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Jeff Hanks
IJV or EJV, does INS and AVA really disagree?

If I'm reading correctly, the INS has a position paper that states properly trained nurses can place external jugular (EJ) PICC's and AVA's position paper states nurses can place internal jugular catheters (IJ) and that EJ's are not recommended.  Do they really disagree or am I missing something?  I am not placing either of these lines but have been asked to explore it for our difficult to access dialysis patients.  If I wanted to learn how and had a final answer on which vein, where would I go to learn?

Jeff Hanks, CRNI, Vascular Access Nurse

lynncrni
I would not interpret this

I would not interpret this as "diagreement" but merely a different approach. INS started with the insertion of short peripheral catheters in the EJ while AVA started with a paper about inserting PICCs through the IJ. Different catheters, different needs, different indications for each, etc.  

 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

momdogz
Who is currently placing IJ

Who is currently placing IJ PICCs? I.e. - who might be able to help us find a person/place to train with? 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

Jonathan Rolt
I would  really like more
I would  really like more info on IJ training if its out there. I hoping to  go th e EJ class this year sometime but our poplation has terrible access and  any new places to go for access is encouraged by the medical staff for the vascular access team
janetpettit
I believe that Doug Burns

I believe that Doug Burns from Vanderbilt has been placing IJ PICCs.

 

Janet Pettit MSN, NNP-BC, CNS 

Jeff Hanks
I'm thinking specifically of

I'm thinking specifically of PICC's when discussing EJ vs IJ.  AVA's paper clearly prefers PICC's in the IJ and even goes so far as to say EJ "is not recommended" for PICC placement.  INS's paper discusses PICC's and PIV in the same document but seems a little less emphatic in that they mention only EJ and do not discourage IJ. 

Based on the fact that AVA gives rationale for not using the EJ (relative smaller size & tortuosity) I'm leaning towards pursuing IJ.  But...I'm exploring it because I have no experience with either.

Has the work Doug Burns is doing with IJ PICC placement published somewhere yet?

I also have the same question as the other posters......Where can one find training?

Jeff Hanks, CRNI-Vascular Access Nurse, Oaklawn Hospital. 

Jeff Hanks, CRNI-Vascular Access Clinical Specialist, Arrow International

lynncrni
The huge difference is that

The huge difference is that EJ is a superficial vein that can more easily be located, while the IJ is a deep vein in very close contact with large nerves and of course, the carotid artery.

 I do not know of anyone with a formal education/training program yet. 

 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Jeff Hanks
Yes, I see from reading that

Yes, I see from reading that the IJ is deeper and near the carotid.  That does concern me.  If it is ever doable, it's definitely a job for ultrasound guidance.  Lynn, Thanks for letting me know about the lack of training.  If you don't know about it I would venture to say it does not yet exist.  Is there a training program for PIV placed in the EJ?

 

Jeff Hanks, BSN, CRNI

Vascular Access Nurse, Oaklawn Hospital. 

Clinical Specialist, Boston Sceintific.

Jeff Hanks, CRNI-Vascular Access Clinical Specialist, Arrow International

Robbin George
I thought the discussion of
I thought the discussion of IJ v EJ revolved around the definition of Peripheral Vein--The bedside PICC RN can only access Peripherals--I thought INS was in the process of composing a position paper on this subject

Robbin George RN VA-BC

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

First off let me start here.  Placing a PICC line in the IJ or EJ is not within the manufacturer's recommendations and is off label.  On the other hand a Hohn type catheter without a cuff can be placed on label in the IJ.  You did see the word internal jugular did you not.  Nurse practitioners at MD Abderson place these.

The external jugular is not a safe site for a long term catheter.  It is tortuous, small and not direct.  High risk of complications.  I do not care how easy it is to access it is also off label to do with any long term catheter I am aware of.  To place a PICC line in the EJ leaves the RN on their own - off label usage.

Is the IJ used for long term access - the answer is yes.  It is large, not tortuous and a direct pathway.  Doctors would never once consider the EJ for long term access unless all other avenues are gone.  When was the last time you say a MD do an EJ for long term access over 24 hours????  Think hard on that one.

EJ is a great emergency site for less than 24 hours and should be accessed with ultrasound.

Yes Vanderbilt has Medical staff approval thru their medical board to access the IJ.   they stopped doing EJ's a long time ago. 

If you embark on this procedure work with your medical staff to set up a competency program for staff with clearance as well as use a catheter that is lableled for IJ usage that is long term.  Complications are arterial puncture, air emobolism to name a few.

