.  Gently advance the catheter onto the connector blunt until it butts up against the colored plastic body.  The catheter should lie flat on the blunt without any kinks.  With a straight motion slide the oversleeve portion of the connector and the winged portion of the connector together, aligning the grooves on the oversleeve portion of the connector with the barbs on the winged portion of the connector.  Do not twist.  Note:  Connector portions must be gripped on plastic areas for proper assembly.  Do not grip on distal (blue) portion of oversleeve.  Advance completely until the connector barbs are fully attached.  A tactile locking sensation will confirm that the two pieces are properly engaged.  (There may be a small gap between the oversleeve and the winged portion of the connector).  q       Aspirate and flush – attach primed extension set and or saline filled syringe.  Aspirate for adequate blood return and flush each lumen of the catheter with 10 cc of normal saline to ensure patency.  Note:  When infusion volume is a concern in small or pediatric patient’s flush with 3 cc per lumen.  Note:  If the single lumen catheter will not aspirate and infuse immediately after insertion and connector assembly, the catheter may be kinked within the connector assembly.  If this is the case, trim the catheter just distal to the connector oversleeve (blue) and attach a new connector.  If this situation persists, verify radiographically that the catheter is not kinked inside the vessel.  Caution:  To reduce potential for blood backflow into the catheter tip, always remove needles and needless caps slowly while injecting the last 0.5 cc of saline.  | q       Attach primed extension set and / or saline filled syringe.  q       Aspirate for adequate blood return and flush each lumen of the catheter with 10 cc of normal saline to ensure patency.  Note:  When infusion volume is a concern in small or pediatric patient’s flush with 3 cc per lumen.q       If the single lumen catheter will not aspirate and infuse immediately after insertion. If this situation persists, verify radiographically that the catheter is not kinked inside the vessel.q       Caution:  To reduce potential for blood backflow into the catheter tip, always remove needles and needless caps slowly while injecting the last 0.5 cc of saline. | |
q       Verify placement (PICC only) – Verify catheter tip radiographically | q       Verify placement (PICC only) – Verify catheter tip radiographically | |
q       Securing the GroshongÃ’ catheter:  Suture wing near venipuncture.  Place two anchor tapes over suture wing or bifurcation.  Form “s†curve in catheter.  Place 3rd anchor tape sticky side up under catheter just above suture wings or bifurcation.  Chevron 3rd anchor tape on top of first (2) anchor tapes.  Place transparent dressing over suture wing or bifurcation and catheter hubq       Apply Stat-LockÃ’ if used in accordance with manufacturer instructions under transparent dressing to secure catheter | q       Securing the GroshongÃ’ catheter:  Suture wing near venipuncture.  Place two anchor tapes over suture wing or bifurcation.  Form “s†curve in catheter.  Place 3rd anchor tape sticky side up under catheter just above suture wings or bifurcation.  Chevron 3rd anchor tape on top of first (2) anchor tapes.  Place transparent dressing over suture wing or bifurcation and catheter hubq       Securing the Per-Q-Cath:  Place S-Curve.  Place 1st anchor tape over wings or bifurcation.  Cover site and 1st anchor tape with transparent dressing up to hub, but not over hub.  Place 2nd anchor tape sticky side up under hub and close to transparent dressing.  Wedge tape between hub and wings.  Anchor only one hub of dual lumen catheter.  Chevron 2nd anchor tape on top of transparent dressing and place 3rd anchor tape over hubq       Apply Stat-LockÃ’ if used in accordance with manufacturer instructions under transparent dressing to secure catheter | |
Micro-IntroducerÃ’Technique for all Groshong and Per-Q- Cath PICC Line and Midline Catheters  |
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q       Remove introducer needle cover |
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q       Stabilize vein below intended access site with non dominant had  (unless using Site RiteÃ’ which is in non dominant hand) |
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q       Grip only the introducer flashback chamber during the insertion |
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q       Perform venipuncture using shallow technique 15 – 30 degree angle.  For Site RiteÃ’ place introducer into needle guide and perform venipuncture.   Use needle guide angle to guide needle puncture. |
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q       After confirmation of blood return, lower introducer angle and advance approximately ¼ to ½ inches further to ensure positive cannulation of the vein. |
