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Performing Chest X-rays for PICC placement in the Emergency Department

At out facility we have a policy that any patient that is admitted as an inpatient with a PICC line, a chest x-ray needs to be done to verify tip location prior to accessing a PICC line. Now we have several patients that are admitted to the ED with a PICC line and the question was should the ED physicians be ordering chest x-rays on these patients prior to using their PICC line?  What are the best practice standards regarding using existing PICC lines in the emergency department? Should a chest x-ray be done even if the patient is not an inpatient and will be discharged home from the ED?

INS standards state

INS standards state that catheter tip location should be confirmed before initial use.  Since tips can spontaneously migrate without any externally visible signs, I would say yes...if they plan to access and use the line.  The standard of care should be consistent throughout the facility.

Keely Ralston RN-BC, VA-BC, CPUI, RCIS

 You will not find a specific

 You will not find a specific "study" addressing this issue for patients with any CVAD arriving in the ED. You will find numerous resources addressing the issue of CVAD tip malposition. In fact there is an INS standard about this as well. Catheter tip migration is a spontaneous and unpredictable fact of all CVADs. Some type of assessment must be used. It would be preferable and much more accurate to obtain a chest xray. However a secondary type of assessment could include ruling out the clinical signs and symptoms of catheter tip migration and assessing catheter patency prior to using it. I would prefer to actually know where the tip is located before I began any infusion through a CVAD for a patient in the ED or admitted to the hospital. I do not think there should be a different approach to this question. I would take this question to the appropriate committees to look at the evidence for tip migration, the standards, etc. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Chest X-ray

I also think it is ok to use the PICC without an X-ray assuming it has already been confirmed. Logically if we are worried about tip malposition after the initial good X-ray, then we should get an X-ray before each and every use! I would X-ray only if suspected complications. But if the policy states must get X-ray before admission, you probably should not change your standard for the ED.

Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness

I agree with the previous

I agree with the previous comment.

My education to the staff is

My education to the staff is to change a dressing for the patient admitted to the hospital with a PICC line. Assess the insertion site for any abnormal symptoms. If there is not, then flush and aspirate from the catheter to check the patency of the catheter. Chest x-ray will then be ordered by MD to confirm the tip location before any medication is given through the catheter.

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