In the process of revising our CVC policy the question of positioning the patient when a PICC is removed has been posed--In the past we did not specify supine vs seated and our Home Health nurses usually wind up removing these lines while the patient is seated at the kitchen table--Some literature that was reviewed stated that the patient should be supine--What light can you shed on this point of protocol--Thanks in Advance Â
I would always recommend the patient be supine instead of seated. This comes from the literature on removing other CVCs. Before I start a huge controversy, let me explain that there is a big difference between removing a line inserted via the subclavian or jugular vs a peripheral vein. Subclavian or jugular veins are above the level of the heart anatomically and the only way to get them at or below the heart level is for the patient to be supine. But the PICC exit site could be at or above the heart depending upon how it is positioned - seated with arm resting on a kitchen table for instance.
Air embolism from a PICC has never been reported in the literature to my knowledge. However that does not mean that it is impossible. It is possible for everything to be set up just right for this to occur. Air embolism on the list of the Big 8 that Medicare will no longer pay for after 10-1-08. It is imperative that each facility have strict policies and procedures about this task. I have 2 legal cases involving air embolism from CVC removal with devastating impact on the patient. So payment for the treatment could be your smallest worry. One case ended with the nurse quitting the nursing profession altogether.
My position is based on why should we take chances with removing any type of catheter. Why should we teach one set of steps for one type of catheter and another set for another type of catheter? This could only lead to confusion and confusion leads to complications. It is much safer to have the same set of standards for removing of all central lines. I am sure there are others who disagree but that is what I teach. Thanks, Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
In regards to the above comment from Lynn, on Medicare's "Big 8" list, is there anything else that is related to central venous catheters or peripheral lines in any way that Medicare will not pay for after 10/1/08?
Thank you for you answer in advance!
Yes. 3 of these 8 are infusion related. Air emboli, blood incompatibility, and catheter-related bloodstream infection. The key is "not present on admission." So the big question would be, in my opinion, when a patient with a CVC is admitted to the hospital and then is found to have a CRBSI, how will it be determined if this was community-acquired or hospital-acquired. The other to me are obvious that hospitals should never be paid for complications caused by faulty or poor care. The basic idea for this list is that these events are frequent but have strong evidence that they can be prevented. There will be others added each year. So we will have to pay close attention for new events annually. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
An interventional radiologist in our Hospital group in response to nursing concerns re pt
positioning when removing CVC has stated that patients should be sitting up with the site above the right atrium to decrease venous pressure when the line is pulled as she feels that bleeding is a more common complication than air embolus. This is also the practice of the nurses in our IR. Critical care practice is mixed. I know that all the nursing literature states that patients should be supine or in Trendelenburg to decrease the risk of air embolus. What say the IV THERAPY.NET gurus?????
Robbin George RN VA-BC
I say call me when you need an expert to testify for the plaintiff when your hospital has a lawsuit. It is true that air embolus does not happen frequently, but your radiologist is putting patients at tremendous risk for this complication. I have testified in court on one case where the patient was sitting up during CVC removal. The patient was in her early 50's and is now in a nursing home unable to care for herself due to this air embolism that traveled to her brain. I would flatly refuse to follow this practice and take it to higher authority in your hospital. Medical QA definitely needs to know about this dangerous issue. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
www.hadawayassociates.com
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861