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q       Holding the needle stationary, advance the introducer into the vessel by pushing forward.  Stabilize introducer, release tourniquet. |
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q       Support the introducer to avoid displacement.  Apply slight pressure to the vessel above the insertion site to minimize blood flow.   Release the tourniquet.  Withdraw the needle from the introducer.  |
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q       Note:  if using Protect-IVÃ’ from Johnson and Johnson follow manufacturer guidelines to activate safety mechanism.  Push safety shield over needle until you hear an audible click. |
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q       Note:  if using Protect-IVÃ’ from Johnson and Johnson follow manufacturer guidelines to activate safety mechanism.  Push safety shield over needle until you hear an audible click. |
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q       Apply pressure with nondominant hand over cannulated vein at tip of cannula to control bleeding and minimize blood exposure |
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q       Insert the flexible end of the guidewire into the needle.  Advance the guidewire as far as appropriate. |
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q       Gently withdraw and remove the needle, while holding the guidewire in place.  |
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q       Using the surgical blade make a small nick alongside each side of the guidewire. |
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q       Advance the small sheath and dilator together as a unit over the guidewire, using a slight ortational motion.  Advance the unit intot he vein as far as appropriate. |
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q       Withdraw the dilator and guidewire, leaving the small sheath in place. |
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o      Insert the catheter through introducer (may use smooth non-groved pick-ups to advance the catheter).  Advance the catheter slowly.  For central placement (PICC only) when the tip has advanced to the shoulder, have the patient turn head (chin on shoulder) towards the insertion side to prevent possible cannulation into the jugular vein. |
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q       Continue advancing catheter to measured point for PICC Line or Midline tip position.  Catheter depth markings are in centimeters.  (Arm at 90 degree angle)  If difficulty is encountered, moving arm to shoulder height may ease passage. Warning:  for PICC Line avoid positioning the catheter tip in the right atrium. |
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q       Stabilize the catheter position by applying pressure to the vein distal to the introducer.  Withdraw the introducer from the vein and away from the site.  Split the sheath and peel it away from the catheter. For GroshongÃ’:  Remove the suture wing from the delivery card.  Squeeze the suture wing together so that it splits open.  Place the wing around the catheter near the venipuncture site.  Caution Note:  To minimize the risk of embolization the suture wing must be secured in place   |
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q       Per-Q-CathÃ’ only – Disconnect the T-Lock form the catheter leur connector.  Stabilize the catheter position by applying light pressure to the vein distal to the insertion site.  Slowly remove the T-Lock and styletq       GroshongÃ’ dual lumen – Stabilize the catheter position by applying light pressure to the vein distal to the insertion site.  Slowly remove the stylet.  q       All catheters - Caution:  Never use force to remove the stylet.  Resistance can damage the catheter.  If resistance or bunching of the catheter is observed, stop stylet withdrawal and allow the catheter to return to normal shape.  Withdraw both the catheter and stylet together approximately 2 cm and reattempt stylet removal.  Repeat this procedure until the stylet is easily removed. |
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q       GroshongÃ’ single lumen only:  Modification of catheter length– Using a sharp scalpel or sterile scissors carefully cut the catheter leaving at least 4 cm – 7 cm of the catheter for connector attachment.  Insect the cut surface to assure there is no loose materialq       Attach connector to single lumen catheter – Retrieve the oversleeve portion of the connector and advance it over the end of the catheter.  If you feel some resistance while advancing, gently twist back and forth or spin to ease its passage over the catheter.  Gently advance the catheter onto the connector blunt until it butts up against the colored plastic body.  The catheter should lie flat on the blunt without any kinks.  