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mklaas
Midline Policy

Good afternoon,

Our facility (ICU specifically) is going to start placing midlines in our patients. The thought is to train a group of ICU nurses, followed by nursing supervisors, charge nurses, and anyone else who may be interested. As this is new to our facility, I have been asked to develop policies/procedures.

So, my question is two-fold:

1. Does anyone have a midline policy they would be willing to share to give us a framework?

2. Is training all of these people to insert midlines a good idea? My gut feeling is probably not, but I am wondering if someone has something better to go on than gut feeling.

 

Thanks in advance!

lynncrni
Based on my experience as an

Based on my experience as an infusion nurse specialist and an educator, this is NOT advisable. This is a specialty practice and it requires dedicated time to develop these skills and expand one's knowledge. This is not a good plan IMHO. 

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

JessNews
Midline Policy

We have identified that not everyone can be competant with ultrasound guidance (USG) and it is a skill that must be used over and over again to maintain competancy.

In my facility we have a vascular access team that places all USG PIVs, PICCs, and midlines. Other areas of our hospital wanted to be trained on USG to place their own PIVs, however, this is NOT a skill that is "see one, do one, teach one." We want our inserters to have 50 sticks with a preceptor present before we turn them "loose." There are a few reasons we do this: 1) when we are called for access we want to preserve the patients veins, thus, we want a 1 stick situation. The inserter needs to be good at what they are doing. USG does not come easy to everyone and takes time to become the expert, you need to have "backup" if you are new to this skill.  2) We want our inserters to master the skill of assessing the vasculature and what device is appropriate for that patient.  

In my facility our vascular access team are the only people trained to place devices with USG (excluding our physicians who place IJ's and subclavians). USG shouldn't just be about placing a device, it is important to take into account what the patient is going to need as dictated by their diagnosis and treatment plan, this is where your vascular access team comes into play to give a "consultation." When I am called to place a midline there are many factors I take into account before placing any device: patient diagnosis, medications infusing through the line, current patient condition, prognosis of the patient. I ask these questions because I don't want to place a midline in a patient and two days later get called because now  the patient needs a PICC for central access. I want to place the correct device the first time. It is my experience that MD's are not always familiar with what is appropriate to infuse peripherally and what needs to be infused centrally. You don't want nursing staff infusing inappropriate medications through a midline (which happens in every unit of the hospital) and can have very serious consequences.

These are just a few things to think about before going down the road of USG. Good luck with your endeavors.

Jessica, RN VA-BC

 

Jessica Newsom

lynncrni
Great message! Best approach

Great message! Best approach for improving outcomes. Thanks for sharing this. 

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

mklaas
Thank you!

Thank you both for your insight ! This was my feeling as well. 

SInce my post, I have since talked with our manager, and it is more of a limited group, with the initial nurses being a "train the trainer" of sorts. The training with the rep is going to be more intensive and shoudl hopefully garner more experience than previously thought. 

If we come across any more hiccups, I will update this. Thanks again to you both! 

M.K.

ICU Nurse

RN, PHRN, VA-BC, NRP

Walker
Midlnes

Hello,  

New to this forum site.  Lynn thanks for a responses, it was a pleasure meeting you at INS.  (I was there with my coworker michael, we're both IV nerds, thanks for selfies!). 

We utilize Midlines in our ICU patients as well.  These are all placed by our Vascular Access Team RN and a select few critical care float RNs who have been trained on USGPIVs, deemed competant and then trained on Midline IVs.  We currently use the BARD PowerGlide placed under ultrasound guidance.  We have a policy in place for thisdevice, a competency, and a training protocol including having us witness a certain amount of lines being placed.  It is a skill that takes consistency and obsessive repitition.  While I would not recommend having ICU RNs place these devices, I would recommend ensure that any midlines inserters are deemed competant and proficient in USGPIVS, familiarity with policies and procedures, and have a competency system in place to ensure initial competency and yearly competency.  We have been using these devices for over 5 years and have good relationships with our vendors.  Please feel free to contact me via email and I can pass on our policy/protocol/competencies etc.  

 

Andrew Walker RN, BSN, VA-BC, CRNI

[email protected]

mklaas
Another Question

Andre-Email sent

Another question - what does your documentation of the insertion look like? Our intervention to document on leaves much to be desired, and we are "free-texting" most of the info in the comment box. What I have been documenting and been trying to get others to as well looks like this:

Order verified

Pt and wife educated and gave verbal consent

Prep and insertion using sterile procedure and US guidance

20 ga, 10 cm catheter inserted Rt brachial Vein

2 total sticks

Biopatch and sterile drsg applied

Sticker indicating 'midline' applied

Do Not Use sign placed above bed

SBAR to bedside RN

Lot # RECT1142

Exp. 2019-08-31

 

Is this over-kill or fairly in line with what you all are documenting at your facilities?

