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Respiratory Therapists placing PICCs under a physicians license

My staff attended a meeting yesterday hosted by my local INS Chapter.I am concerned about information they were given. Is this fact, fiction or inaccurate. Please post your responses, comments and reactions. Is this true? Accurate? Legal? What is happening in your community? ...... Respiratory therapists are now placing PICC in arm vessels, in the IJ and doing arterial lines "under a physicians license in 28 states in the USA.

 I can not confirm that it is

 I can not confirm that it is happening in 28 states but I do know that respiratory therapists are placing PICCs, other types of CVADs and have been doing arterial lines for a long time. If there state board or governing body in their state has indicated that it is within their scope of practice, then yes, it is legal. Radiology technologist are also doing PICC insertions. They would be required to follow the same Joint Commission requirements for competency validation as any others doing these procedures. This is happening because respiratory therapists were willing and able to meet the business need and nurses were not. Simple matter of who stepped up and said I will accept this role. RTs did in these situations and nurses did not. I do not think this should mean a competition between RTs and nurses. The group that is able to meet the needs of patients 24/7/365 and produce a track record of good outcomes is the group that should be doing it. Many times nurses have not been willing to do this. Or hospitals have not been willing to "allow" nurses to do this. Will a group of RTs that are employees of the hospital be more effective and produce better outcomes that a contracted service? This is yet to be determined. What impact will the new healthcare law have on these services? Yet to be determined. This can be a lesson though for many nurses on teams. Be willing to do the complete job at all hours. Don't leave until the correct tip location is confirmed and the job is finished. Track your outcomes, not just productitivy. In other words, know your rates of all complications, not just how many PICCs you are placing. Be able to support your practice with good outcome data. Or some other group who is willing to be there at all hours for all patients and keep the needed records could step in and take over. As you can see, it has happened. 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

Dan Juckette
  I know that in New Mexico,


I know that in New Mexico, placing vascular access devices has been in the scope of practice for Registered Respiratory Therapists (RRT) since about 1995 and they do not perform this under direct physician supervision. Certified Respiratory Technicians (CRTT) are the equivalent of LPNs and do not have this within their scope without special training and LIP Supervision. The regulations concerning scope of practice within any licensure are set by the professional standards of that specicialty and are not set or regulated by some other profession. In this state, the Medical Licensing Board has a representative on every specialty licensing board, and if they find something they strongly disapprove of, they can make their case to the Legislature like anyone else. Otherwise, the specialty is self-regulating.

Lynn is absolutely correct that the reason other specialties are entering vascular access is because nurses are unwilling to "champion" and excel in this, and many other areas of practice. Anytime you think you can rest on your laurels and continue just getting by because you are "the Nurse", you will find someone eager and hungry to show that they are a better value when it comes to performing in that area of practice. Anytime you make an administrator ask the question, "is this the best way we can do this?" you might find out that there are answers that you may not like. So, if you complain about going down to CT to start an IV, or that you are too busy to do that ABG, or you don't have time for dressing changes, don't be suprised when they get done anyway. Other specialists are glad for something to enhance their practice and credential.

Daniel Juckette RN, CCRN, VA-BC

Diane C Lauer
PICC insertion

Our hospital looked into this issue.  I am a solo radiology nurse and do most picc insertions.  The rad technologist wanted to perform this as well.  The hospital did a search to see if any other hospitals in NH were using technologists for central line insertions.  We could not identify this as current practice in NH.  I also do not this this is in the job description for technologists in Massachusetts.  Not sure about Maine, Vermont, Conneticut or Rhode Island.  Interested in a poll of this, to identify this as a regional choice, or are individual hospitals deciding the issue.

Celia Brown


First I suggest you google the wonderful articles written by Chuck Ramieirez RRT over the last 6 years.  The last one being a comparison of CVAD placement between MD's and RRT's at Banner Estrella in Arizona.  His data indcates that options do exist for vascular access placement for other disciplines.  Chuck's tracking of outcomes is proof that his program and trainig component is a success.

RRT's are placing art lines all over the United States and are now adopting ultrasoud to place arterial lines.

Margy Galloway just showed me the Canadian RRT guidelines which shows that the RRT may access the femoral vein.  I was unaware of that one.

RRT's work under their certification board and and their practice is guided by the certification board as well as the state.  You will find most often their practice guidelines under the physician practice guidelines of that state.  RRT's are able to give drugs such as conscious sedation, intubate, perform bronch's.  Just as RN's are moving forward into more technical skills so are the RRT's.

So far I have found RRT teams placing PICC lines in Colorado, Wisconsin, Arizona (at least 10 teams and growing), Texas, Washington and New Mexico.  There may be more that I have not encountered.  To date only in Arizona are RRT's placing subclavian and jugular lines.