With a straight motion slide the oversleeve portion of the connector and the winged portion of the connector together, aligning the grooves on the oversleeve portion of the connector with the barbs on the winged portion of the connector.  Do not twist.  Note:  Connector portions must be gripped on plastic areas for proper assembly.  Do not grip on distal (blue) portion of oversleeve.  Advance completely until the connector barbs are fully attached.  A tactile locking sensation will confirm that the two pieces are properly engaged.  (There may be a small gap between the oversleeve and the winged portion of the connector).  q       vessel.  Caution:  To reduce potential for blood backflow into the catheter tip, always remove needles and needless caps slowly while injecting the last 0.5 cc of saline. |
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q       Attach primed extension set and / or saline filled syringe.  q       Aspirate for adequate blood return and flush each lumen of the catheter with 10 cc of normal saline to ensure patency.  Note:  When infusion volume is a concern in small or pediatric patient’s flush with 3 cc per lumen.q       If the single lumen catheter will not aspirate and infuse immediately after insertion. If this situation persists, verify radiographically that the catheter is not kinked inside the vessel.q       Caution:  To reduce potential for blood backflow into the catheter tip, always remove needles and needless caps slowly while injecting the last 0.5 cc of saline. |
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q       Verify placement (PICC only) – Verify catheter tip radiographically |
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q       Securing the GroshongÃ’ catheter:  Suture wing near venipuncture.  Place two anchor tapes over suture wing or bifurcation.  Form “s†curve in catheter.  Place 3rd anchor tape sticky side up under catheter just above suture wings or bifurcation.  Chevron 3rd anchor tape on top of first (2) anchor tapes.  Place transparent dressing over suture wing or bifurcation and catheter hubq       Securing the Per-Q-Cath:  Place S-Curve.  Place 1st anchor tape over wings or bifurcation.  Cover site and 1st anchor tape with transparent dressing up to hub, but not over hub.  Place 2nd anchor tape sticky side up under hub and close to transparent dressing.  Wedge tape between hub and wings.  Anchor only one hub of dual lumen catheter.  Chevron 2nd anchor tape on top of transparent dressing and place 3rd anchor tape over hubq       Apply Stat-LockÃ’ if used in accordance with manufacturer instructions under transparent dressing to secure catheter |
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Action | Timeline |
First Catheter dressing change | q       24 hoursq       Assess the dressing in the first 24 hours for accumulation of blood, fluid or moisture beneath the dressing.  During the dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred.  Periodically confirm placement of tip location, patency, and security of dressing. |
Dressing changes after first change at 24 hours | q       7 days or PRN if damp, loosened, or soiledq       During the dressing changes, assess the external length of the catheter to determine if migration of the catheter has occurred.  Periodically confirm placement of tip location, patency, and security of dressing. |
Injection cap change | q       Every seven days (about 18 needle insertions). q       When the cap has been removed for any reasonq       Anytime the cap appears damaged, is leaking, blood is seen in the catheter without explanation, or blood residue is observed in the capq       After blood withdrawal through the injection cap |
Blood sampling | q       10 cc positive pressure fluid flush of sterile 0.9% sodium chloride (for open Per-Q-Cath products utilize heparin after saline)q       Change injection cap |
Catheter irrigation / flushing | q       Groshong (only) every seven days or after IV administration of TPN, IV fluids, or medications.  10 cc syringe filled with 5 cc of sterile 0.9% sodium chloride. (use positive pressure flush)q       Per-Q-Cath (only) every 12 hours or after IV administration of TPN, IV fluids or medications.  10 cc syringe filled with 1 cc of sterile 0.9% sodium chloride and heparin in accordance with institution policy.  (use positive pressure flush) |
Repair | q       Groshong single lumen catheter may be permanently repaired by following procedure of placement of a catheter hub in insertion policyq       Per-Q-Cath can be repaired using a Per-Q-Cath repair kit, however, the repair kit only exists for certain catheter sizes. |
Blood occlusion | q       Utilize thrombolytic agent |
Purpose:
