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Dan Juckette
PICC Handoff Communication Form

 Here is a Hand-off communication form for PICC patients that I believe addresses the NPSG on Hand-off communication/documentation better than most of the forms I have seen online. It has been in use for 2 years and is due for revision in 2011. I would like suggestions on how to make it better meet the standard.

 

 

 
Primary Nurse to PICC Nurse Assessment and Report: Please obtain and witness PICC Consent prior to arrival of PICC Nurse. Please insure patient is in bed with a clean over-bed table in room.
 

Date:
Order Present::
Consent Signed:
Ordering MD:
Allergies:
 
Relevant History and Diagnosis:
 
 
Indication for PICC Placement:: ( Check all that apply )
Antibiotics:
TPN:
Pressors:
Poor Access:
Infiltration:
Blood draws:
Vessicants:
Power Injection:
Other:
Current IV medications and fluids:
 
Is patient anti-coagulated? Y or N
If so, Which Drug(s)?
Last PTT if on Heparin Drip     
Last PT/INR if on Coumadin                 Date
Suspected Septicemia? Y or N
Positive culture or GS? Y or N
Site:
Precautions: (Check all that Apply)   Standard       Contact       Droplet        Respiratory    Other
Mental Status( check all that apply)  Alert      Oriented       Confused      Unresponsive        Agitated
Restraints?                        
Is the patient on telemetry? Y or N
Does the patient have a pacemaker? Y or N   L or R
Hx of Mastectomy? Y or N    L or R
Dialysis graft/ Catheter? Y or N L or R
UE DVT?   Y or N
Hx of Previous PICC Y or N L or R
Hx of CVC, Port, CABG, or Central Venous Stent?      Y or N
Is PICC intended for use in an outpatient setting? Y or N 
Is Patient diabetic? Y or N 
O2? Y or N
Most recent Vital Signs:
T:
HR:
R:
BP:
SpO2:
 
                                            Nurse Signature: _________________________________________________
 
PICC Nurse to Primary Nurse Assessment and Report:
 

Date/Time:
Consent Verified:
Order Verified:
Prior IV site:
Start Time:
Finish Time:
Prior IV Discontinued Y or N
Catheter Brand:
 
Exp. Date:
Lot Number:
Fr. Size:
Number of Lumens:
Original Length:
Trimmed Length:
Site: R or L
Vein:
External Length:
Internal Length:
Maximum Barrier Precautions: Yes
Ultrasound Guidance: Yes
Lidocaine 1% 1-5 ml SQ:   Y or N
Number of Attempts:
Site Circumference:
External Site to SVC Length:
Access Needle Ga.
Introducer Length:
Guide-wire Type:
Tip Location Method:
Sherlock TLS: 
Jugular Ultrasound Scan:
Visitors Present:: Y or N
Who?
Blood return verified:
Procedure Notes:
 
 
 
Complications: Y or N : Description:
Time X-Ray Ordered:
Time Tip Verified:
Radiographic Verification by:
BioPatch Applied: Y or N
StatLock Applied: Y or N
Transparent Dressing Applied: Y or N
PICC Re-positioned? Y or N : Description:
 
Patient and bed left the same as pre-procedure Y or N
 
                                             Nurse Signature:_________________________________________________
 

Patient Label

 

 

 


      Revised May 2009                                                                        

 

8/31/2010

lseaver
I couldn't see the

I couldn't see the form.........am I the only one?

Dan Juckette
attachment

I originally

Daniel Juckette RN, CCRN, VA-BC

MarkCVL
If I am reading this

If I am reading this correct....the floor nurse (who is not doing the procedure) is uptaining consent.  I personally and professionally do not agree with this practice.  I feel the most appropiate person to uptain inform consent is the professional who will do doing it!  Just my 2 cents. (or more)

lynncrni
This looks like a very good

This looks like a very good form. I just have one major resservation about the note at the top of the form. I never think that it is appropriate for the primary care staff nurses to obtain the informed consent for PICC placement. Informed consent is actually all about patient education. The PICC inserter is the one that should do the education because they know more about the procedure and can best address any questions the patient may have, along with explaining the alternatives to the patient/family (a critical component of a truly informed decision). Staff nurses simply do not have this knowledge nor do they have the time. Also, the person doing the education should not also be the same one who witnesses the patient's signature. 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

