At this time it is not policy for our facility, but if the patient has not had a CXR we ask the primary care nurse to call the doctor to obtain the film. We have not had any push back for MD's or the nurses.
At this time it is not policy for our facility, but if the patient has not had a CXR we ask the primary care nurse to call the doctor to obtain the film. We have not had any push back for MD's or the nurses.
You either need a policy requiring a chest xray on admission or you teach all nurses to know and assess for the signs and symptoms of catheter tip migration. This is such a sporatic occurrence that no specific time interval would work. Lynn
Yes, this is our policy. It is on our admission order sets as well as an ER policy (unless emergent). We have caught several malpositioned tips with this policy - the line was running ok, no symptoms, but the tip was up the jugular or in some other less-than- ideal location. Our major push-back from physicians was oncology, who are using the PICC perhaps even daily for chemotherapy, then the patient gets admitted, and we require an xray. I understand their concerns and wish that there was some consensus regarding if and/or how often to check tip location. Chemo is a huge risk, as we all know, but a daily CXR? I don't have the answer to that.
Thanks for all of the responses thus far. My hospital does not check daily tip locations, but there seems to be concern over admissions with a PICC in place. We collected data for 3 months to see how many of the CXRs that our IV team ordered for new admits identified a malpositioned PICC. Our team orders admission CXRs for new admits, but do not have anything to support our practice. Our data collection showed a 15% malposition rate. This is from the tip being positioned in the RA to the brachiocephalic veins. What percent of malpositioned PICCs justifies a CXR for all admits that have a PICC in place? this is the big question.
This sounds like primary malposition, where the catheter was not correctly positioned on insertion. I was thinking about secondary malposition where the tip moves into another vein such as from SVC to IJ. Do you think your 15% was due to inadvertent withdrawal or just not correct to begin with? Lynn
I think that you may be right. These are probably all primary malposition and not placed properly the first time. Most of these PICCs were from an outside hospital.
It is our hospitals policy to get a CXR on a pt admitted with a PICC to reconfirm tip placement especially if it wasn't placed at on of our sister facilities where we could confirm the actual tip placement by looking at the film. If the tip is correctly placed in the low SVC/CAJ it is much less likely to get malpositioned. But you rarely get that good of information on a transfer, much less if the patient comes from home. It has been rare that we have found a malpositioned PICC and usually the underlying problem was a tip in the upper part of the SVC more easily move by coughing, aggressive flushing ect. Our policy is not to get daily CXRs for PICCs but pt's with pneumonia are usually getting daily or every other day anyway. If I had a patient with risks for a tip getting repositioned due to coughing from pneumonia or history of pulmonary hypertension or on high pressure ventilation and the PICC tip did not get placed in the very low SVC/ CAJ I would strongly consider overwiring that PICC with a longer one. If the CXR makes you unsure of the position then get an order to instill a little contrast you can pull back after CXR to be sure of tip position and get a 2 view if that is possible for the patient.
How are all of you dealing with the issue of getting information on your incoming PICCs. No one seems to think that it is important to send that information with pt transfer, even from hospital to hospital. If I know a PICC I place is going to be sent out to another facility, I print the important information for the receiving facility including my procedure note so that they would be aware if there we any particular issues with the insertion and put it in the discharge information. Mary Penn RN
At this time it is not policy for our facility, but if the patient has not had a CXR we ask the primary care nurse to call the doctor to obtain the film. We have not had any push back for MD's or the nurses.
Matt Gibson RN, CRNI, VA-BC
At this time it is not policy for our facility, but if the patient has not had a CXR we ask the primary care nurse to call the doctor to obtain the film. We have not had any push back for MD's or the nurses.
Matt Gibson RN, CRNI, VA-BC
You either need a policy requiring a chest xray on admission or you teach all nurses to know and assess for the signs and symptoms of catheter tip migration. This is such a sporatic occurrence that no specific time interval would work. 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
Yes, this is our policy. It is on our admission order sets as well as an ER policy (unless emergent). We have caught several malpositioned tips with this policy - the line was running ok, no symptoms, but the tip was up the jugular or in some other less-than- ideal location. Our major push-back from physicians was oncology, who are using the PICC perhaps even daily for chemotherapy, then the patient gets admitted, and we require an xray. I understand their concerns and wish that there was some consensus regarding if and/or how often to check tip location. Chemo is a huge risk, as we all know, but a daily CXR? I don't have the answer to that.
Wendy Erickson RN
Eau Claire WI
With all the emphasis on reducing radiation exposure, I can understand the concern for daily xrays. Love your polcy on admission though. 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
Thanks for all of the responses thus far. My hospital does not check daily tip locations, but there seems to be concern over admissions with a PICC in place. We collected data for 3 months to see how many of the CXRs that our IV team ordered for new admits identified a malpositioned PICC. Our team orders admission CXRs for new admits, but do not have anything to support our practice. Our data collection showed a 15% malposition rate. This is from the tip being positioned in the RA to the brachiocephalic veins. What percent of malpositioned PICCs justifies a CXR for all admits that have a PICC in place? this is the big question.
David Dempsey MS, RN
This sounds like primary malposition, where the catheter was not correctly positioned on insertion. I was thinking about secondary malposition where the tip moves into another vein such as from SVC to IJ. Do you think your 15% was due to inadvertent withdrawal or just not correct to begin with? 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 think that you may be right. These are probably all primary malposition and not placed properly the first time. Most of these PICCs were from an outside hospital.
David Dempsey MS, RN
It is our hospitals policy to get a CXR on a pt admitted with a PICC to reconfirm tip placement especially if it wasn't placed at on of our sister facilities where we could confirm the actual tip placement by looking at the film. If the tip is correctly placed in the low SVC/CAJ it is much less likely to get malpositioned. But you rarely get that good of information on a transfer, much less if the patient comes from home. It has been rare that we have found a malpositioned PICC and usually the underlying problem was a tip in the upper part of the SVC more easily move by coughing, aggressive flushing ect. Our policy is not to get daily CXRs for PICCs but pt's with pneumonia are usually getting daily or every other day anyway. If I had a patient with risks for a tip getting repositioned due to coughing from pneumonia or history of pulmonary hypertension or on high pressure ventilation and the PICC tip did not get placed in the very low SVC/ CAJ I would strongly consider overwiring that PICC with a longer one. If the CXR makes you unsure of the position then get an order to instill a little contrast you can pull back after CXR to be sure of tip position and get a 2 view if that is possible for the patient.
Mary Penn RN
Mary and Wendy Erickson what facility do you work at?
Erika Anderson RN,
How are all of you dealing with the issue of getting information on your incoming PICCs. No one seems to think that it is important to send that information with pt transfer, even from hospital to hospital. If I know a PICC I place is going to be sent out to another facility, I print the important information for the receiving facility including my procedure note so that they would be aware if there we any particular issues with the insertion and put it in the discharge information.
Mary Penn RN