 To prevent external infection of the peripheral or central venous catheter  Frequency:  Assess the dressing in the first 24 hours (change) for accumulation of blood fluid or moisture beneath the dressing. After the first 24 hours the frequency is every seven days and PRN (as needed) if dressing is loose, damp, or soiled.  Supplies:  Sterile dressing kit or sterile supplies:q       (3)  Isopropyl alcohol swabsticks (Caution – do not use with polyurethane Per-Q-CathÃ’ PICC Line or Midline catheters due to potential for catheter damage)q       (3 ) Providone-iodine swabsticksq       (2)  2 in. x 2 in. gauze – Optionalq       (1) 10 x 12 transparent dressing q       (1) Pair sterile gloves / (1) Pair clean glovesq       (2) Masks (patient may wear mask if they can tolerate)q       (1) Protective eyewear or shield depending on hospital policyq       Sterile gown (optional – full barrier precautions)q       Stat-LockÃ’ securement device (optional)q       Injection cap / extension set / T-Port (optional)  Procedure:   1.      Identify patient assess patient’s chart for any signs, symptoms of complications related to his/her vascular access device  2.      Question patient about any concerns over their catheter or experience.  Explain procedure to patient  3.      Wash hands  4.      Don clean gloves and carefully remove the old dressing and discard in accordance with blood and body fluids and universal precautions.  Avoid tugging on the catheter, or use of scissors, or other sharp objects near the catheter.  5.      Inspect the exit site for swelling, redness, exudate.  During all dressing changes assess the external length of the catheter to determine if migration of the catheter has occurred.  Periodically confirm catheter placement, tip location, patency, and security of dressing.  Notify physician if any problem observed.  6.      Wash hands thoroughly  7.      Put on new pair of sterile gloves  8.      Using friction clean the catheter exit site with an alcohol swabstick starting at the exit site and spiraling outward until a circle at least 2 inches in diameter has been prepped (Caution do not use alcohol products on polyurethane Per-Q-CathÃ’ products).  Do not return to the catheter exit site with the same swabstick.  Repeat with the remaining two swabsticks.  Allow antiseptic to air dry (i.e. do not blow or blot dry)  9.      Using friction clean the catheter exit site with a providone-iodine swabstick starting at the exit site and spiraling outward until a circle at least two inches in diameter has been prepped.  Do not return to the catheter exit site with the same swabstick.  Repeat with the remaining two swabsticks.  Allow providone-iodine to dry at least two minutes.  10.  Optional if used – Change Stat-LockÃ’, injection cap, extension set, T-Port when dressing is changed  11.  Apply transparent dressing according to manufacturer’s recommendations  12.  Position sterile dressing over insertion site, catheter tubing and hub.  Tape over the winged connector for added securement, if desired.  13.  Gently smooth dressing from center toward edge; do not apply excessive tension to skin shearing may result  14.  Avoid sealing transparent dressing edges with tape  15.  Do not cover dressing with roller bandage  16.  Change dressing immediately if integrity is compromised, and / or if there is excessive drainage or moisture  17.  Note:  When a transparent semipermeable membrane is applied over gauze, it is considered a gauze dressing in accordance with the Intravenous Nursing Society Standards and must be changed every 48 hours,   ÂÂ
 Policy and ProcedureFlushing and / or Blood withdrawal – Aspiration ProcedureFor PICC Line and Midline Catheters  Purpose: ÂBlood Withdrawal:
 q       To obtain blood samples for laboratory evaluation, eliminating the need for peripheral vein punctureq       To verify venous placement prior to administration of hypertonic or vesicant solutionsq       Note:  If you encounter difficulties with blood withdrawal see troubleshooting guide-aspiration difficulties “Bard Access Systems Groshong Peripherally Inserted Central Venous Catheter (P.I.C.C.) Nursing Procedure Manual†ÂCatheter Irrigation / Flushing
 q       To maintain patencyq       Prevent mixing of medications and/or solutions that are incompatible  Routine flushing shall be performed with the following:  q       Administration of bloodq       Blood samplingq       Administration of incompatible medications or solutionsq       Administration of medicationq       Intermittent therapyq       When converting from continuous to intermittent therapies  Supplies:  q       Isopropyl alcohol (Note: do not use on body of polyurethane Per-Q-CathÃ’) and / or providone-iodine wipesq       10 cc syringe filled with 5 cc of sterile 0.9% sodium chloride (normal saline) – flushq       10 cc syringe filled with 10 cc of sterile 0.9% sodium chloride (normal saline) – blood withdrawalq       Injection cap (blood withdrawal)q       1 in needle or needless adapterq       Heparin solution in 10 cc syringe barrel in accordance with institution policy for Per-Q-CathÃ’ cathetersq       Gloves / sharps containerq       Blood specimen tubesq       Vacuum blood collection needless deviceq       Needless transfer devices   Procedure:  1.      