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corpsman8404
Just started May of 2009 inserting PICC's
I use a Site Rite U/S and Bard PICC's. I tried some 5fr Sherlocks but have had a hard time with the Sherlock device. So I am back to the regular 6fr PICC. I have aproximately 45 Solo PICC's and had 28 in training. For the months of May, June and so far July my procedures are infection free.  I hear the standard is to utilize and assistant during the procedures. Any truth in this and any suggestions on furthering my expirience and training. Thanks.
Cherokee people
I have trialed the Sherlock

I have trialed the Sherlock but are not presently using it at my facility. Check with your Bard sales Rep. in your area. They may have some pointers for you on how to improve use of the Sherlock.They may also have a Clinical Educator on board that can work with you.

Are you saying that you are using a 6fr on every patient you are placing a PICC on?  Not every patient is a 6fr candidate. The vein diameter must be big enough to accommodate the catheter or you will increase the patient's risk of DVT. Vein diameter is a factor in developing a DVT. Look up Virchow'sTriad: 3 factor's that increase risk for thrombosis is  1) Venous stasis (Catheter too large for vein), 2) Hypercoagulability and 3) Vessel injury/disruption. If this was not your intention please excuse my comment, but since you are new to placing PICCs this maybe helpful to you.

I was trained to place PICCs independently. Which can be hard especially if you are new and you forgot something and you have to drop it and put on another pair of sterile gloves. It's not impossible to do but can be time consuming. Sometimes if we are not too busy we can team up and help each other. Speeds things up tremendously. One is setting up while the other is positioining the patient,assessing veins ,etc. I think this is great keeps you from having to drop extra supplies and changing gloves. Also keeps you from being so tired at the end of the day. Doesn't happen a lot though because usually we are too busy to team up together. My facilty won't approve an assisstant because of expense when they know we can place them independently and maintain our sterile field. We do call on each other though when we are having difficulties.

As to how you can further your experience/knowledge. Become an active member of the INS (Infusion Nurses society) or AVA (Association for Vascular Access). This membership includes a magazine subscription. These organizations sometimes have IV Therapy lectures at their meetings. They both have websites. I don't know what state you are from but there is a local NC and SC INS chapter. Check to see if there is one in your state. INS has IV Therapy textbooks. Read everything you can find on IV Therapy. It's also really helpful to have a mentor in IV Therapy. I'll be glad to help you as much as I can. My personal email address is [email protected] Welcome to the wonderful world of IV Therapy. Good luck in your PICCing!!!!!  Vickey

 

Michelle Todd CRNI
I was going to say the same

I was going to say the same thing regarding 6Fr PICCs. I was also trained to do the procedure independently. I typically have out 5 pairs of sterile gloves. I don't feel I need an assistant in order to maintain my sterile field or get anything for me, although it might be nice. I have certainly heard of hospitals using two nurses until everyone is up in their skill level. In fact, when we started doing it at LMPH in 1995, we had two nurses for about 6 months to a year, depending on the nurses comfort. But this was also because both nurses were learning to do the PICCs after they had just had a class to get them started. But if you have had someone watch you do that many PICCs, you probably should do fine on your own now. You can still call for help if you are having a difficult case but I don't think an assistant is required.

 

Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland [email protected]

Michelle Todd, CRNI--Head PICC Nurse, Vibra Specialty Hospital of Portland [email protected]

corpsman8404
I thank you for the reply
I thank you for the reply and encouragement.
ted
There is no "standard"
There is no "standard" directing the number of health care professionals needed to place a central venous catheter or picc.  Have been placing picc's for fifteen years by myself.  I maintain sterile technique by myself.  It may be easier and more time efficient to place with two people but that does not mean that one person can't maintain sterility during this procedure.
corpsman8404
Yes we use only one size,
Yes we use only one size, but I make sure the vein can accomodate the size inserted.  The rep here was very helpfull, but the 5FR Sherlock is close to 300 dollars each, the 6Fr are 750 for 5, a big difference and less equipment to play with. I will look into the Virchow's triad immediately. The local private PICC inserter that was used prior to my being trained, had stated the industry satndard was to have an RN and Nurse Aide. I don't use help because I prepared a PICC cart, have a OCD sequence I follow, and if I need to break sterile field, about 3 times now, I just back off and pull my equipment and re start/continue. Works well for me. My facility has 3 hospitals in Houston and between all 3 we place about 40 to 50 in a month, with 3 "RN PICC plumbers". I did join the INS last month and as you can see using the IV Therapy>NET, very usefull. Thanks for your comment and advice. Wendell
MarkCVL
Of the two (INS and

