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delay in receiving x ray confirmation

Our facility is looking at using a prn PICC nurse to place PICCs "after hours". My concern is that we will not be able to obtain x ray confirmation of tip location until the following morning, possibly as long as 18 hours after the PICC is placed.  I'm uncomfortable with a potentially malpositioned PICC being in place for that length of time.  Any thoughts on this? We do not use any type of tip locator during insertion and are unlikely to purchase one.

Robbin George
I'm sure I am missing

I'm sure I am missing something but what is the point of an "After Hours" PICC insertion

if the catheter cannot be used until the tip location has been confirmed?


Robbin George RN VA-BC

The nurse inserting the PICC

The nurse inserting the PICC can take a course on chest xray assessment and begin using the PICC immediately after they have demonstrated competency in this assessment. We have an online course about this skill. 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

Karen Day
Karen Day's picture
The chest XRay interpretation

The chest XRay interpretation class would be extremely beneficial in this case.  It sounds to me like your facility realizes the need for providing this service at all hours of the day providing for continuity of care, with that in mind, you could approach them with the question of allowing the ER doctor to interpret these chest XRays until the radiologist can read them in the morning.  All ER doctors are capable of reading a chest XRay and though interpreting the film for proper positioning of a picc line may be new to them, your radiologist and your current picc nurses can provide them with the information they would need to correctly interpret these films.  I have not had the opportunity to take this chest xray assessment class as of yet, but am challenging my facility to allow for this.    I do look at every single chest xray of every line I place and although I am not allowed to interpret, I do know when a picc is good and when it is not.  I challenge each of you to look at your films whether you are allowed to interpret or not, you will gain so much more knowledge and respect for what you do.  There are so many interesting things you will come across.

night hawk

Did you ever hear of night hawk?

I guarantee there is a service that is reading films in the middle of the night for you MD's.  Who do you think reads the films for MD's doing CVC's and who reads the ER films.  ER MD's do not read their own films due to liability and lawsuits.  Hospitals have contractural arrangements with a night service.  Talk to you ER Director regarding after hours radiology services.

Kathy Kokotis RN BS MBA

Bard Access Systems


Dianne Sim RN VA-BC
delay in receiving x ray confirmation

In this day of digital XRay, your CXR should be able to be taken ASAP and the image reviewed by your vascular access RNs. There are courses available in reading CXRs for PICC Tip Location; all of my consultants have done the course and now view the image themselves when possible (if the case is after hours, our triage RN is able to pull up the image online and review it) - it has been invaluable! We have found that non-radiology MDs don't know where the CAJ / distal SVC is, and that radiologists barely look at the films and often give us a reading of innominate / subclavian when the tip is either clearly in correct position at CAJ / distal SVC, or the CXR has been poorly taken and they call the last part of the PICC they can see 'the tip'! With the aid of Sherlock, we are pretty confident of the PICC tip location, and are able to repeat the CXR if necessary, or review the current film with the radiologist.  The interesting fact is that we have been 100% correct on ALL readings we have questioned. I shudder to think of the number of PICCs we advanced / withdrew / exchanged when we were taking the MDs word on the readings (prior to the advent of our high-tech tools).

It is my opinion that as vascular access specialists, we practice and are held to a higher standard. We can't just poke them and run!!! We have to own, and be responsible for the whole process, including CXR reading for PICC tip placement.

Dianne Sim RN, CEO

IV Assist, Inc

Dianne Sim RN, VA-BC, CEO; IV Assist, Inc.

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