Identify patient assess patient’s chart for any signs, symptoms of complications related to his/her vascular access device  2.      Question patient about any concerns over their catheter or experience.  Explain procedure to patient  3.      Wash hands  4.      Don gloves.  Use aseptic technique and observe standard blood and body fluid precautions and universal precautions throughout procedure  5.      Clean injection cap with alcohol or providone-iodine wipe  6.      Note:  If resistance or complication occurs at any time during flushing, discontinue and notify physician  Groshong PICC and Midline Saline only flush | Per-Q-Cath PICC and MidlineSaline and heparin flush | Groshong PICC and Midline Blood withdrawalHub to HubPer-Q-Cath PICC and MidlineBlood withdrawal | Groshong PICC and Midline Per-Q-Cath PICC and MidlineBlood withdrawal  Needle to needless adapter through injection cap (vacuum blood collection system or syringe) |
Connect saline-filled syringe to cannula via insertion into prepared cap or needleless device | Connect saline-filled syringe to cannula via insertion into prepared cap or needleless device | Draw up 10 cc normal saline in syringe and set aside 0.9% sterile sodium chloride solution. Â If TPN is infusing draw up 20 cc of normal saline | Draw up 10 cc normal saline in syringe and set aside 0.9% sterile sodium chloride solution. Â If TPN is infusing draw up 20 cc of normal saline |
Bard Access System note:  If blood is aspirated prior to infusion of medications(to verify venous placement), catheter should be irrigated with 10 cc of normal saline prior to attaching medication, syringe, IV or infusion pump tubing.  Failure to do so may result in an occluded catheter, leading to difficulty in aspirating in the future | Insert needle or needless adapter on syringe filled with 1 cc of sterile 0.9% chloride (normal saline) into injection cap or needless systemSlowly inject flush maintaining positive pressure | Stop any IV fluids infusing through the catheter including another lumen of the catheter.  Remove cap/I.V. tubing from catheter hub.  Clean catheter hub with alcohol and /or providone-iodine.  Attach an empty 10-cc syringe to catheter hub.  Pull back syringe plunger 1-2 cc, pausing for 2 seconds to allow catheter valve to open and blood to come into the catheter.  Slowly continue to aspirate 5 cc of blood | Stop any IV fluids infusing through the catheter including another lumen of the catheter.  Remove cap/I.V. tubing from catheter hub.  Clean catheter hub with alcohol and /or providone-iodine.  Attach an empty 10-cc syringe to catheter hub.  Pull back syringe plunger 1-2 cc, pausing for 2 seconds to allow catheter valve to open and blood to come into the catheter.  Slowly continue to aspirate 5 cc of blood  Note:  A vacuum collection specimen tube may be used to withdraw the discard sample but be sure to use one with at least 5 cc capacity |
Insert needle or needless adapter on syringe filled with 5 cc of sterile 0.9% chloride (normal saline) into injection cap or needless system | Connect heparin filled syringe to injection cap with needle or needless system | Disconnect syringe and discard (saline in catheter dilutes specimen and may alter lab values)Clean injection cap with alcohol / providone-iodine wipe | Disconnect syringe and discard (saline in catheter dilutes specimen and may alter lab values). Â Clean injection cap with alcohol / providone-iodine wipe |
Slowly inject flush maintaining positive pressure (infusing last 0.5 cc as the needle or needless adapter is withdrawn from the injection cap. (Helps prevent vacuum which can pull a small amount of blood into tip of catheter)) | Slowly inject flush maintaining positive pressure (infusing last 0.5 cc as the needle or needless adapter is withdrawn from the injection cap. (Helps prevent vacuum which can pull a small amount of blood into tip of catheter)) | Attach empty syringe 10 cc syringe and aspirate by pulling back plunger 1-2 cc pausing for 2 seconds to allow the catheter valve to open and blood to come into the catheter. Â Slowly continue to withdraw amount of blood needed for testing | Insert vacuum blood collection system needle or needless adapter into the injection cap. Â Push blood specimen tube into vacuum collection device sleeve so that rubber stopper is pierced. Â Blood needed for specimen will flow into specimen tube. Â Change tubes as needed for required tests. |