Of the two (INS and AVA)...in my opinion...AVA offer more education and networking for the Vascular Access Specialist.

piccmasters
Yes, it is nice to have

Yes, it is nice to have another person to assist you while doing this procedure. I make use of a CNA to assist me in doing this procedure. It helps especially for patients who are difficult to position the arm. I trained my assistant,very time effecient. It is up to your facility to employ an assistant. A second PICC RN would be nice for difficult sticks.

I am also in Houston area. I am trained to use the Sherlock.

Incidently, I go to one of your facilities to do the PICCs.

You may contact me if you need more help/questions: [email protected]

corpsman8404
Are you hiring?

Are you hiring?

Gwen Irwin
I would agree that the use

I would agree that the use of 6 fr is not acceptable for all patients, based on their vein size.  Besides that, the CDC says use the fewest lumens necessary to accomplish the therapy.

I would recheck your pricing for 5 fr vs. 6 fr.  I don't think there is that radically a difference in price.  I do believe that the 6 fr is more expensive.

We love the Sherlock.  We work independently for almost all patients.  It is possible to maintain sterile field when doing them independently.  Our infection is very low.  Wish I had numbers at home to support that.  We are finding that most of the infections taht do occur are at least 7 days beyond insertino.

 We do have some patients that may not cooperate or have limitations in positioning, then another PICC RN is asked to help.

We do over 350 per month at 6 sites now.  Starting in October, it will be 7 sites.  OMG, we are not ready for this!

Gwen Irwin

Austin, Texas

corpsman8404
Do you need help?
Do you need help?
blacba
The pricing I have been
The pricing I have been charged for bard piccs (4fr groshong and 6fr triple) The 4 fr are cheaper.  The 6 fr triple are 300 dollars more per case of 5 than the case of 5 of 4 fr groshongs. 
blacba
oops. sorry, just realized
oops. sorry, just realized you were talking about 5 fr.  Actually my pricing on the groshong 5fr vs 6fr triples were exactly the same. 
corpsman8404
Not a problem, thanks for
Not a problem, thanks for looking at my entry.
coffeemania
Be careful with the 6Fr.

Be careful with the 6Fr. Remember that the taper part of the PICC is 8Fr, not 6. The diameter of that part is close to 2.7 mm. If you put a 2.7mm in catheter in an average vein (3-4mm), risk for DVT is high. Lots of patients that I put in TL 6fr PICC's developed DVTs. Many times I have to put in 2 PICCs for very very very sick pts in ICU. One arm had a TL 6fr and the other had a DL 5fr. Almost always the arm with TL 6fr developed DVT's.

 5Fr is a lot better. The taper part is about 7fr, and is tapering up gradually from 7cm mark (for Bard's PICC, only 3cm for the AngioDynamic PICCs). If you have 2 cm of the catheter externally, plus approximately 2cm subcutaneously, you only have the last 3 cm of the tapered part in the vessel, about 5.5 fr or about 1.8mm in diameter. So lower the DVT rate.

In short, 2.7mm catheter in 4mm vein = bad

            1.8 mm catheter in 4mm vein = better

 Good luck.

