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smarison
pt comes in with Picc
Ok we have a new intensivist who started in our ICU.  He is thinking that any Picc that a patient comes in with, particularly from a nursing home should be D/C'd because of this new thing that we will be responsible for our infections.  So basically as a just in case.  I do tend to think another reason though is that he is trying to train the residents on triple lumen subclavians.  he as already had us pull piccs so he can place a triple.  Any documentation out there?  I think INS states change dressing and caps and x-ray, nothing about pulling without any sign of infection.  Any feed back would be great.  Thanks Susan
swensonals
You could draw a blood

You could draw a blood culture from the PICC line,for a baseline, to see if anything is growing. If your hospital would allow it, perhaps you could do this on a number of patients, to establish whether the lines are being removed unnecessarily. I would also think some of the patients' labs would indicate if there is an infection brewing.  I would not think it is in the patient's best interests to have the line removed solely for residents' practice!  A lot depends on the patient's admitting diagnosis--if sepsis or infection is a question, then the blood cultures could establish a possible source, at which point you would want the line out. You would have some preliminary results in 24-48 hours. If the line is a problem, you may also see some temperature spiking within an hour or so of flushing it.

At our hospital, when someone comes in from a NH or another hospital with a PICC line, we get a chest x-ray to determine tip placement, replace caps and dressings, check for patency and blood returns, and look at the site and arm for problems.  If everything is ok, the patient keeps the line. 

Cindy Schrum
Cindy Schrum RN CRNI
Cindy Schrum RN CRNI

Cindy Schrum RN CRNI

Cindy Schrum
Cindy Schrum RN CRNI If he
Cindy Schrum RN CRNI
If he is replacing a Picc with an antimicrobial inpregnated CVC, he's giving the patient the best chance of avoiding a CRBSI.  The Arrow CVC is impregnated intraluminally, externally, and on the extension tubings.  We don't have a Picc on the market yet that can offer that.  I don't know if this is the catheter he's using or if this is what his thoughts may be.  From that perspective, it may not be a bad thing.

Cindy Schrum RN CRNI

lynncrni
The changes in our clinical
The changes in our clinical practices will be coming based on the CMS changes in reimbursement, although no one knows what the most appropriate changes will actually be. I can understand the reason for the idea of changing any percutaneous CVC that has been in place for a number of days or weeks - there will be biofilm on the internal and external catheter surfaces and thus an increased risk of CRBSI. The question is going to be how do we determine what was present on admission to the hospital and what occurred while in the hospital. So your patient can come in with any type of CVC and have it pulled and another placed, but the question still remains of which catheter caused the hospital-acquired CRBSI. How will you distinguish between which catheter actually lead to the CRBSI? Will you have a blood culture drawn from the old catheter and then be able to compare the organisms from a subsequent BSI? What is they are both producing the same organism(s)? Will you have the ability of DNA typing to determine if the bugs have a different structure and therefore came from a different source? What will these tests do to the cost of care? So I do not think that a policy of automatically changing all CVC upon admission will be one that will prove to be financially beneficial for the hospital, but I do not know what will be the best practice at this time. Lynn

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

Matthew Vivian
Recently, I provided Picc
Recently, I provided Picc line dressing changes weekly for an outpatient who was scheduled to have additional AF Bypass because of original postbypass infection. Length of time Picc was in, environment which it was used, and site condition prompted me to use persuasive arguments to have it removed prior to admission. Most of my career has been spent in-house and the cost/ benefit analysis would support pulling it.
Robbin George
To paraphrase a famous line

To paraphrase a famous line from "The Graduate".....one word....."BRUSHING"

May be the practice of routine interluminal brushing could facilitate screening patients admitted to the hospital with a preexisting CVC--Much in the same way we now swab wounds and orifices for MRSA--This would address at least one of the 2008 CMS changes 

Robbin George RN VA-BC

lynncrni
If we started endoluminal

If we started endoluminal brushing of all catheters on patients admitted to the hospital, I would predicte that 100% would be positive and therefore in need of replacement. All catheters grow biofilm and the brushing technique removes the biofilm. The unknown question is when does the biofilm actually produce a bloodstream infection. We do not have a complete answer to that question yet. It could be related to the biofilm breaking loose and floating into the bloodstream. This could be caused by the brushing or flushing techniques. It could be related to normal mechanisms within the biofilm or to the decreased defense mechanisms of the patient. So I do not think that brushing all catheters present on admission will be beneficial. At least we need much more science to support this practice to be used for this purpose.  

 

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

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