 

Thanks!

M.K.

ICU Nurse

RN, PHRN, VA-BC, NRP

lynncrni
Certainly not overkill! All

Certainly not overkill! All of this is needed in addition to use of US, catheter to vein ratio, extenal length. See INS SOP on Documentation. 

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Walker
Here is a copy of a note we

Here is a copy of a note we use when we place midlines in patients.  We are on Epic 2017.  The first note is a template.  The second note is a faux patient. 

Midline (Powerglide) Insertion at Bedside

 

@NAME@ is a @AGE@ @SEX@ with a history of:

 

@PMH@

@PSH@

 

Admission Date: @ADMITDTTM@

Date of Insertion: @TD@  

 

Pre-procedure Assessment 

Insertion procedure and follow-up care discussed with {patient/other:17404}. 

Indications for Midline:  ***

Limitations/Precautions:  ***

Anticipated length of treatment based on diagnosis/type of therapy: {Blank single:19197:s:"***","Outpatient Therapy","Discontinuation prior to discharge"}

 

       

Powerglide (Midline) Procedure Insertion:  

Midline was placed using bedside ultrasound guidance.  Maximum sterile technique was used including {Blank multiple:19196:a:"hand hygiene","sterile gloves","cap","mask","skin antiseptics","sterile arm drapes"}. Local anesthetic used: {Blank single:19197:a:"***","0.9% Bacteriostatic Saline","1% Lidocaine"}.  Midline placed after {Blank single:19197:s:"***","3","2","1"}  insertion attempt(s).

Insertion of {Blank single:19197:s:"20","18"} Gauge {Blank single:19197:s:"8","10"} cm long midline performed in {RIGHT/LEFT:16} {Blank single:19197:s:"***","Brachial","Cephalic","Basilic"}

Catheter was flushed with {Blank single:19197:s:""***","20","10"} mL of 0.9% normal saline. Antimicrobial disk, securement device and transparent dressing applied. 

Patient response to procedure: {PROCEDURE TOLERATED:24554}

Ultrasound system used: {Blank single:19197:s:"BARD Site~Rite Prevue+® (A)","BARD Site~Rite Prevue+® (B)","SonoSite Edge Ultrasound System®","BARD Site-Rite 8 (A)","BARD Site-Rite 8 (B)"}

Catheter Information:

Catheter Brand:  BARD POWERGLIDE 

Lot Number: ***

Expiration Date: ***

 

Filed NOTE FOR PATIENT Example. 

Midline (Powerglide) Insertion at Bedside

 

Johnny Cash is a 54 year old male with a history of:

 

Etc. 

 

Admission Date: 8/14/2018

Date of Insertion: 8/15/2018

 

Pre-procedure Assessment 

Insertion procedure and follow-up care discussed with patient and family member. 

Indications for Midline:  Poor Venous Access, Multiple insertion attempts, extended hospitalization > 4 Days, blood draws, ABX. 

Limitations/Precautions:  Hx of stroke.  Left side paralysis

Anticipated length of treatment based on diagnosis/type of therapy: Discontinuation prior to discharge

Powerglide (Midline) Procedure Insertion:  

Midline was placed using bedside ultrasound guidance.  Maximum sterile technique was used including hand hygiene, sterile gloves, cap, mask, skin antiseptics and sterile arm drapes. Local anesthetic used: 1% Lidocaine.  Midline placed after 1  insertion attempt(s).

Insertion of 18 Gauge 8 cm long midline performed in right Cephalic

Catheter was flushed with 20 mL of 0.9% normal saline. Antimicrobial disk, securement device and transparent dressing applied. 

Patient response to procedure: The procedure was tolerated well.

 

Ultrasound system used: BARD Site~Rite Prevue+® (A)

 

Catheter Information:

Catheter Brand:  BARD POWERGLIDE 

Lot Number: etc. 

Expiration Date: etc. 

_______________________________________________________________________________________

We also place orders for care and maintenance, insertion, flush panel, lidocaine.  A charge is placed for billing.  And an LDA is created in the EHR for documentation of standardized assessments. 

 

Andrew Walker BSN, RN, VA-BC, CRNI

 

 

 

mklaas
Thanks!

Thanks for that template!

We are working with our clinical team to develop a template to make this whole thing easier. Thanks all for the input!  

M.K.

ICU Nurse

RN, PHRN, VA-BC, NRP

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