 |  | Disconnect syringe and attach saline filled syringe.  Flush the catheter with 10 cc normal saline. Slowly inject flush maintaining positive pressure (infusing last 0.5 cc as the needle or needless adapter is withdrawn from the injection cap. (Helps prevent vacuum which can pull a small amount of blood into tip of catheter))  | Clean injection cap with alcohol and / or providone-iodine wipe. Insert needle or needless adapter of saline-filled syringe and flush the catheter with 10 cc of normal saline  |
 |  | Attach new injection cap or needleless system | Slowly inject flush maintaining positive pressure (infusing last 0.5 cc as the needle or needless adapter is withdrawn from the injection cap. (Helps prevent vacuum which can pull a small amount of blood into tip of catheter)) |
 |  | Attach 1 in needle or needleless adapter to blood sample syringe to transfer to blood collection tubes | If unable to flush all of the blood residue out of the injection cap, attach a new sterile injection cap. |
Â
                         Policy and Procedure for Clearing OccludedPICC Line and Midline Catheters  ÂPurpose:
 To restore patency to a catheter with a blood or chemical occlusion   Supplies:  (1)   Sterile injection cap or needleless system(1)   Thrombolytic agent
(3) Â Â 10 cc syringe with attached 1 in. needle or needleless adapter
(1) Â Â 10 cc sterile normal saline filled syringe with attached 1 in needle or needleless adapter
q       Isopropyl alcohol wipes
(1) Stopcock – 3 way
ÂProcedure:
Â1. Â Â Â Â Â Notify physician immediately of suspected catheter occlusion and type of occlusion (i.e. blood, chemical precipitate)
Â2. Â Â Â Â Â Obtain treatment orders for thrombolytic agent. Â Cautions contained in medication package insert should be observed
Â3. Â Â Â Â Â Review patient chart for allergies, medical history & condition, lab coagulation studies, and contraindications to procedure
Â4. Â Â Â Â Â Explain procedure to patient and obtain patient informed consent
Â5. Â Â Â Â Â Wash hands and glove and any personal protective equipment needed
Â6. Â Â Â Â Â Use aseptic technique and observe blood and body fluid precautions and universal precautions
Â7. Â Â Â Â Â Remove injection cap, attach an empty 10-cc syringe and attempt to aspirate. Â If aspiration is successful withdraw clots and flush. Â If aspiration is unsuccessful proceed forward
Â8. Â Â Â Â Â Document procedure in patients medical record upon completion of one of the two methods
ÂTwo Methods available: Â Syringe and Stopcock Method Â
Syringe Method Declotting | Stopcock Method Declotting |
Draw up thrombolytic agent into a 10 cc syringe to equal the internal volume of the catheter (volume may be reduced if catheter length has been altered) | Attach stopcock to cannula hub. Â Turn stopcock to off position. Â Unclamp catheter. |
Aseptically attach thrombolytic filled syringe to the catheter hub. Â Slowly and gently inject the thrombolytic agent using a push-pull motion to achieve maximum mixing. Â To avoid catheter rupture do not force entire amount into catheter if strong resistance is felt | Connect empty syringe to one port of stopcock. Â Connect syringe filled with thrombolytic agent to second part of stopcock. Â |
Leave 10-cc syringe attached to catheter. Â Do not attempt to aspirate for 30 - 60 minutes | Open stopcock port connected to empty syringe. Â Gently aspirate empty syringe to 8-9 cc, then close port, creating negative pressure |
After 30 – 60 minutes attempt to aspirate 5 ml of blood to assure removal of all drug and clots | Open stopcock port connected to syringe filled with thrombolytic agent.  Gently inject thrombolytic agent into catheter.  Do not force. |
Remove blood-filled syringe and replace it with a 10-cc syringe filled with normal saline.  Flush catheter to verify patency | Close stopcock to catheter.  Secure device to patient and label “Do not use† Allow agent to dwell in catheter for 30 – 60 minutes |
Attach sterile, saline-filled injection cap or needleless device | Open stopcock to catheter aspirate 3-5 cc of blood and discard. Â Flush with 10 ml of 0.9% sterile sodium chloride. Attach sterile, saline-filled injection cap or needleless device |
If unable to aspirate, repeat procedure, Â If unsuccessful notify physician | If unable to aspirate, repeat procedure, Â If unsuccessful notify physician |
Â
Policy and Procedure Catheter Removal forPICC Line and Midline Catheters  Policy: Â
A physician order is required to remove a PICC Line. Â (Midline catheters being a peripheral catheter are removed when there is evidence of peripheral complications or the end of infusion therapy
