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Chest Xrays

Is it a standard to do a chest Xray to confirm PICC position on patients that come into your facility that already have a line in place?

We had a pt. come from a different hospital where he had surgery on his hand, a picc line placed and started on ABX. He came to us because our facility was closer to his residence. He was set up for outpatient Nafcillin and end up having a huge thrombus. They discovered at the time of the scan that his "PICC line" was actually a midline.

If they would have done an xray on initial assessment, they would have known it was a midline, and the outcome could have been different.

I would like to change our hospital policy and it is always good to say "this is the standard everywhere else"!!


2006 INS standards leaves

2006 INS standards leaves this decision to each hospital - see Standard 42, PC N, page S43. A couple of years ago, we had this discussion at our chapter seminar in Atlanta where many hospitals were represented. Most with IV teams definitely obtained a chest xray when a patient is admitted with a catheter placed by some other facility. They are unwilling to take the risk that you described. As you can see we still do not have consistency with the use of terms for catheters, so repeat xray is the safest practice.  

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

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

If admitted with the central
If admitted with the central line, think any should be verified. Placed a PICC once and upon confirmation their port was found to be up their jugular, had the port for quite some time.
At the hospital where I come

At the hospital where I come from, we tried to make this a written standard for all patients admitted to the hospital with a PICC line to have a CXR upon admission to confirm tip placement.  Unfortunately, we were unable to get this passed in the higher administrative levels so we compromised with them and wrote into the PICC policy that upon admission that a chest x-ray order will be obtained from the admitting MD for catheter tip placement and this has worked out very well.   

Vera Deacon
As a member of a PICC team
As a member of a PICC team that has been in existence for over 12 years, we are fortunate to have the adminnistration of the hospital behind us and it has been incorporated into our policy that on all patients admitted with "PICC"s have xray tip confirmation prior to use of the line. There have been many incidents whereas the PICC is malpositioned on admission (even ones that we placed at our own institution-that obviously were correctly positioned after insertion) So for us, across the board-all patients admitted with PICCs get xray tip verification.
One quick(less than 2
One quick(less than 2 minutes), inexpensive (about $17.00 for materials), x-ray free way of checking for migration into the right atrium is using an ECG signal. The P wave begins to change as the catheter transitions from the proximal SVC to distal SVC into the RA. Its shape changes from a "u" shape to a large spike and its voltage increases 4-8 fold (i.e., the changes are not subtle). (See tracings at The signals can be derived during placement from the guidewire but after placement from the saline in the catheter. If a spiked P wave is seen, the catheter has migrated inward and you can pull back following the ECG to an appropriate position. This technique, however, can only detect distal SVC/ RA positioning. It would not exclude the catheter being pulled outward or malpositioned elsewhere.
Chris Cavanaugh
This EKG device is another

This EKG device is another type of tip location system that is a good idea, but needs further improvement to REPLACE an XRAY.  It can only tell you if the tip is in the RA, not if the tip is in the IJ or coiled somewhere.  PICC tips move, and a prudent nurse would follow INS, AVA guidelines, manufacture guideliness and FDA guidelines and only use the catheter if the tip is in the SVC.  Currently, the ONLY way to tell this is with a chest xray.

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

mary ann ferrannini
Yes we get a CXR unless
Yes we get a CXR unless patient had PICC placed recently in our sister hospital and has no s/sx of malposition. We caught too many near misses and insisted this was the safe way to go. One of my many similar stories....saw a nurse setting up for TPN on a patient with a PICC that was not on my PICC list. I stopped her of course and requested the CXR. The patient was clueless about the hx of the line. Yikes, it flipped back down and was in his Basilic vein. I think the nurse was grateful. One of the key issues when placing Midlines is to be able to differentiate them from PICCs to prevent errors like this. Was it not labeled on the dressing or the tails or the hub(s) of the product. Or did no one look? I know this story too and it is frustrating. Even with Big labels and signs we would find Dopamine and Vancomycin and other goodies being infused through these lines. That is one reason we rarely use midlines anymore. I sometimes place them when a patient is going home on comfort care and only has a very short time to live or patient is self pay and is going home for less than a week of home IV therapy (also must meet criteria).
Gwen Irwin
 PMRMD, I have seen your


I have seen your posts before and have wondered about the use of an ECG signal being in the scope of nursing practice.  Mostly, because we would be making adjustments based on that signal.  Some states would determine that making that kind of decision as out of the scope of nursing.

Where are you and what is your experience with the scope of nursing practice in your state?

Gwen Irwin

Venous Access

Austin, Texas

Hi Gwen: I am in

Hi Gwen:

I am in California.

There are visitors to this website who are far more expert than I in the rules of nursing scope of practice within a particular state. Notwithstanding even what is within this "scope", there may be additional local factors within a certain facility where there may be a "division of labor" and even secondary pressures between interventional radiology, the PICC team and local politics. I can tell you what I have seen -  The procedure has to go through a series of the appropriate new technology/ best practices committees and any number of other committees to obtain approval. Generally, chest x-rays are performed for a first several procedures to validate it locally and let people become comfortable with it.

In broader terms, interpretation of ECG's is a common part of many nurses' practice, for example a standing order in an ICU to bolus a medication/ start a drip for V. Tach, PVC's, control the rate of atrial fibrillation, etc. At 2:00 A.M., these happen automatically; no strips are faxed to the M.D. for confirmation. Assessment of the increase in P voltage is far less subtle than distinguishing PVC's from Ashman beats or PAC's with aberrancy.  It comes back to the credentials and training of the nurse(s) involved. I understand governing bodies may limit the breadth of a practice but specifically regarding this limited interpretation of ECG's, my experience is that "scope of practice" is dependent on what you are trained to do, and not generic to an R.N. or other degree. We have R.N.'s in our facilities who are not ICU certified and thus restrict their practice to what their qualifications permit. I have an M.D. but I don't do open heart surgery.

I would disagree with Chris Cavanaugh's statement that ECG guidance can ONLY tell you if you are in the right atrium and that a chest x-ray is the ONLY way to document SVC positioning. If you examine the references at and the additional references cited in the full text versions there, you will find copious documentation of the accuracy of ECG guidance, its correlation to echocardiographic localization and the inaccuracies of x-ray in tip location. If you advance a catheter and the "u" shaped P wave transforms to a spike that is 50 - 100% of the QRS , that may ONLY happen between the mid-distal SVC and upper RA, but NOT in the IJ, proximal SVC or elsewhere in the vasculature. On the other hand, if you only see a small, "u" shaped, P wave, that would mean the catheter is anywhere proximal to the mid SVC and you would need a CXR or other navigational system to define it more precisely.


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