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Beth George
Policy for nurses determining proper placment of a PICC line by reviewing an xray

I know this subject has been addressed before but I have a question.  This question is for those hospitals who do have a policy in place to allow the PICC certified RN to veiw the xray for tip location and ok the PICC for use.  How did you go about getting this approved at your hospital?  I am assuming we would need to meet with the radiologists.  My colleague and I both attended the seminar on Implementing a competency-verified PICC Tip X-ray verification program for the registered nurse.  We have a lot of literature to present to the radiologists.  What did your hospital do about implementing this?  I know we would have to put into place some sort of policy and procedure.  I am trying to make sure that I do everything right.  We just began our IV/PICC team back in Sept 2007 and everything is still very new here and this is the first time in my career that I have played a part in developing policies and procedures.  I want to make sure I cover everything correctly.  If anyone has any suggestions please do reply.  I appreciate it and I absolutely love this forum and site.  It is a world of information @ my fingertips.

 

Thanks again,

Beth

mary ann ferrannini
I assisted with our
I assisted with our implementation and it was easier than I thought. I am asuming the state in which you practice allows this. Start there and find out exactly what your state requirement is. In California ours must be written in a standardized format as opposed to just a policy.A standardized procedure is a gray area where there is an overlap between medicine and nursing and the nurse must be certified with specific criteria usually on an annual basis. I then started with the nursing department and once we showed them that it was allowed in our state and shared with them how it would benefit the patients the radiologist did not have a say so,but of course they were informed. We then wrote a standardized procedure and ran it through the approval system. Once in place our cardiovascular CNS recruited an MD to give us a class. I would recommend a radiologist b/c the IV nurses could have given a better class than we got. No worries for me since I had been looking at radiographs for 21 years. We all took our test and then and then had 3 successful reads. Once that all done we ironed out the process of reporting the nurse read to the end users of the PICC. It is crucial that you have a system in place to follow-up on the radiologist read, reconcile the nurse report with the rad report so you do not miss any radiologist recommendations. Hope this helps..let us know how it goes and if any more questions feel free to ask Mary
Angela Lee
Are you in Alabama?

Are you in Alabama?

Beth George
Yes Angela.  I am in
Yes Angela.  I am in Alabama

Beth George, CRNI, VA-BC
Nurse Clinician/Vascular Access
UAB Medicine
Birmingham, AL

lynncrni
You must begin with your

You must begin with your state board but you also must know the process used in your state to make scope of practice decisions. Many states use a decision-tree and the board will not actually make these decisions nor will they give you any advise on the question about what is or is not within the scope of practice. I have attached the example of these tools.  

 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Beth George
Lynn,   Thank you for the

Lynn,

 

Thank you for the advice and decision tree example.  I am going to get started looking these things up. 

 

Thanks again,

Beth

Beth George, CRNI, VA-BC
Nurse Clinician/Vascular Access
UAB Medicine
Birmingham, AL

Gwen Irwin
We went through our state

We went through our state board's decison tree amd then had phone calls to the board to discuss this being in the scope of nursing practice.  We are in Texas.  After much discussion, our board said that it would require the instution to have a policy in place to support this practice (and that the hospital take on the liability for this practice).

When I presented this to our Nursing Executive Committie, I had all of the states that have a "clause" or a statement that allows and supports RNs assessing the tip location and reported the sites in Texas that already have the RNs identifying tip location (MD Anderson).  We had a policy created and approved with the support of the radiologists.

I also pointed out the time from PICC insertion to the time of its use if the PICC nurse could identify the tip location.  This was a great time difference compared to our previous practice.

Gwen

Beth George
Thank you Gwen.  I have

Thank you Gwen.  I have some work to do to get this rolling.

 

Beth

Beth George, CRNI, VA-BC
Nurse Clinician/Vascular Access
UAB Medicine
Birmingham, AL

PMRMD
ECG guided placement would

ECG guided placement would be a way to avoid an x-ray altogether. The transitions from a small to larger back to smaller P wave can only occur in the SVC / RA as you advance and pull back. Documentation of this transition serves as your "proof" of tip location. I have now added journal references at the PacerView website ( www.pacerview.com and go to "Journal References") demonstrating the reliability of ECG guidance and correlation of the ECG to echocardiographic localization (the true "gold standard" short of dye studies). In fact, in the cited 2003 article by Madias, part of the title is: "Is It Not Time to Forgo The Post Insertion Chest Radiograph"  (http://www.chestjournal.org/cgi/content/full/124/6/2363?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=madias&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT). There are numerous additional references in the full text papers available there.

This forum particularly might enjoy this reference (not on the website) by Dr. Pittiruti  entitled: "Positioning the Tip of Central Venous Catheters: Where. Why and How". His discussion includes ECG guidance (Pages 13-17) but as he's based in Italy, he addresses methods used in Europe (www.evanetwork.info/uploads/pittiruti_2007_-_tip_location.pdf ).  (Copy and paste this address into your browser.) 