Kathy Kokotis

 

 

 

 

Kathy Kokotis

Bard Access Systems

Jeff Hanks
Kathy,  Thanks for the info

Kathy, 

Thanks for the info and advice.  I understand the off label issue & that is a concern.  Thanks for reminding me of that.  I think however, that I would avoid placing an IJ (regardless of AVA's position) mostly because I don't have the resources required for learning the skill set that are available in an organization such as Vanderbilt.  Too risky for me without those resources....my opinion.  I do however believe that this will, in the future, become an option for pt's and RN's that meet the specific criteria noted in the AVA position paper.

Based on AVA's position against, and in spite of INS's stand that a nurse can place EJ PICC's,  I would not place a PICC in the EJ.   AVA states the very specific reasons that you cited. 

As I mentioned earlier, I would like to learn EJ PIV placement for those very few pt's that have no other options and need urgent access.   Where can I learn?

Jeff Hanks, CRNI-Vascular Access Nurse, Oaklawn Hospital.  Clinical Consultant, Boston Sceintific.

Jeff Hanks, CRNI-Vascular Access Clinical Specialist, Arrow International

bartina
Nancy Rose RN IV Team VA

Nancy Rose RN IV Team VA Medical Center Wilmington, DE (800) 461-8262 ext 4830

I just read in Gray's Anatomy that the external jugular vein has two sets of valves, one near the subclavian and one about 4cm above the clavicle.  "These valves do not prevent the regurgitation of the blood, or the passage of injection from below upward." I realize the EJ is a last resort but should it be used at all?l

Nancy Rose 

kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Jeff:

there are simulator labs for various procedures in Minn, so you may be able to learn on a simulator

Kathy

Kathy Kokotis

Bard Access Systems

ncosta
Jeff, EMTs are trained to

Jeff,

EMTs are trained to place EJ PIVs.  Contact your ER, that is how we were trained.

Hope this helps,

Nancy

Mats Stromberg
Hi, can these position

Hi,

can these position papers be accessed on line somewhere? Or could they be legally shared through this site?

Mats 

Jeff Hanks
Mats   I attached both the

Mats

 

I attached both the AVA paper & the INS paper.  If that does not work Google both, they come up without much searching. 

 

Jeff Hanks, CRNI-Vascular Access Nurse, Oaklawn Hospital.  Clinical Consultant, Boston Sceintific.

Jeff Hanks, CRNI-Vascular Access Clinical Specialist, Arrow International

Jeff Hanks
Nancy & Kathy,   Thanks,

Nancy & Kathy,

 

Thanks, I'll check with my ED.  I know they are doing it here but when I have asked about the training they receive it seemed rather scant, but I 'll explore it with them in greater detail.

 

Jeff Hanks, CRNI-Vascular Access Nurse, Oaklawn Hospital.  Clinical Consultant, Boston Sceintific.

Jeff Hanks, CRNI-Vascular Access Clinical Specialist, Arrow International

Mats Stromberg
Jeff, great thanks for the

Jeff,

great thanks for the help.

Mats 

EKH
Jeff, I have taken both

Jeff, I have taken both position papers to my medical director at a small hospital in Lansing, Michigan and after showing the evidence-based articles I made our policies and procedures within 2 days and got the program running shortly there after. My medical director took the position as my champion physician which was awesome. I have a lot of automony at this institution as I have continually opted for the most cutting edge, best practice possible. Change is not a problem at our institution as this small hospital has me as the lead PICC nurse and one of my other colleagues as back-up. So, my first EJ PICC was shortly thereafter the INS statement came out. It was a toruous vessel, for sure! Lots of valves. Thankfully the IJ position paper came out because it is such a better vessel. I have no placed 5 IJ PICCs. I have a prime example of vessel preservation in patients with CKD. She is a case study right now. Her R IJ PICC (5 Fr DL with 13cm internal and 12 external as it is thread out onto the chest to decrease risk of infection even more) is "comfortable; hardly noticeable" and very functional. There haven't been any issues with infection (and one patient had a trach and vent with the IJ PICC covered in an intact sterile occlusive dressing but the ladies secretions were a lot...no issues at all). I only change the dressings so migration hasn't been an issue. Not a single one of the lumens have had to be declotted either. The longest so far was 37 catheter days. I placed my first L IJ PICC due to R IJ occlusion. I am so excited about all of this...truly doing what is best for the patient. If you want anymore info or pics of my case studies feel free to email me @ [email protected].