Dan Juckette
Informed consent vs witnessed consent

There is nothing in the form that iimplies that the floor nurse is obtaining " Informed Consent". They are witnessing a signature on a form. They do it for surgical consents, Medicare release information forms, discharge instructions, and even Advanced directives. Nor does the consent form they witness anywhere state it constitutes an " Informed Consent" The Joint Commission Standard is pretty clear that obtaining "Informed Consent" is the responsibility of the Provider (MD, PA, CNP) who is ordering the procedure, test, or whatever. Of course, patient education about the procedure, the possible later complications, and answering any questions falls to the person placing the line. But none of that should take place before the Provider who ordered the line explains the risks, benefits, and alternatives to the patient and/ or family in person. That is " Informed Consent" and cannot be deligated. If the Nurse placing the line finds out that the Physician has not done this they should not begin the procedure. It is no different from them signing an anesthesia consent in pro-op and the anesthesia provider coming in and performing " Informed Consent " prior to giving the first sedative.

Daniel Juckette RN, CCRN, VA-BC

lynncrni
As I said, your form is a

As I said, your form is a very good one. I guess the language at the top to "obtain and witness the informed consent". It looks like this is directed to the primary care staff nurse and it could be interpreted to mean that you are directing the staff nurse to obtain this. Maybe it is my own interpretation and maybe it is because there are so many unanswered questions about informed consent for PICC insertion. The JC may be clear on surgical and other invasive procedures as you state, but there are numerous other documents that state the person performing the procedure should be the one to obtain informed consent. Informed consent is synonmous with patient education as education is required before there can be an informed consent. I have always obtained consent for PICC insertions beginning in 1981 and still teach that this should be done by the person doing the insertion. Most physicians do not understand what the PICC is, other than it is a form of CVC, have never seen one go in, do not know the risks involved, or the outcomes produced by the facility and never discuss alternatives. Many times, the physician is not present before the PICC is inserted so this portion can not fall to them. Also, do you realize that there are some hospital risk managers now saying that PICCs have become such as common procedure that they are now included in the consent signed upon admission and a separate informed consent is not required at all? Then again there are states such as CA that have laws directing who can obtain informed consent. So there are numerous variations across the country. I do totally agree that the staff nurse can easily be the one to witness the signature of the patient as long as they understand that is all they are doing and have no responsibility for anything else. I would not proceed with PICC insertion until I had educated the patient, regardless of who obtained the signature on the piece of paper.

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

Dan Juckette
That is why this form

That is why this form says obtain and witness PICC Consent, rather than Informed Consent. There is a specific PICC Consent form also, with a signature line for the patient, the witness, and a line where the person placing the line attests that have done patient education regarding the specifics of the procedure, patient related strategies for prevention of line infections and given the patient an opportunity to have their questions answered. Our facility is not so large that the Ordering Provider would not be able to speak with the patient personally. I would still never begin a procedure where the first time the patient hears that they are getting a line is from the PICC nurse coming to place it. It may just be a personal quirk but I do not think we should let ordering providers off the hook for explaining the risks, benefits, and alternatives. Whether consulting or attending, it is a conversation they should be willing to have if they are ordering central lines. If it is a placement they concider so urgent or emergent this process can not be followed, they can sign the consent themselves and state it is a medically necessary lifesaving intervention. Then explaining the risks, benefits and particularly the alternatives fall to them at a later time. This process also forces the Provider to become more educated about why they are asking for this and what the risks are for the patients for doing it and the risk for the floor staff when they don't order the appropriate line. I see that as a Win/Win. Our educational responsibilities as Vascular Access providers end with patients and families, but begin with the people ordering lines and caring for lines. This is a good mechanism for working both ends of the road.

