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MIDLINE MISUSE

I have been working in vascular access since 2006 and have learned a tremendous amount of knowledge coming from the floor as bedside nurse.  There have been times when the patient requests a midline for home Vanco and the IV nurse that was refusing to place it was told that she was being a "barrier" to patient care because the patient wanted the midline over the PICC after the education was given about the appropriate device that needed to be placed.  This is the same as when the MD orders a midline for vesicants and the IV nurses refuse to place it.  It says clearly in our policy that a midline is not supposed to be used for medications with a ph of less than 5 or greater than 9 but our management insists that this is the patients and the MD's right to get the line that they want.  What would happen in a court of law if this IV nurse placed the midline for home Vanco and he developed a DVT, compartment syndrome or worse?  The management involved insists that we are going against orders if we don't follow them, even if we know that it is the wrong order.  Any thoughts or ideas on how to handle this almost daily occurence???  Thanks in advance. 
 

Chris Cavanaugh
Education is key

Why would a patient even know what a midline is to ask for it?  If the order is for a vascualr access device, and the patient is educated about what is needed, how does midline even come into the conversation?  It should not be a discussion.  The patient needs to be educated that a midline is not an appropirate device. 

As far as the MDs go, you need to address this with your legal and risk management departments.  Educate the legal and risk management departments about the right line for the right patient, the risks and liability involved, and campaign to have MDs place orders for a "Vascular Access Consult"  not a specific device, deferring to the expert to choose the right linie for the patient at the right time.   There is mountains of text books and literature published to back you up, use this to state your case.

No one orders an MD to replace a knee with a "stryker" device over some other, or to perform a procedure that may not be needed.  MDs get consults and they decide what is the best course of treatment for the patient.  Vascualar access specialists should be treated with the same respect.  Ask for respect for your knowledge base, and act like the expert that you are, not a staff nurse who needs to follow orders.   You are a specialist. 

Good luck.

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

JackDCD
Well said

Couldn't have said it better myself, Chris

 

lynncrni
 Education is the key to

 Education is the key to solving this but I would not try to address it individually with each physicain or patient. I would take this to the organizational level. You have a written policy that correctly states how a midline should be used. What committee(s) in your hospital reviewed and accepted this policy? I would gather the facts about what has been prescribed. Then I would locate all of the published literature about midline catheters and totally educate myself about the published outcomes, national standards and guidelines. The committee will need this information and your knowledge as the in-house expert. Clearly there is an issue with the way practice is expected at your facility and the written policy is not understood and adhered to. If there were to be a lawsuit, your written policy would be a critical element. Remember that each case is very specific to the facts in that case. So we can not generalize about what would or might happen in a legal case. However I can tell you that your practice would be measured by all of those documents - research, standards, guidelines, and internal policies and procedures. It looks extremely bad for the defense when written policiies are not followed. In my opinion, I woiuld not deal with this using a one-on-one approach, but would go to the appropriate committee(s) and the leadership of those committees. You should also involve your risk management dept. Lynn

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

lynncrni
 One other factor - you did

 One other factor - you did not say how long the course of vancomycin is needed in these patients where a midline is prescribed. If you are waiting for cultures to determine whether vancomycin is the appropriate drug, then neither a PICC or a midline is appropriate. For those 2-3 days, I would use a short peripheral catheter - smallest gauge, NO joint insertion sites, an engineered stabilization device, and correct dilution and infusion rates. Then when the culture results are known and the need for long term vancomycin is established, a PICC is indicated. Lynn

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

JackDCD
Vanco

Lynn,

I would agree with most of what you said. However, a Midline for 3 days or a peripheral for 3 days amounts to the same thing regarding Vanco. In fact,  I think there may be an argument in the case of the Midline being in a bigger part of the vein. But, we really need to emphasize the fact that any meds with ph out of range should not be used in a Midline. We are have that problem at our facility, everyone wants Midlines but not everyone understands it's limitations.

lynncrni
 Sorry, but a midline tip

 Sorry, but a midline tip location is much deeper in the tissue than a short peripehral. So they are not the same because the nurse might be able to detect an extravasation from a PIV much quicker than a midline. With vancomycin it is both the drug pH and the vesciant nature that must be cosidered. Lynn

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

JackDCD
Tip

Correct, But extravasation is a much more common event with a peripheral than a Midline. I've seen maybe 3-4 midline extravasation is my 10 years as an inserter. Now that not saying it can't happen...just saying a Midline extravasation should not be even a semi-common occurance. It should be extremely rare. Now, a phlebitis?...different story. Your absolutely correct in not catching that until it's too late.

That is why I say no longer than 3-4 days for Vanco and even getting that line out ASAP. But that is theory not always practice.

 

Jack

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