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Gina Ward
Air Embolism Prevention Initiative

I am employed by a HCA facility and they are responding to  a sentinel event with a new protocol for preventing air embolism.   Never Events Air embolism.

They are requiring this process be implimented Hospital wide and to include picc lines.  I  have been doing picc lines for about 3 years now.( small hospital 100 beds average 0-5 piccs a day).I have reviewed the recent INS standard book out.  I am not yet a member of INS of AVA so I  have not been able to examine much on their website.

They are requiring head of bed down 15-20 degrees for insertion. I know the rationale of this for a central line inserted in the subclavian or juglar but not inserted peripherally.  Are any of you doing this in your facility?  Do you think or is their evidence to support this position for PICC lines inserted in the arm?

I will just state the steps I have not utilized in the past.

For removal; 

they want the patient placed in trendelenburg, and after removing the dressing they want sterile technique and  the site to be cleansed with chlorhexidine. , pt for perform the Valsalva maneuver during catheter removal.  After removal of line and removal of gauze to put on antiseptic ointment ( vaseline gauze is recommended in their protocol) then opsite do another valsalva while changing gauze to vaseline.  Another is to then have patient remain supine for a minimum of 60 minutes.  Maintain occlusive dressing for 72 hours post PICC  removal.

I have done many searches and have found that the insertion site for the picc line of basilic vein, brachial etc...reduces the risk of air embolism but does not eliminate.  I also understand the whole fibrin sheath and change in pressure to cause the air embolism.  I am just wondering are any of you doing all of the above for a picc line removal? 

As I mentioned I have read the INS standards and it is not as specific as what HCA seems to be requiring of us. 

Thanks you  in advance for your responses!  Gina Ward R.N., C.P.A.N. 

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Air embolism can occur with a PICC line insertion/removal.  There is one published case in a neonate.  None in adults

However the rationale for this technique is in 2009 CMS may add this to the rules.  There are products that prevent air embolism - introducer valves.  They are used on dialysis catheter placements, ports and tunneled catheters now.  I do not know of any acute care lines with this innovation.  I do think that companies making catheters should look at this post as safety is a number one consideration regardless of CMS reimbursement. 

Here is where manufacturers can easily fix this issue and produce a product that eliminates this issue from happening

kathy

Kathy Kokotis

Bard Access Systems

lynncrni
Am I reading your message

Am I reading your message correctly that they are now requiring a Trendelenburg position with the head down for a PICC insertion? I do not know of anyone doing this and have certainly never seen this in any literature.

The PICC insertion site will always be at or below the level of the heart, making the risk of AE much less than with IJ or subclavian. In fact, I have always taught that PICCs are indicated for patients who can not tolerate that position - respiratory diseases, curvatures of the spine, increased intracranial pressure, etc. This position for PICC insertion is a little strange but I can only infer that they are being overly cautious.

 I have no problems with all the remainder of your policy as this is standard procedure for all CVCs, including PICCs. While AE from a PICC is very rare, it can happen and therefore all precautions should be taken to prevent it. The one issue is the length of time to have the patient remain lying flat. I recently searched the literature for that specific time and found 3 different times recommended - 10, 30, and 60 minutes. These times were based on experience and opinion because we do not have studies on this due to ethical reasons. 

 

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Gina Ward
Gina Ward R.N., C.P.A.N Yes,

Gina Ward R.N., C.P.A.N

Yes, they did say trendelenburg for position of insertion  for ALL  CVC lines including piccs. I'll try my best , dont know how that will work.   I agree with you, many patients cant even tolerate going supine , much less trendelenburg.

Why would removal require sterile gloves and chlorhexidine cleaning?  Is this to keep site clean with bandage that may last for 72 hours?  Unfortunately I have never seen a central line of any type removed using sterile technique, however, as I research it I do see using sterile gloves seems standard.

So, apparently HCA had mandated these standards ; (including supine for 60 minutes )and expect us to do this by October.

 Thanks for your response,  Gina Ward

Gina Ward R.N., VA-BC

lynncrni
Oct 1 is the date when the

Oct 1 is the date when the value-based purchasing processes from CMS actually goes into effect. This means that CRBSI and AE, among other complications conditions will no longer be reimbursed to hospitals for Medicare patients. Many insurance companies are also following this same process. I suspect that HCA has decided to err on the side of extreme caution with these new policies.  

 

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

FConnor
Hello I am an Oncology Nurse

Hello I am an Oncology Nurse working between community and a cancer centre. I have been asked to write up a protocol for removing picc lines but hsve found the literature confusing as it seems to generalise re cvad removals (femoral,jugular, brachial ). Do we need to [place a patient in supine/trendelenburg position and use valsava manoevre to remove picc lines? I can find literature to support this position for jugular and subclavian lines but not specifically piccs. However if patients with piccs are at risk of a/e does it not make sense to take these precautions. Also the vaseline dressing I hear you talk about is it have atiseptic qualities. If INS  state antiseptic what do they meanif the site is cleaned with chlorhexidine is this not an antiseptic. Does the vaseline dressing not act as a plug only?

Anyone any answers?

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