Liz Holowasko BSN, RN, CRNI

Liz Holowasko BSN, RN, CRNI

monicasorg
Liz,  Would you be willing

Liz,  Would you be willing to post these pics in the photo gallery on this site with a little info under the pic?  I'm sure all would love to see.  Thanks! How is your medical director addressing the off label use of the PICC?  That would be a big concern to me, from a legal standpoint.  I would imagine that if there were, God forbid, major problems resulting in a law suit that the inserter of the line would be a sitting duck.  Deferring to one of the legal experts on this site, I would imagine that having the medical directors support would not shield the inserter at all from legal action. Am I correct?  Does anyone know if any PICC manufacturers are addressing this issue from their standpoint?  More PICC inserters wanting to place PICCs via IJ and it being off label use in their own literature? 

lynncrni
I have not reviewed any

I have not reviewed any catheter instructions for use in a while, so don't recall the exact wording to say for sure that an IJ or EJ placement would be considered an off-label use. Any support from a physician in any capacity (e.g., medical director or patient's physician) would provide no protection in any form during a lawsuit.  The nurse inserting the catheter would be held accountable for decisions made during placement - location, technique, etc. The concept of anything a physician does or says providing "protection" for a nurse is a misguided idea. This is not possible because both professionals are operating on their own individual license. One can not protect the other. If this was judged to be off-label use (and I am not saying that it is), it could still be an acceptable use of the catheter based on patient assessment - vein preservation, etc. 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

roger
Lynn, With this said, does

Lynn,

With this said, does this also translate to contraindicated sites i.e. bil mastectomies with lymph removed/AV shunts with specific MD Orders that says "OK to insert PICC" on Mastectomy/AV shunt side? Will the inserter be protected then?  When is it ever "OKAY" to use these types of sites?

We always get these requests but we don't give in.

 

Roger

lynncrni
There is no way to guess in

There is no way to guess in advance about the outcome of any specific legal case. Each case is very different and the goal will always be to settle out of court. So each side will have their experts giving depositions, then the attorneys haggle it out to reach a settlement if possible. If this is not possible, the case goes to court and is then in the hands of the jury. So there is no way to know how a physician's order will be interpreted. 

The bottom line is that nurses must be patient advocates and never go beyond what your professional judgment tells you is best for that particular patient, regardless of a physician's order or not. This requires the nurse to have the knowledge and skill to make a thorough assessment. I see to many cases where the catheter inserter is acting like a technician, simply following what someone else has told them to do. This is not nursing. In a patient with bil. mastectomies, you may decide that it is or is not in the best interest of the patient to place a PICC. This would depend on many factors - factors that the physician may not include in his/her assessment. 

This brings me to another approach - a collaborative practice environment where decisions in these cases are made collectively with both professionals listening to the points made by the other with a focus on patient safety, not egos or which professional can control the other. 

 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

ann zonderman
Ann Zonderman, BSN, JD,

Ann Zonderman, BSN, JD, CRNI, LHRM

There is a legal theory "learned intermediary" which addresses physicians having more information about a drug or product than the general public.. In some situations this allows for further explanation of why a produce/ medication was ordered.  It is possible there is credible evidence for the jury to evaluate and understand why something was prescribed.  If a physician "orders to use/ place" a line (ie. mastectomy side) the court and jury can consider that the physician's further education and training led to belief that in that situation it could be an appropriate order.  That may help explain some.

However at the PICC inserter also has extensive knowledge, if you believe it is inappropriate to place the line, for some reason--- Talk to the prescriber, discuss options, alternataives, inform the patient of the situation, allow for the  informed consent process.

Legal considerations would include   Did a manufacturer - say do not use for x .. or is there research evidence to support the decision for the order....

It is not always  black and white....Room for consideration exists..

Ann Zonderman, BSN, JD, CRNI

msiegelrn
Jeff you are correct when

Jeff you are correct when you state that the INS has a position paper on EJ placement and that AVA has one on IJ placement. The INS paper is a Position Statement and merely does that, state the position of the INS on EJ placement. That is what it addresses and deals with. It does not state the EJ placement is preferred over the IJ as that was not the intent nor the purpose of the paper. It was done in response to many questions raised by INS and non-INS infusion nurses. You would have to ask the people at AVA about their paper and how they came to the conclusion of one line being better or preferred over another. As far as finding out which vein should be used that is an organizational question as far as education, training, competency, patient specifics and purpose. It has been my experience that when the INS puts out a position statement it is in response to questions asked and not to show favoritism of one line or catheter to another. I hope this helps in some small way.      

 

If I'm reading correctly, the INS has a position paper that states properly trained nurses can place external jugular (EJ) PICC's and AVA's position paper states nurses can place internal jugular catheters (IJ) and that EJ's are not recommended.  Do they really disagree or am I missing something?  I am not placing either of these lines but have been asked to explore it for our difficult to access dialysis patients.  If I wanted to learn how and had a final answer on which vein, where would I go to learn?

Jeff Hanks, CRNI, Vascular Access Nurse

[/quote]

Marvin Siegel RN CRNI

Director of Clinical Services

Town Total Health

NY, NY

Marvin Siegel RN CRNI

Director of Clinical Services

Town Total Health

NY, NY

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