 

corpsman8404
Thank you, I will adjust,
Thank you, I will adjust, ASAP.
kokotis
Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Once again you will all have me but hate the new "The Joint Commission iinstead"  or JC as I am now referring to them.  As of Jan 1, 2010 you will have to have a second person in the room with you when doing a PICC line to do the checklist and stop the procedure at any time technique is broken.  There must be two signatures on your new measurable form.  Now believe me read the compendium and the NPSG's for 2010.  This does not have to be an RN or MD by the way.  I am now recommending PAT's.  PICC Associated Technologists as this is the most cost-effective method to do this.  No more singualr PICC line placements after Jan 1 2010 if you want the JC to approve your hospital.    Independent contractors out there you better figure out who in the hospital is gping to watch you or you will lose your business!!!

There is lots more in the NPSG's from JC so I think you better start reading

For those attending AVA you will fing these JC recommendations in my talk

kathy 

 

Kathy Kokotis

Bard Access Systems

corpsman8404
Thanks for the FYI. I will
Thanks for the FYI. I will start getting ready to adjust now.
Gina Ward
new npsgs for 2010

Kathy,

I did some searching and cant find any info on this new change. I did see on the JCAHO site one blurb about the only change to standards will be to number 7 , regarding healthcare associated infections. I am sure this is what you are referring to.

Can you forward me a copy of any of the written info you have on this change, or their wording? This change will be a major event for me in my small facility and I need all the heads up and administrative support I can get.
Thanks, Gina Ward R.N., CPAN [email protected]

Gina Ward R.N., VA-BC

rmcbeath
JC NPSG's

Kathy, I have looked on line at the 2009 JCAHO NPSG's, and I can't find the goal you are referring to for the 2 person PICC placement etc.
Can you give me the specific goal in case I missed it. I need to justify staffing if this is going to be the requirement. Thank you, Robin

calamuci1
2 person PICC placement

Please post the link to JC statement on the use of 2 persons when placing a PICC, under the NPSG 2010 #7 it is not stated.

Kathy Evans
In regards to using all 6fr

In regards to using all 6fr catheters- our hospital has just put out a study that proves higher incidence of venous clot using the 6fr. catheter- this will be presented at AVA in September. I hope you are not solely looking at cost in your decisions on what size of catheter to place in a patient. After presenting our study results to physicians, we rarely place 6fr catheters any more- and we are a trauma 1 center.
We use Sherlock and I honestly have found no difference in the 5fr and 6fr lines (or 4fr for that matter) in reading sherlock.
At our hospital, we have a 2 RN PICC insertion team. It is much more efficient for us and if there is a difficult line, having another RN's input or assistance is great! We place roughly 190 PICC line per month in our facility.

coffeemania
New change in NPSG 2010?

Dear Kathy Kokotis,
Could you please kindly list the exact reference, the wording, where you got the information about 2-person PICC Team? Many professionals in the forum and I tried to search for it without luck.
Thank you.

kathykokotis
Compendium 2008 October from The Joint Commission

You need to go to the Compendium which is a collaborative project from the Joint Commission to understand how a checklist is employed. A checklist involves an individual who must observe and stop the procedure thereby two individuals must be in the room during the actual insertion. One inserting and one who does the checklist. Does that make sense

Here is the compendium quote which is also on the joint commission website
B. At insertion
1. Use a catheter checklist to ensure adherence to infection
prevention practices at the time of CVC insertion (B-II).23,29
a. Use a checklist to ensure and document compliance
with aseptic technique.
i. CVC insertion should be observed by a nurse, physician,
or other healthcare personnel who has received
appropriate education (see above), to ensure that aseptic
technique is maintained.
b. These healthcare personnel should be empowered to
stop the procedure if breaches in aseptic technique are
observed.
2. Perform hand hygiene before catheter insertion

coffeemania
the compendium

http://www.jcrinc.com/New-Tool-in-the-Fight-Against-Health-Care-Associated-Infections/

Download the Compendium of Strategies to Prevent Healthcare–Associated Infections in Acute Care Hospitals

http://www.journals.uchicago.edu/toc/iche/2008/29/s1?cookieSet=1

A Compendium of Strategies to Prevent Healthcare‐Associated Infections in Acute Care Hospitals

http://www.journals.uchicago.edu/doi/full/10.1086/591059

Infect Control Hosp Epidemiol 2008;29:S22–S30
0899-823X/2008/2910S1-0004$15.00
DOI: 10.1086/591059
Supplement Article: SHEA/IDSA Practice Recommendation

Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals

Gwen Irwin
Compendium 2008 October from The Joint Commission

I agree that the compendium has that info, but I do not see anything from JC in NPSG 07.04.01 that indicates that someone else doing the checklist is required from JC.  Even if JC was involved in the development of the Compendium, to me, that doesn't indicate that the JC requires it.

