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Radiologic Confirmation of central line placement

The state I practice in does not allow nurses to interpret X-rays.  When a  central line is placed in my facility a CXR is ordered.  The radiologist typically reads the CXR and gives a location for the central line tip.  I am not sure that nurses know where a central line tip should be located.  Do other facilities have physician confirmation telling the nurse the line is properly placed and is OK to use? This would be written as a physician order or a note in the progress.  I would like to know what others do.

Thank you.

Angela Lee
I do not read CXRs.  However,

I do not read CXRs.  However, I look at each CXR with the radiologist and together we come up with an agreement on the tip position and a plan of action if required.  I make the final decision as to what I need to do but the radiologist's name goes on my procedure note to indicate that a physician has read the xray.  After this process I clear the line for use, not the radiologist or the patient's MD.  This is documented also on the procedure note so that no order is required.  I feel strongly that the nurse should take ownership of the PICC from start to removal and not abdicate a portion of care or decision making to the MD entirely.  I have had situations in which the radiologist has been wrong in their interpretation until I pointed out what I saw.  Two heads are better than one sometimes.  

Since you did not specifically mention PICCs I will tell you I do not make those decisions on physician placed CVLs. 

The issue of whether your

The issue of whether your state allows nurses to assess chest xrays for catheter tip location is not relevant to your question. Some one has to assess the xray and provide an anatomical location of the catheter tip to the nurses. This can be a radiologist or primary physician. The process is much faster and accurate if the nurse inserting the line assesses it but this still must be done. The issue of "releasing" a catheter for use is one I have never understood. If it is in the correct location it can be used. If it is not, it must be corrected  before it can be used for any and all infusion. It is as simple as that. All nurses with responsibility for caring for a patient that has a central venous catheter of all types is held to the national standard. That standard is they must know the correct tip location, receive an antomical description of where it is ("in good position" is not sufficient) and know the signs and symptoms of a malpositioned catheter, which can occur at insertion and during the dwell time. There is no excuse for nurses not to know. I am not just talking about infusion nurses. I am talking about all nurses who accept the responsibility for caring for a patient with a CVC of any kind. I have seen too many times when the catheter tip was left in the innominate (far too short) or in the contralateral side or in the jugular vein and a physician said it was OK to use. This is blatantly wrong and the nurse must know this and know when to refuse to accept a doctor's order to use the line. I have seen a tip located in the jugular when the doctor said to use it for phenytoin! I have also found another patient receiving TPN through a tip in the jugular. This is nursing responsibility to know where the tip is located and when to use the catheter and when not to use the catheter. A physician's order to use the line will not release the nurse from their responsibility to know tip location, regardless of who is assessing the actual film. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

Angela Lee
I agree with Lynn and need

I agree with Lynn and need to clarify my last sentence.  Our MDs and many others deliberately place their CVLs in the RA.  And as Lynn has said I have actually heard a neonatologist state that if the line was anywhere in the chest it was central.  So while I do not clear their lines for use I do continuoulsy emphasize to nurses that they are responsible for how they use these catheters and it is their responsibility to know where the tip is.  Any deviation should cause the nurse to investigate and question and if necessary, refuse to use the catheter.  Blindly following orders regarding CVLs is asking for trouble.

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