I think the 28 states refers to nursing practice and states that have decision tree models for nursing practice.  I so far have not found 28 states performing PICC lines insertions with RRT's but the number of states with RRT performing art line placement is likely higher than 28.  Saying that does not mean that RRT will not start to expand beyond the 6 states thus far where RRT has started to palce PICC lines.  In fact I believe that we will see the growth of multidisciplnary teams accross the spectrum of licensed individuals placing all types of vascular access devices.

I would refer to Lynn's comments on outcome monitoring and the future.  As an RN, I would look to not only tracking outcomes but become aware of what I could offer my institution in 24/7 service, CVAD placement services, etc.  Look around and how many MD's today do you see placing a PICC line?  Not many!  We are replaceable if we do not keep up with what the enviroment needs.




Respiratory Therapist placing PICCs



This is not my account (judy is my friend) as I have yet to be granted permission but can be reached at [email protected]

Hello KL,

I hope to help clarify your concerns with respiratory therapists placing central venous devices. I am a practicing respiratory therapist from Phoenix Az. I have been a PICC clinician since 1999 and in Arizona there are several hospitals moving to non-traditional vascular access models for several reasons. I appreciate Daniels response and concur with his opinion. In today’s healthcare organizations utilization of a multidisciplinary approach may move from traditional models to improve outcomes of our patients. Respiratory therapists hold a license much like nursing and under the board direction is approved for practice as deemed within the scope. I think that there is opportunity to enhance patient care by not eliminating the possibility of a better practice by a non-traditional discipline. Our patients deserve the best opportunity regardless of clinician title. 

Historically respiratory therapists have placed arterial catheters for 20 year, PICC insertions since 1999 with use of ultrasound. This practice moved to CVC insertions both IJ and SC with full administration and physician support in 2007. In fact respiratory therapist placing CVADs aiding in the nursing board in Arizona to advance its scope to also include IJ placements. We are very much a collaborative team and keep a very patient centered approach to care. In addition to collaborative care we insert, monitor and maintain all catheters from insertion assessment to catheter discontinuation this practice enhances outcome and patient experience.

My personal feeling is that we as vascular access specialist need to remain educated, resourceful and agile to enhance each patient we touch, regardless of title. 

Thank you


Amy Bardin MS,RRT, VA-BC


 Thanks Amy. I appreciate you

 Thanks Amy. I appreciate you input. I do have questions about the license held by a respiratory therapist. Do all states require that the RT have a state license or can this vary between states. Does the license have any connection or be dependent upon a physician's license? The original question was about respiratory therapists inserting PICC under a physician's license. Your message stated that RT's hold a license much like nursing. I am seeking clarification on that issue. As you know a nursing license is required in all states, is mandated by law to indicate that the nurse is ready for entry into practice, and is awarded to the individual for indivudual's practice and is in no way tied or linked to a physician's license. Depending upon your answer, an RT license may or may not be the same as a nurses license. Hope you can clarifiy my confusion on this issue. Thanks, 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


Hi Lynn,

Every state but Alaska is licensed. In regards to practicing under medical direction, within each facility policy dictates specific practices and a medical director oversees departmental practices. We work from a physicians order under our own license not under a physicians license.



 Amy Bardin 


I know there are Respiratory

I know there are Respiratory Therapist that place PICC lines. I never understood why nursing would be supportive of this practice. Would this be because of staffing issues?...would it be because RT's are cheaper than nurses?...nurses need to stand up and stop being the one profession you can poke a stick at. Let me lay out a scenario for all the RT's. If nurses can do blood gases, give breathing treatments , and make appropriate vent changes....why would we need RT's? seems since we absolutely need nurses on the floors to administer medications, we can certainly teach RN's to do those things I mentioned and we can eliminate RT's all together.

But, as nurses, we never would propose that. Yet I read constantly how other services are inching into nursing practice. I ask again, is this a staffing problem fix?....or maybe a squeeze to get nurses to do less and less...and therefore reduce the need for nursing.

I'm very interested how this forum feels about this.