If they do, I believe there will be revisions to inform all of us.  I have contacted JC and have had no response on this issue.  I know of others that have also contacted JC and have had no response.

I believe that the JC makes the NPSG and doesn't tell us exactly how to do it.  They don't tell us how to meet other NPSG or criteria for review that they have, there is no detail.  I really don't expect them to come out with this kind of specific information.  In an economy (including hospital economy) that is distressed, I find it hard to believe that they would require additional FTEs to accomplish this goal, therefore more financial distress to the institution.

Gwen Irwin

Austin, Texas

kathykokotis
checklist

Being I am an infection control nurse as a background this is going to be my suggestion to the chat board on checklists

If the MD's inserting CVC's are using a checklist and being checked off by an observer that can stop the procedure in your hospital than the RN placing a central line (PICC line) must follow the same procedure in that institution.  One cannot provide two different standards of measurement in thier own facility.  On the other hand, if the MD's are checking themselves off I see no reason why the RN's cannot do the same although I see no value in even using a checklist in that situation as no one is going to stop the procedure anyway and one's word that they are compliant would have no weight in a court of law anyway.  The next time you step on an airplane I would suggest to the pilot that they take the word of the mechanic on check off as there is no need for the pilot to be a second eye to following protocol.  I will not be on that plane with you all.

It is not about labor.  It is about standardizing care and procedures for patient safety.  If the MD's are required to do it so is the PICC Team.  If the MD's are checked off by the floor staff than the PICC RN's must be checked off by the floor staff.  End of soap box.  This is the discussion to have with hospital administration.

Kathy Kokotis RN BS MBA

Bard Access Systems

 

Gwen Irwin
JC requirements for 2 people per CVC insertion

Kathy,

I am aware of your background as an infection control nurse.  I understand the concepts that you are describing and agree, but JC doesn't specifically state that a second person is required to do the checklist for the insertion.  Telling people that this is required by JC is not what JC says.

Regardless of who does the checklist, the JC doesn't state what or who is required to complete that checklist.  We can't over interpret this and say that 2 people are required.

I look forward to standardized care and procedures for patient safety.  We (Seton Family of Hospitals) are so committed to that.  Even though we have done insertion checklists for over 4 years, I still don't believe that a staff nurse (floor staff) has the knowledge to recognize a break in sterile technique and to stop the insertion.  I wish they did.  However, in this time period of over 4 years, we have not had an insertion related CVC insertion BSI, not by doctor or by PICC RN.

Presenting what JC requires comes from JC.

Gwen Irwin

Austin, Texas

 

 

kathykokotis
checklist

We are agree the compendieum is endorsed by JC.  It is also found on the JC website

We all agree the compendium gives a description of how to use a checklist

We all agree that JC gives no description of how to implement anything so if you chose to say it is evidenced based in your facility to use one person checkoff and in the case of MD's you use a two person check-off who am I t say what is right.   It fits your facility.  You have reviewed the evidence based research on the IHI website on checklists and deemed a one person check-off is fine and evidence based.

However, I do find amusing that the clueless bedside RN is checking off the MD for aseptic technique.  Why bother using the clueless RN at the bedside and just have have the MD's check themselves off like the PICC RN's?   I find no point in using a clueless bedside RN if they are really clueless to check off the MD's.  Besides that is offering two standards of care by having checkoff for MD's and not for RN's

Just my opinion take it for what it is worth.  I see things somewhat differently.

Kathy

 

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