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"Pull back to subclavian" IR Docs say
Re: Tip location: Our PICC insertion policy states –Subclavian placement of PICC tip is considered a malposition, and will require MD order from the patient's MD (not IR doc) for use if indicated on a case by case basis.If we have a PICC up the IJ that we are unable to reposition, IR is our backup and will reposition.  If they are unable to get to the repo that day, they are asking us to pull the catheter tip back to subclavian, and they will reposition the next day.  They say that it is safe, and because they are MD's, they can order us to do so (though they are not the patient's MD's). We don't want to do this, and they have our SOPs for PICCs, and references (listed in our policy).  They say that because they are MDs, we can leave the tip there if they say so, and it will be fine.  I disagree and say that if I am practicing against my own SOP, having an MD say it's ok doesn't make it so and I won't do it.   Leaving the catheter lying on the skin is bad practice, and leaving a tip in the subclavian is bad practice, and against manufacturer IFU's.  The Power PICC scenario is especially scary.  If the patient ends up with a tip in subclavian vein, it is only after IR has tried, we've had a discussion with the pt.s MD, and it is the best choice for the patient (with apparently few choices!). Our plan:We're going to meet with them, the Medical Director of IR, his Medical boss, and the hospital attorney for Risk Management, and try to come to a solution.I've spoken with the executive officer of the state BON,  who supports us if we've met 5 criteria the following (and we do):Feels like a power play to me, and other than the patient not having to go through the complete PICC procedure again, I can't see how the IR MD plan benefits the patient.  We have a lot of articles and evidence (although a significant amount of the data is old; if anyone has more current data it would be very helpful.  I've got the material posted in the downloads of this website). I apologize for such a long post, and REALLY would appreciate feedback.
Kristin Walker
I feel your pain!  I don't
I feel your pain!  I don't know what I have to share will be too helpful but you are very correct to state that sterility of the line cannot be sustained if the pt has to wait overnight until IR can take them the next day.  I have had a situation like that and simply aborted the procedure and dc'd the line.  I wanted the case completly out of my hands (legally and proffesionally).  If MD's have a problem with that, have them take it to the higher level.  In the end, you will be found to have conducted your practice to the highest standard and how can that be wrong.

Kristin Walker RN, BSN, OCN Maui Memorial Medical Center IV dept.

I think you are correct in

I think you are correct in your practice, your assessment and your strategy. I agree this is a power play and you can not do something simply because a physician orders it.We have our low license and must make decisions based our standards and what is in the best interest of our patients. We must advocate for patient safety. Hang in there and keep working on it. Physician education is never easy. Stand your ground and refuse to do something just because a physician ordered it! Lynn


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

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

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Mari Cordes, BS RN  Nurse
Mari Cordes, BS RN 
Nurse Educator IV Therapy
Fletcher Allen Health Care
I'll keep y'all posted about what happens, and what we learn.  We've been getting great support - you, and Tom Vesely, Sue Masoorli, Nancy Moreau.....

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

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