 A PICC Line or Midline catheter can be removed by a qualified Registered Nurse who has successfully completed competency in removal and understands emergency and complication management  Supplies:  Sterile 4 x 4TapeGlovesAntibiotic Ointment  Procedure:  1.      Review patient’s chart for any contraindications to removing the patient’s PICC or Midline catheter  2.      Obtain physician order for PICC Line removal only  3.      Explain procedure to patient and obtain informed consent  4.      Remove dressing and discard  5.      Assess insertion site  6.      Grasp catheter near insertion site and remove slowly.  Do not use excessive force  7.      Use a gentle steady motion to prevent catheter damage going back to insertion site each time.   8.      If resistance is felt, stop removal.  Apply warm compresses and wait 20-30 minutes  9.      Resume removal process.  Should the catheter embolize during the removal process, tie a tourniquet around the upper arm and immediately contact a physician regarding this emergency situation  10.  If catheter continues to resist removal notify physician  11.  After removal, apply pressure to site and 4 x 4 gauze until bleeding stops.  12.  Place sterile 4 x 4 gauze dressing on site  13.  Examine catheter tip for any indication of incomplete removal.  Compare measurement taken out to insertion measurement.  Notify physician immediately if there is a problem  14.  Document procedure in patient’s chart                                   ÂÂ
Policy and Procedure PICC Line and Midline RepairFor Groshong Single Lumen Catheters Only  Purpose: ÂTo repair a damage or loose connector
 Note:  Catheter should have been clamped with an atraumatic non-toothed clamp or kinked and taped between the catheter exit site and the damaged area when damage or connector separation occurred and must remain clamped or kinked and taped during repair.  Supplies: ÂReplacement connector (3Fr. - #7712300 – forest green) (4 Fr. - #7712400 – gray)
Isopropyl alcohol wipesProvidone-iodine wipe
Sterile ScissorsSterile Gloves10 cc syringe attached 1 in. needle or needleless adapter filled with 5 cc sterile 0.9% sodium chloride (normal saline)   Procedure:  1        Review patient’s chart for length of IV therapy and any contraindications associated with catheter Repair  2        Explain procedure to patient and obtain informed consent  3        Wash hands Â4         Obtain a new sterile replacement connector of the correct size
 5        Determine where the damaged catheter is to be cut off.  Do not cut at this time.  Be sure to retain as much of the original external segment as possible.  At least 2 in, of intact catheter beyond the skin exit site is needed to be able to repair the catheter  6        Thoroughly clean the catheter with alcohol and providone-iodine wipes at the point where it is to be cut  7        Wearing sterile gloves and using sterile scissors, cut the catheter at a 90 degree angle, ½ inch distal to the location of the previous connector or damaged site to remove any damaged catheter material  8        Retrieve the oversleeve portion of the connector and advance it over the end of the catheter.  If you feel some resistance while advancing the oversleeve, gently twist back and forth or spin to ease its passage over the catheter  9        Gently advance the catheter onto the connector blunt until it butts up against the colored plastic body.  The catheter should lie flat on the blunt without any kinks  10    With a straight motion, slide the oversleeve portion of the connector and the winged portion of the connector together, aligning the grooves on the oversleeve portion of the connector with the barbs on the winged portion of the connector.  Do not twist  11    Note:  Connector portions must be gripped on hard plastic areas for proper assembly.  Do not grip distal (blue) portion of oversleeve  12    Advance completely until the connector barbs are fully attached.  A tactile locking sensation will confirm that the two pieces are properly engaged.  (There may be a small gap between the oversleeve and the winged portion of the connector)  13    Attach syringe to connector and aspirate blood to confirm patency.  Irrigate the catheter with 10-cc normal saline solution.  Attach pre-filled injection cap or I.V. tubing  14    Note:  When infusion volume is a concern in small or pediatric patients, irrigate the catheter with 3 cc of sterile normal saline in a 10 cc syringe  15    Document the repair in the patient’s chart             ÂOUTCOMES MONITORING
 As nursing practice has become more scientifically based, the emphasis on evidence-based and quantitative practice has increased.  This is as true for PICCs as it is for any other aspect of nursing practice.  It is important to monitor how well vascular devices are performing, whether or not the therapy was completed without complications, and the patient’s level of satisfaction with this mode of treatment.   The effectiveness of vascular access devices, whether or not therapy was completed without complications and the patient’s level of satisfaction all translate into the quality of care rendered to this patient.  The age old question of how we measure quality and what quality indicates comes to mind.  In reality quality indicators don’t measure quality, they point to problem areas that need improvementâ€â€the entire point of a quality improvement system.  