In this day and age of cost containment, while also trying to capture increased revenue, IV therapy nurses need to look for more ways to be useful and supportive of the organizations they work for. At the facility I work for, layoffs are imminent in various areas of the organization. The subject of PICC nurses expanding their skills to the insertion of non-tunneled CVC lines has come up as a possibility and a way of expanding our services. The IV team I work on already does what we have named as "overwire" procedures. That particular procedure is the exchange of a PA introducer for a triple lumen CVC prior to transferring open heart patients out of the ICU environment. I am pretty sure we are one of the only facilities in the country performing this skill. Performing this skill is supported by our nurse practice act (yes, we have verified) and was well supported by our pulmonologists/ intensivist and cardio-thoracic surgeons at our facility. Taking on the skill of placing IJ CVC lines under ultrasound guidance would allow us to be an even greater support to the hospital while at the same time preserving our jobs and possibly even increasing our hours of service to 24 hrs per day. Currently, we are a team with hrs 7 days a week but only 12 hrs per day. Is there another facility that has taken on this skill??? Is it feasible? Do you have any outcome statistics that you could share with me for us to present our case effectively? Please and thank you.
Yes, there are many nurses already doing this. I firmly believe that 100% of all vascular access practice should be totally in the hands of nurses with documented competency. You should get several responses about this from this group. Lynn
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
Jenny and Lynn,
I have had the same idea about this population of patients. I work for a Heart hospital and often times peripheral access is very difficult to obtain after surgery add the fact that the patients who have complications end up on various vesicants, using the PA catheter sheath to insert a triple lumen central catheter made sense to me. I have been a little timid about this idea because people look at me a little funny when I bring it up. Can you guys give me references or contacts as to who is doing this? I need supporting information to take to administration about this procedure.
Matt Gibson RN, CRNI, VA-BC
Check the instructions for use from the PA catheter you are using. The introducer for these catheters should always be used to remove the PA and insert another and more appropriate CVC. Those introducers are so large, they can cause complete exsanguination in a very short period if the set become disconnected. This has happened and patients have died. So the PA should never be simply removed and leave the introducer for infusion, especially if the patient is moving out of ICU onto a regular nursing unit. So there are strong recommendations to use this introducer to insert another CVC through an exchange procedure, totally removing the introducer. The question is who is doing this procedure. I strongly believe it should be infusion/VA nurse specialist. I can not recall any publications about nurses taking this procedure into our scope of practice. What are the laws that govern nursing practice in your country? Who makes rules and regulations for nursing practice? I would start there to see what you have to do to have this procedure legally accepted as being within nursing scope of practice. In the US, this is a state-based decision, so one state could allow it, another may have a rule against it, and many others have a set of standard questions for nurses to answer to make their own decisons about scope of issues. So each state is different. Once you get that settled, then you could use references from this group to support the fact that other nurses are doing this. Lynn
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
The IV access team that I work for does this procedure routinely. It is done on open heart patients after the PA line has been discontinued via the introducer. Prior to transferring the patient out of the ICU we do the over wire exchange under full sterile barrier precautions using the central line bundle protocols. A wire is inserted via the introducer, the introducer is d/c'ed "over the wire" and then a new 7 french triple lumen Arrow Guard Blue catheter is inserted "over the wire" and finally, the wire is removed. We have had incidence where an MD will insert an introducer on a trauma patient for whatever reason and then in the middle of the night (for various reasons) they will then insert a central line through the introducer itself and suture it in place. On a few occasions we have had them attempt patient transfer to a lower acuity floor with this in place. Unacceptable. We are very diligent in our assessments of lines each day, what types of lines the patients have and then being vigilent in our plan for the care of the patients upon transfer out of the ICU. In general, we do the "over wire procedure" on open heart patients related to vascular access issues following their surgery. The state in which I practice (Oregon) does in fact allow the exchange of a line over a wire for an access already established (such as a PA introducer). However, my original question was the IV team being able to take on the initial access for IJ placed central lines using ultrasound technology. For the team I work on this practice would not be a very far leap, based on the fact that we have used ultrasound for our PICC line placements over the past several years and that we know the equipment quite well. The initial access would not be difficult to learn. Also, is there anyone out there (RNs') doing subclavian placed lines under ultrasound? Of course, that is an entirely different can of worms but one that could be learned. I am not sure if any state would cover that for an RN but I was just wondering. With all of the cutbacks and layoffs recently it would make sense for IV access nurses to broaden their horizons and become even more important to the care of the patients. I also am curious as to how others have overcome the push back from certain MDs'. For example, at my facility there are two sets of intensivists/pulmonologists......one set of them are employees of the hospital and the other set are contracted from another facility. Basically, the set from my facility would most likely be gracious and appreciative of our undertaking such a skill. The MDs' contracted out may not be as supportive related to the charge billed out for the procedure on their behalf. I am very intrigued about taking this on because it would serve many purposes.......job security, skill enhancement, support for our intensivists, as well as being absolutely certain about the procedure under which each line was placed for infection control purposes. I am not sure about the MDs' in other facilities but we all know that some are much better than others at maintaining a sterile field. Nurses are diligent in that task on my team. Anyhow, any input would be greatly appreciated. I am also glad to email privately with anyone wanting to know more about the over wire procedure.