I also want to mention that this form is specifically directed to tha National Patient Safety Goal of " improving hand-off comminication across the spectium of care". Most hand-off communication from floor nurses is very sketchy at best. PICC nurses, in order to do "due diligence", have to comb the medical record for why the patient is getting a line, what therapy they will get, where the line is going next, and a host of other things. Many times the floor nurse doesn't know that a line is ordered, or why, or enough about their patient to know if it is still indicated. The physician is ordering the line "because the nurse told me to" or " because the IV infiltrated" or " because the case manager told me too". The PICC nurse comes and looks at the chart, does the PICC, charts and leaves without ever seeing the busy floor nurse. And the first the floor nurse hears their patient has a line is when the radiologist calls to OK it. And that is if the secretary remembers to tell them about the call.

Just like the surgical time-out, this  process causes everyone to take a step back. The floor nurse has to know enough to give a written report, the ordering provider has to actually speak with the patient. The PICC nurse, rather than spending all that time with the chart, spends it with the patient. They actually take the patient from the floor nurse at a specific time and give them back at a specific time, and are responsible for all their care while they have them. The staff at the next level of care can see this as well.

Daniel Juckette RN, CCRN, VA-BC

Margieh
Margieh's picture
PICC consent

 I really like the idea of witness PICC consent opposed to informed consent. I live in Nevada and I have had discussion with the nurse practice regulator of the state board related to the infusion nurse obtaining informed consent. I was referred to a decision tree on the board website that addresses several areas such as :

1. Has the board made a practice decision regarding the task/skill in question (NO...not in Nevada)

2. Is it in your hiring agency policy and procedure manual ( NO... I am a PICC contractor and it is not in the P&P of any facilities I service)

  One of the facilities I service is requesting that I obtain informed consent.  Do any of you think it would be prudent for me to obtain the consent without regards to the criteria above.

I plan to go back to this Medical director and ask him to word the consent specific to PICC as witnessed consent and put it in the facility P&P.

Any input would be greatly appreciated.

Great nurse communication an procedure form!

Thx. Margie          

Margie Hood RN

lynncrni
A rose by any other name is

A rose by any other name is still a rose! So i think regardless of what name you give to this process it is still informed consent. Your board of nursing referred you to their scope of practice decision tree, which is the recommended and best method for a state board to use. This is the most common method used by state boards now. You and your employer make these decisions based on this decision tree rather than these decisions being made by your board of nursing. I am also a little concerned that your company does not have its own set of policies and procedures for you to work under. All that you do must be addressed in P&P. Without this, you are in a very legally precarious position if anything should happen for you to end up being sued. Who has the P&P for PICC insertion - your PICC insertion company or the facility that insertion company contracts with? What is done for other aspects of your service? I think that the inserter can and should be the one to obtain this informed consent but I do realize that there are various state regulations that prohibit that for some nurses. But remember informed consent is a process and not simply a signature on a piece of paper. This process begins with the education given to the patient before you begin to insert the PICC. You can and should be the one doing this education, answering all questions, and getting the piece of paper signed with a second nurse as the witness. And you do need this addressed in a P&P from your employer. 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

Freetoridehdlynn
PICC Hand-off Communication

 I was wondering how many others are using a communication form?  Currently where I work we give a verbal OK and sign on the MD order sheet the PICC is ok for use.

Lynn Davis-Deutsch

Seton Family of Hospitals

Vascular Access

Dan Juckette
communication forms

I think they are more common in the western US than the east, but since improving handoff communication is a national patient safety goal, anyone who doesn't use one has can show an immediate and verifiable improvement in qualiity of care by implementing one. Since I provide contracted PICC services as well, they are essential for any facility using a contract service. A facility is really not happy paying for the services of a contractor who came in on-call for a PICC placement when the patient refused consent or reallly didn't have a therapy that indicated a PICC was needed. What began as a cost control screening tool ended up morphing into a genuine handoff communication when it bacame a national patient safety goal. Most facilities I visit now are using a formal report form for shift to shift handoff as well. This dovetails into that documentation so that there is always written documentation of who is assigned to care for the patient and what they need to know about the patient from report.

Daniel Juckette RN, CCRN, VA-BC

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