â€œA valid measure of quality specifically identifies an aspect of care where there is a known problem and describes the extent of the problem.  Quality measures are definitive end points that do not require future investigation in order to make judgements about quality of care.â€Â[1]  So how are quality indicators determined?  The most definitive method is through the collection of data that can be reviewed for trends.  These trends are then studied and a plan of action developed to address those trends that could improve the quality of care patients are receiving.  Bard Access Systems has developed several tools that can be used as they are or as guidelines for developing hospital specific tools.  Samples follow.  If you should decide to develop your own outcome monitoring tools, remember that all quality indicators should address the following: ¨      Address current clinical knowledge and technology ¨      Be predetermined and agreed to by all involved practitioners in advance of data collection and measurement ¨      Be consistent and reflect current internal policies, procedures and protocols as well as external rules and regulations ¨      Reflect standards[2]           BARD ACCESS SYSTEMS                                   VASCULAR ACCESS DEVICE INSERTION/ PATIENT OUTCOME FORM                                                       ASSESSMENT FLOW PROCESS   Patient Name: __________________________ Pt. Room # _________Pt. Sex________  Pt. Diagnosis ___________________________________________________________  VAD Assessor Name _____________________________________________________  VAD Selected ________________________ Reason: ___________________________  Comments: _____________________________________________________________  Device Placed On (Date) __________ Where Placed ____________________________  Who Placed Device? _____________________________________________________  (If Device Not Placed, Why?) _______________________________________________  Insertion Complications: _________Yes _________ No  Comments ______________________________________________________________             TO BE COMPLETED WHEN DEVICE IS REMOVED OR PATIENT IS DISCHARGED WITH DEVICE (Prior to discharge)   Pt. Name ____________________Pt. Age _________ Pt. Sex ______ Pt. Room # _____  Pt. Adm. # ______________ Pt. Diagnosis ____________________________________  Vascular Access Device Removed ______ Yes ______ No           Date _____________  Reason for Device Removal:    ________ End of Therapy   _______Complication_______ Infection   _______ Leakage   _______Patient Death   _______ Thrombosis_______ Occlusion   _______ Breakage  _______ Phlebitis   ________Pt. Pulled Out______________________________Other (Specify)  Complications During Device Removal ________Yes ________No  Specify ________________________________________________________________  Device Removed By ____________________ Date ______ Where _________________                                                   SEND FORM TO QUALITY ASSURANCE  INSTRUCTIONS:IF PATIENT IS DISCHARGED WITH VAD, FILL OUT THIS FORM AND SEND A BLANK FORM WITH THE PATIENT.  INSTRUCT THE PATIENT TO HAVE THEIR AGENCY COMPLETE THE FORM AND SEND TO THE HOSPITAL QUALITY ASSURANCE DEPARTMENT.  IF THE AGENCY IS WITH THE HOSPITAL, PASS ALONG A BLANK FORM.BARD ACCESS SYSTEMSVASCULAR ACCESS PATIENT SATISFACTION FORM                                                        PATIENT OUTCOME PROCESS  Patient completes form prior to discharge or upon I.V. removal  Patient Name ________________ Pt. Room # _____ Pt. Sex _____ Pt. Adm. Date ____  Were you satisfied with the I.V. device placed? _______ Yes _______ No  If no, why? ______________________________________________________________  Were you satisfied with the person placing the I. V. ? _______ Yes _______ No  If no, why? ______________________________________________________________  Was this a ______Physician ______Nurse ______Other  Was the I.V. insertion _______ Painful? _______Uncomfortable?  How many times did they stick you? _______ Sticks  Explain (If the stick was painful/uncomfortable) _________________________________  Is this the first time you have had an I.V. device placed _______ Yes _______ No  If no, what type of I.V. have you had before ____________________________________   Patient Teaching:  Did you fully understand:   what the I.V. is used for? _______ Yes _______ No  how the I.V. is placed? _______ Yes _______ No  What the complications are? _______ Yes _______ No  If no, what did you not understand? __________________________________________  Overall, did you find that the I.V. therapy was to your satisfaction? ______Yes ______ No  If No, Why? _____________________________________________________________  Comments ______________________________________________________________           Â