Teleflex sponsored a pre-conference workshop at last year's AVA that was tailored toward RN's who were starting to insert IJ and subclavian lines. They may be able to provide some resources that could help you get your program going.
Mirador makes a patient safety device that is used during CVC insertion by several RN's that attended the above mentioned course, so I may be able to connect you with a few of them. Please send me an email with your contact info and I will forward.
Steve Gappa
Mirador Biomedical, Inc
[email protected]
www.miradorbiomedical.com
425-894-4134 cell
I am going to this course that was offered at AVA. It is a Teleflex sponsored course in Houston on Feb. 4th. I do know a nurse in Kerrville, TX who went to the same course, and is now placing these types of lines. I think it is very safe for RNs who have been using ultrasound to place PICCs. We are not doing this yet at our hospital system, but I can see it in the future. Our PICC nurses are very skilled. We place over 400 PICCs/month. Sorry, I cannot help with information since we are not doing this yet, but I do encourage you in this endeavor, and perhaps this nurse I know can give you some stats/info on it. I will get in touch with him and try to get some info to you. You can email me at [email protected]
Sheila Hale, RN, CRNI, VA-BC
I agree withLynn
I feel we need to be consistent in what we call ourselves. Currently you hear IV access teams, IV Teams, PICC teams, and more. We need to strive to call ourselves Vascular Access Teams. We need a consistent, united front for our profession to move forward.
In addition, we ALL need to be collecting consistent, uniform comparative data! We need to know what the national averages are for simple and complex data points. This way we will have the evidence we need to move our profession forward.
If the national success rates for first attempt PICC placement is 85% (defined as one venipuncture and tip termination in the lower one third SVC) and overall success rates are above 90% (basically getting a may use order when procedure completed) it is only natural that we as group would and should move to placing IJ and subclavian CVCs.
Many clinicians tout they are 90-98% successful - with success rates based on what? Attempting both arms with multiple attempts each? There is no national comparative data today and without it, we cannot move forward. The intensives/pulmonologists at my hospital see me place lines successfully and are now asking me if I would learn CVC placement. Could you imagine if I had national comparative data to show these physicians and my administration? How easy would that data be to support my cause and give me even more job stability?
Jenny, you are valuable to your hospital. Unfortunately, the burden of proof falls on you, and local and national comparative data will show how good you are. I was a Beta Test Site for the new www.piccregistry.com and I presented from the podium and gave a poster presentation at the national AVA convention in October.
Check out the winter AVA journal “letter to the editor.” By collecting comparative data with the current hospitals enrolled in www.piccregistry.com, I have in fact shown my value to my physician partners and nursing management and soon I hope to be expanding my team and my skills with CVC placement. How powerful would it be if we all were collecting consistent, real-life, un-biased data to show the quality of care and skill in our profession of vascular access? We could change the way our entire specialty practices!
I have gotten some great input both on this forum and via private emails. I am so thankful for the expertise. It appears that we will have to apply to change our nurse practice act to incorporate support for this skill. I will continue my investigation, data collection, and consulting with colleagues. Thank you!!! I will now need to pursue the state board of nursing which seems like it will be an entirely different ball of wax than what I thought I was starting out with. I like a challenge. :-) Is there anyone out there who has had to apply to their state board and gotten the change request approved? Any pointers or tips?