So not all of our nurses use US which I know is not standard but not something we can currently control. INS says prefered method is MST I have some nurses who prefer direct stick which to me MSt with a 22g cath is much eassier on a patient then an 18 g introducer needle. Thoughts?
I do not know your role but I would like to comment. You say "our nurses" and "not something we currently control" in the same sentence. Who controls it? Are you trading the standards you know for nurse convenience, or profit margin? Why are you using a 18g? I would hazard a guess that your direct stick nurses wander down to the antecubital region, and then infections and DVTs go up! Which is why we use ultrasound!! If you have a choice on the preferred method how do you justify taking the non preferred route. We as health care practitioners have to ask ourselves these hard questions. It sounds to me like you already know the answers!
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
Unfortunately do to the nature of were we place PICC lines ( not in a standing facility) we are not afforded an US for every nurse, so unfortunately I dont have a choice . I completely agree an 18g is a horrible idea and a 22g with then using MST is a much more humane approach but the feedback I recieved was that MSt without an ultrasound was risky, not sure how it is more risky then sticking an 18g in someone but maybe I am missing something. Yes, unfortunately AC is the only option with direct stick.
I apologize for sounding harsh but you do have a choice and frankly you are making the wrong one. You are a Registered Nurse(I am assuming this) performing a procedure you are solely responsible for and you are letting your company or your customers dictate how it is done. Would you feel good with an AC PICC in you, or your mother? Of course not! You said in a previous post you are aware it is not the standard. Why are you comfortable not meeting standards? Again I do not mean to be harsh, but many nurses long before us worked very hard to incorporate PICC placement into the nursing scope of practice. We all have a responsibility exceed expectations!
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
google the emergency room physician organization and american college of surgeons who both made strong ultrasound recommendatons for all central line placement. A ICC is a central line. The world is moving entirely to ultrasouind as a result of litigation, malpractice insurance, and strong recommendations. At this time 90% of all PICC lines I am proud to say are placed with ultrasound
i am proud to say this because I led that revolution and it was a success for patient safety and insertion profieciency. It also put RN's ahead as well as my friends in respiratory therapy in Arizona. We led a revolution of which MD's placing central lines are now just starting to engage in. We are there. Time to take our place with oiur skills. Only 20% of CVC's from surveys are placed with ultrasound my MD's. That learning curve of 25-50 insertions is not easy.
Kathy Kokotis
Bard Access Systems - I am biased but at the time I led the revolution I was not an employee of Bard I was a consultant for Bard
What I am reading (and then interpreting) is that you work for an independent practice and don't have enough US to do all patients the same way. You have a double standard of care based on availability of US machines. Is that right?
I think that is a huge problem.
Gwen Irwin
Years ago after learning about ultrasound guided insertions I told the facility I worked at I would not do any more basic PICC insertions. I kept to my word and they eventually bought an ultrasound and did not regret it. MST in the antecubital fossa is still a bad place for a PICC no matter how you put it there. If you keep doing it, your facility will keep on letting you do it and your patients will suffer.
Every now and then I still hear that nurses are inserting PICCs without the use of ultrasound and that to me is the biggest injustice to our patients. Whether you are the nurse doing the insertion or the facility refusing to purchase an ultrasound; you are both to blame for the repeated damage to your patients physical status as well as emotional well-being. There are PICC companies in my community that still do not use ultrasound and I continually hear the horror stories; yet the facilities that contract with these companies do nothing. It is really up to us as vascular access specialists to make the change; better yet- demand a change. Because when it's all said and done, YOU are the nurse that's doing the actual procedure and YOU will be the one at fault when something really bad happens to your pateint. Whether or not your facility handles the problem, the pain and suffering you caused your patient will be on you!
Michelle Bowman RN, BSN, CPUI & Michele Thune RN, BSN, CPUI
M&M Medical Enterprises, Inc
954 Flamango Lake Drive
West Palm Beach, FL 33406
Website: MandMmedical.net
Email: [email protected]
I totally agree that ALL PICC insertions should be done with MST and ultrasound. The safety of the patient is imperative!
It does worry me that so many people in my proffesion have such a poor opinion of vascular access companies, presuming that all companies operate at a lower standard to increase profit margins. I am proud to say that all of my Vascular Access Consultants have a company-supplied ultrasound machine, utilize MST exclusively, and most hold either the CRNI or VA-BC certification. I also pay the conference expenses for INS or AVA conferences. Because our services come from an independent service doesn't mean we are sub-standard. In fact I believe we offer an excellent service for many facilities who require backup for their overloaded PICC teams (delaying commencement of IV therapy, or discharge from facilities), or being the PICC service for smaller hospitals and SNFs who can't afford to have a full-time PICC RN, or who don't generate enough PICCs to maintain their proficiency. We have established our P&P to INS standards and are ready for any JCAHO audit.
I agree that there are sub-standard services out there, but all providers should be checked as thoroughly by the contracting hospital / facility as they would their own employees. Many of the independant services will stand up to the scrutiny; some will not.
Dianne Sim RN, VA-BC
Dianne Sim RN, VA-BC, CEO; IV Assist, Inc.