Forum topic

This is the statement from the 2011 Infusion Nursing Standards of Practice addressing this issue:

"The nurse should use a standardized checklist to encourage adherence to recommended practices for access site preparation, infection prevention, and safety precautions. The CVAD placement produced should be stopped for any breaches in sterile technique that occur during the procedure." This statement is supported by 3 references and has a ranking of IV. While it does not specify the number of people required, it is your task to adhere to this statement. If you can do that with only one person, then go for it. Frankly I don't see how one person can safely perform the procedure while meeting the patient needs during the procedure. How many physicians do you see inserting a subclavian or jugular CVAD without assistance? I would bet on none. Why then do we think that nurses can do this alone? In addition to the checklist and observations for breaches in technique, there could be many things the patient needs during the procedure including moving or repositioning the arm, moving the head to the chest, management of any other problems that might come up during the sterile procedure. The PICC inserter is focused on doing the sterile procedure and can not attend to the patient needs. This addtional person does not have to be another PICC inserter. Many facilities have a technician trained for this assistant role. Lynn

Lynn is correct is stating that IHI suggests that there is someone empowered that is observing to stop a procedure.  I guess when you grade you own paper you honestly check wrong answers 100% of the time.  MD's never place lines without an empowered observer who also signs a form.  Who is your empowered observer to sign your form as the observer who can stop the procedrure?  What is your liability for not having an empowered observer?  What is the hospital liablity for practicing two standards of care for central line insertions?  Ask infection control those questions.  I do not believe PICC's should be placed as they are a central line without an empowered observer to stop the procedure. 
This observer can be a staff RN.

kathy

The checklist was of major discussion for us back in 2008 when we introduced it.  We did not have the staff to bring in for the procedure and the patient's nurse could not be tied up for any amount of time.  Hiring a tech, etc. wasn't a consideration.

I think honestly, our team had been performing bedside PICC procedures for 20 years and having another person in the room was unthinkable~not needed.

Our Director of Infection Control considers our team "the gold standard" and having a zero infection rate doesn't provide a lot of ammunition to expend additional costs with the procedure (right or wrong).

How many PICC Nurses continue to work alone, completing their own checklist and self monitoring their sterile field? Please comment YES or NO.

Unfortunately still alone after 15 years and +12,000+ bedside PICC procedures

We help each other when dealing with a "difficult" patient circumstance

Robbin George RN VA-BC

 In 2014 the SHEA Compendium on CLABSI clarified this by stating clearly that this checklist should be completed by someone other than the inserter. Lynn

We are a team of three covering 7 days a week. One of us only works two days a week. So needless to say, we often work solo. We don't have the staff to or the bedside RN has the time to be available for the checklist. I don't see our facility even considering adding a tech to the team either.

Touchy subject to bring up and looks like a issue for many of us.

Debra Rivie

Long Beach Memorial Medical Center

Long Beach, CA

We require an assistant at the bedside to move the arm, hold the arm, apply the tourniquet, etc. This person can be a patient care assistant, RN, SN.  We also require an RN to audit the procedure using the checklist and is empowered to stop the procedure at anytime for breaches of sterile technique.  Staff nurses DO have time, they just don't want to make time.  Tell them "no audit, no PICC". 

Is it important that the auditor be familiar with the insertion procedure to know what to look for? The first time I saw a PICC insertion, I was very overwhelmed. I had never seen so much blue in one place! I had no idea what I was watching! I am semi-intelligent, minimally experienced and familiar with "sterile technique," but I wouldn't have known as a staff nurse if procedure was not being followed. I certainly wouldn't have stopped these obviously more experienced and competent nurses to stop their important procedure to ask a "dumb" question! It seems to me like the auditor really ought to be familiar with the procedure and in a position to be comfortable to stop it if necessary. A staff RN/LVN/technician isn't that person.
BTW, how are these minimally staffed PICC teams finding the time to also do all their dressing changes / catheter care?!
When is a professional organization going to publish a standard of care that explicitly states that full-service vascular access teams ARE the standard?!
I placed PICC lines solo, but I went through a LOT more sterile gloves and it took forever. Seems like duets would ultimately decrease resources and free teams up for more full-care services.

I see this is still an issue all over.  We, or should I say I, am still doing PICC insertions solo.  Once a day I have a nurse observe my insertion, sterile technique etc...and fill out an audit/data collection tool on this.   I do , however, the entire rest of the day , do all my insertions solo, and complete my insertion checklist in the computer.  Stating that I obseved all the insertion bundles, because I did, and yes I do it 100% of the time.  If there is a breach it is corrected before it hits the pt. 

I read below in the discussion about Physicians having empowered observers during insertions etc......  As far as I have known in my 30 year nursing career, when we have had an additioanl person in the room with the MD it was because he needed help, not because we were there to observe and stop if sterile procedure breached.  We certainly do that if the event occures, but......our being there was to help them with set up , supplies, pt positiong, final dressing , flushing of lines etc....as they usually want everything handed to them.   So,  if a trained competent R.N. inserting PICC lines doesnt need help, and can function independently I do not feel it is a double standard.  Certainly, if we need help it is there and available.   

I realize the significance of CLABSI, and all the efforts to prevent it  and am not downplaying them in anyway.      Just a question,  how many of you inserters have had your obsever spot a breach in sterile technique, that you did not already identify?   I certainly am aware that we do breach it as time, gloves touchiing something, drop something etc....and we resolve that when identified, but  truly  how many unidentified  events happen that are corrected by having the observer there?

Thanks,  Gina

 Evidence shows that the infectionr rates with PICCs is the same as with other nontunneled CVADs, therefore the standards and guidelines are written to apply to all CVADs including PICCs. I believe there are patient needs during a PICC insertion that the most experience inserter can not meet while they are using max barriers. About 15 years ago, IHI recommended that a checklist be used with an empowered staff member to stop the procedure if a breach of that list occurs. No one can observe their own technique. In 2014 the SHEA Compendium on CLABSI stated clearly that the checklist must be completed by someone other than the inserter for every CVAD insertion which includes PICCs. Lynn

I want to thank everyone for commenting on the subject. It is an issue that will not go away until our profession embraces proven safety processes. Lynn's continuing efforts to advise and lead us is because of her never ending concern for patient safety. Everything she said and more is documented. Here is a list of professional originations that call for an empowered observer (2nd person) and completion of the checklist. The CDC, INS, ASA, SHEA, AORN, Joint Commission have stated, in some cases, then re-stated with stronger language this "recommendation".