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abnormalities of chest anatomy

We are a brand new vacular access team. (2 weeks) I placed a PICC last week and the chest Xray report is this: Portable chest was performed for PICC line placement. Extensive pleaural-parenchymal disease is seen on the left side. PICC line is placed on the right side. It is at the mid mediastinum and points under the aortic arch. Because there is a mediastinal deformity the exact apposition of this is unclear.

CONCLUSION: Deformity of the PICC line tip as described. the position relative to the superior vena cava is unclear based on these images.The mediastinum is distorted due to apical retraction. Repositioning may be necessary. Cross sectional imaging may necessary to document position of this line. Contrast injection under fluoroscopy may also document position.

My supervisor spoke with an interventional radiologist who placed PICC lines and he looked at the Xray and said to pull the PICC back 3 cm and as long as there was a blood return to leave it and let the patient go home. My concerns are: there was no written order to reposition the line, only the radiologist's conversation with my supervisor. She pulled it back and the patient was sent home. What is our legal responsibility in a situation like this? There was also no documentation in the patient's chart, only documentation in the PICC team office. I would appreciate any advice or comments.

Put an addendum in the medical record

Obtain the medical record, an add an addendum with the date of the day you write it for the date that it happened, exactly who did what. Otherwise, your only hope is to pray that there is no serious complication that leads to a lawsuit. This is a serious breach of the standard of care to perform catheter repositioning without any form of documentation. What meds were prescribed for this patient? What was the final pH and osmolarity of those drugs? How long is the anticipated length of therapy? The thing that worries me is the note about "points under the aortic arch" as this raises the possibility of arterial placement. Not saying that is the case, but needs to be ruled out by blood gases from the line or transducing for pressure. The national standard is for all people taking care of this line to know where the tip was originally located and that this tip was properly positioned. I am actually surprised that a home infusion company accepted this patient without knowing tip location. There could easily be a valid, justifiable reason for the chosen action given the patients disease process, but without sufficient documentation to the intervetion that was taken, you have nothing to support this action, even if it was the best for this patient. This must be placed in the medical record. At this point, the best you can do is to add an addendum documenting what was done. This is not ideal, but is the best you can do at this time. But I would want it in the medical record as to exactly what happened, who made the decisions, who performed the intervention, etc. This is better than having nothing. Just my opinion, eager to read others. One other thought is to seek the advise of your hospital risk manager and follow their advise on this situation. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

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