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Halle Utter
Hospice Patients/PICC Lines and CXR verification

Could I get some feedback on whether everyone is xraying PICCs that are placed in terminal hospice patients?  A hospice we work with would prefer no xrays to verify tip, to keep costs down. Their reimbursement is so low that any additional cost is reviewed carefully.  Mostly these are used for a very slow infusion of Morphine or Dilaudid.    Does everyone xray no matter what?  I know it is my license that is on the line, so I have concerns.  What is the standard of care for this in the hospice population?  Thanks.

 

Halle Utter, RN, BSN

Intravenous Care, INC 

fizerjk
I would not reccommend
I would not reccommend placing a PICC line for any reason without xray comfirmation.  Perhaps a midline catheter would serve these patients better.

Jeffery Fizer RN, BSN

Halle Utter
Yes, we did try that.  If
Yes, we did try that.  If it is very short term life expectancy it does work.  But some of these hospice patients live for several months, and the midlines always seem to leak.  We are for the CXR but were wondering if the standard of care was to xray in the hospice population.  

Hallene E Utter, RN, BSN Intravenous Care, INC

Halle Utter
Yes, we did try that.  If
Yes, we did try that.  If it is very short term life expectancy it does work.  But some of these hospice patients live for several months, and the midlines always seem to leak.  We are for the CXR but were wondering if the standard of care was to xray in the hospice population.  

Hallene E Utter, RN, BSN Intravenous Care, INC

PMRMD
This is a situation where

This is a situation where ECG screening from the catheter tip can be expedient and cost saving:

An ECG signal may be derived from a placed catheter by flushing the line with saline and leaving a syringe with metal needle still in the IV port (see www.pacerview.com/index_files/CVC_AND_PICC_TIP_LOCATION_WITH_PACERVIEW.htm). (During placement, the signal is derived from the guide wire.) If an elongated P wave  is seen rather than the "u" shaped one typical of location in the proximal SVC or other "non-SVC" locations, than one can say the catheter tip is at least in the mid SVC (with the proximity to the SA node / caval-atrial junction inversely related to the height of the P wave - see the same PacerView web page). As the P wave approximates 3/4 -to- just-shy-of-the QRS voltage (there are other criteria as well), the catheter will be in the distal SVC. When equal to the QRS, particularly if a small initial spike is seen before the oppositely deflected spike, it is  in the very distal SVC or upper RA (if the spike is seen)(see the same web page). If only a "u" shaped P wave is seen, the catheter tip is no further in than the proximal SVC or elsewhere in the vasculature and then you could do a CXR.  This procedure literally takes less than two minutes and costs less than $17.00, a huge time and expense savings over x-ray..

lynncrni
The standard is no different

The standard is no different for hospice patients than for any other patient population. 

 

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

rivka livni
If the midlines leak, how

If the midlines leak, how about inserting a "short" PICC in end of life situation.

Measure it so the tip resides in mid to distal Subclavia, use a small FR PICC, don't check CXR, make sure there is blood return.

I wonder what Lynn thinks about it.

 

 

lynncrni
I think it would be a bad

I think it would be a bad idea. Just because these patients are in hospice, we still can not predict how long they may live. So they could have this PICC for weeks or even months. Many may be dehydrated or have diseases that increase the risk of thrombosis. This midclavicular tip location is well known to increase the risk of vein thrombosis. That is why we have worked so hard for the past 15 years to get rid of this practice. I think this could pose serious risk to these patients, making their dying process more painful or could even hasten their death through PE, infected thrombus, etc. I also think this would be lowering the standard of care because they are dying and I do not think this would ever stand up through a court of law. Just my opinion though.

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

rivka livni
Lynn, I hear what you are

Lynn, I hear what you are saying.

Don't you think though that if Hospice will not use a PICC because of added cost, the patient will suffer more with repeated PIV insertions, not to mention a leaking mid line.

My understanding is that Hospice admits patients with 6 months or less life expactency. I am not sure the risks in this case out weigh the benifits. Do you think Most of the "short" PICC catheter will develop problems within that ime frame?

 

 

lynncrni
First, there is no "short

First, there is no "short PICC" according to any document I have ever seen. AVA has a position paper that is 10 years old written specifically to combat the midclavicular tip location. INS does not recognize the midclavicular as an acceptable tip location. And yes, I do think that serious complications can develop within a few days or weeks with this tip location. I think if a hospice patients needs therapy that requires a PICC, the hospice must meet the same standard for insertion and tip location as all other facilities. However with 3 hyaluronidase products currently on the market, hypodermaclysis could be a better alternative. 

 

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

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