A chest x-ray would still be necessary to rule out a complication of the procedure or if the patient were pacemaker dependent or in a rhythm other than sinus.

lynncrni
He gave this presentation at

He gave this presentation at the recent INS conference and it was good. Lynn 

 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Angela Lee
Let me know how things

Let me know how things go and if I can be of assistance.  Our BON is rather conservative (probably they all are since they're there to protect the public) and requires submission of an application for standardized procedure, which you're probably familiar with as it is necessary to do MST.  I don't know if it would apply to this but I have not seen this topic addressed on the BON site.

My e-mail is [email protected] if you'd like to contact me.

Michele Spohn
We are currently trying to
We are currently trying to start this process of the VAT team nurses doing initial assessmnet of PICC tip placement in our facility and would really like to not completely reinvent the wheel as it were. Does anyone have a sample Policy & Procedure or any associated forms for documentation? How long has it generally taken to educate the nurses and was that done by the staff radiologists or an outside education vendor? I appreciate any info.

Michele Spohn

Clinical Coordinator

Infusion Services

lynncrni
My company is in the process

My company is in the process of creating an online continuing education course on chest xray assessment. We are in the final stages but I can't say exactly when it will be ready. I had hoped to announce this was ready at AVA, but I don't think that will happen because we are waiting on copyright permissions for some artwork. Sorry I can not offer more details than that but will be making an announcement when it is ready.  

 Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

bnosal
I would check with your BON

I would check with your BON and make sure that this is acceptable practice. As a nurse I would be cautious about placing my license on the line for verifying a tip location. Not sure that any certificate of completion would stand in a court of law if a complication developed due to the tip location. I believe it was posted here of a tip being arterial that was placed by a PA, and the line was being used? The radiologists have the expert training for this. Would the nurses be liable for not identifying another complicvation on the fils as well? I would however have no problem with verifying the tip location for your own personal benefit of knowing that the tip was adequately positioned. 

 I am sure that Ms. Hadaway is more knowledgable of the legalities of this, and would love to hear her expert opinion.

lynncrni
Ms. Hadaway is my mother but

Ms. Hadaway is my mother but I will give you my thoughts. First, no nurse should ever be in a position where they are not willing to accept the accountability for the outcome of their practice. We are responsible for carrying out the task and we also must accept the accountability for the outcome. So you must be comfortable with what you are doing. It is my opinion that a knowledgeable, skillful nurse with PICC insertion and CVC management experience and documented competency should not have any legal barriers preventing that nurse from assessing a chest xray for catheter tip location and beginning therapy through that catheter. About half of the boards of nursing in the US use the decision tree model for making scope of practice decisions while the other half may use other methods such as advisory opinions or declaratory rulings. All nurses must know and practice within the legal scope of practice as defined by their state board. If your state uses the decision-tree, there will probably not be a formal document written by the board of nursing. You and your employer make this decision.

So the only way you would "place your license on the line" would be if you were practicing outside of the legal scope of practice. As the nurse placing that catheter, you could be held with a portion of the liability if a problem due to tip location resulted in a law suit, regardless of whether you saw the xray or not. There is no way you could guess what the outcome of any legal case would be because they are all different. I have seen xrays where the IV nurse's assessment was correct while the radiologists was not. Two heads are better than one. The nurse is not assessing for pathology on that xray, only assessing catheter tip location. So I know this is being done successfully by nurses, and think this can and should be within the legal scope of practice when the nurse meets established criteria. 

 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

bnosal
Thanks Lynn, my caution is

Thanks Lynn, my caution is with the idea of practicing outside of the legal scope. Would be concerned that if an issue arose, the prevailing thought would be why was the line not approved by a radiologist, it is without question that it is within their scope. It does become gray for nurses however.

 Unless we continue to move forward and make it commonplace and standard I guess we'll always be holding ourselves back however.

lynncrni
As Mari stated, the

As Mari stated, the permanent written report is still dictated by the radiologist and placed on the chart. The nurse is making the initial assessment so that therapy is not delayed while waiting on a radiologist. PICC insertion alone is a form of advanced practice and chest xray assessment is not new to this clinical specialty. I was doing it as far back as 1981. Many trauma, ER, and critical care nurses have been assessing other rad films for many years - no difference.  

 

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

www.hadawayassociates.com

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

bnosal
With the radiologist

With the radiologist dictating as well and being a "preliminary" report, agree that there should be no concern. We do this all the time and can frequently contact the physician ordering the line and give them our interpretation and they will clear for use with a verbal order. 

 

momdogz
My understanding, and what

My understanding, and what will occur at our facility, is that the final reading is always done by an attending radiologist, so we will never be working within a vacuum.  We'll be doing the preliminary reading so the PICC can be released sooner.

And - Lynn is right.  We have corrected our radiologists many times - two heads are definitely better than one.  We haven't completed the work to formalize this practice within our hospital, and the state BON, and our training has already been a huge help.

If we were wishing to avoid any liability for advanced practice, we wouldn't be placing PICCs either!  Establish good competency training and assessment, develop your relationship with radiologists, and keep track of your success rates - this can be part of your annual competency. 

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

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