Jack Diemer RN, BSN



Robbin George
I don't know about RTs but I

I don't know about RTs but I know that some of the very reasons you outlined below do apply to the dismantling of the full service IV team concept at my institution

For more than 10 years "nursing techs" have been encouraged and are now required to become proficient in "Starting IVs and Drawing Blood"

I have seen the level of excellence our nurse lead IV team once demonstrated been disminished by the lesser skill of these techs

I attribute this to the fact that we chose to become specialized

We studied and invested our career goals in the unique Art and Science of Infusion Nursing and more recently Vascular Access

There is a difference in just "sticking" in an IV and assessing each individual patient for the correct access the first time 

This can be quantified and I think this should be a national referendum

Think of all the pain, damage, waste and errors you have witnessed in your institution related to the mispractice of IV Therapy 

Thank you for letting me have this platform

Robbin George RN VA-BC Inova Alexandria Hospital Vascular Access Resource Department Virginia USA





Robbin George RN VA-BC

Bravo Robbin!!

Bravo Robbin!!

IRR as backup for PICC placement issues

I would like to know how dependent the PICC teams that are available 24/7 are on IRR for any malpositions, stuck wire or any other complication that may arise? Is IRR available 24/7 at your facilities, are they on call? I know at my facility they are on call but will not come in for any PICC issues and state we should not be placing PICC's when they are not here. The facility would like us here 24/7 but IRR will not agree to be available. Any other team have this issue or have any suggestions.


P. Roberts, RN, BSN,VA-BC

time suggestions

Respiratory Therapy that places lines 24/7 in Arizona I have found do not necessarily place PICC lines 24/7 but rather acute CVC's.  This still leads to the problems of delayed care if a patient needs a PICC rather than an acute CVC if we follow the right line for the patient and not just the available service line at the time.  I believe if a patient needs a PICC they wait until the AM hours as PICC lines stop at 8 PM or 10 PM or maybe earlier

That being said with the ability to get night service one can use a night reader if radiology is not available to read the tip.  But with new technology tip reads are not necessary for 90% of patients with ECG.  PICC lines therefore can be placed sans x-ray depending on equipment and hospital policy. 

Back to your original questions as well.  The radiology department will not come in 24/7 as back-up to non successful PICC.  You are right and in those cases the respiratory therapists place an acute CVAD at night as stated above.  PICC lines are not done on evenings and midnights.  I however see a better solution 24/7 can be incorporated for PICC lines with new ECG technology and there are so far two vendors with more to come offering this option.  For non-successful PICC placement or patients not PICC candidates we learn to place acute CVAD's 24/7.  However at this time there has not been a discussion of elimination of x-ray with acute CVC's so you would still need to make plans for a night service read for tip position and pneumothorax to boot.

Do not hate me here but this may mean we cross train other disciplines in line placements.  These placers can be respiratory theapists, radiology technicians, Nurse Practitioners, Physician Assistants, Rapid Response Teams which is my favorite, and ICU RN's or clinical Supervisors.  We need to figure the 24/7 piece of this situation to incorporate sepsis protocols which are being embraced as part of care bundles for the future.  We need to look at what model will suit the faciility and a multi-disciplinary models may be the best option.  Nursing has been known to successfully manage multi-disciplinary team patient care and this is just another multi-disciplinary team.

this post is not to endorse a product, or program and strickly provides information regarding patient flow and service offerings

Kathy Kokotis RN

Bard Access Systems


time suggestions

You are correct Kathy, we are a vascular access specialist team not a PICC team. We assess and place the most appropriate device in each situation (PIV, Temp HD, CVC or PICC. PICC's are not stat and can be scheduled and through decision trees and needs assessment access can be provided 24/7. As clinicians we need to find processes that best work within our institutions and disseminate those processes so that better outcomes and early intervention is achieved.

I think as we move forward and promote VAS teams, service coverage needs to be considered. Access needs don't stop at 430pm and this should be considered as business plans for vascular access services are created. Within my facility we service all code sepsis and rapid response calls, as well as 99 % of all ER line insertions with this we have been infused into a multidisciplinary culture with high expectations both of ourselves and outcomes.

As you said we need to look at models that fit the organizations need. Please don't feel like everything has to be compared to Arizona as there are some amazing programs and individuals outside the Wild West.

Amy Bardin


 Amy Bardin 


Dan Juckette
One of the things I like most

One of the things I like most about being a member of AVA is that it is not a nursing organization. People who have a passion for vascular access get there through many diciplines. Being part of an organization composed of physicians, nurses, sonoghaphers, respiratory therapists, radiologists, infection preventionists, and members of industry who all share a passion for excellence in vascular access is much more gratifying and exciting that guarding my turf and only accepting ideas and practices from within my specialty. Our strength together does more to prevent the propagation of inept and unsafe practice in the name of cost effectiveness, than anything we could accomplish separately. If our concern is in doing what is best for our patients, then we should be ready to enlist everyone who shares our desire to see every patient get excellent care.

Daniel Juckette RN, CCRN, VA-BC

Arizona Board for RT's

I did some research and wanted to post what the Arizona Board minutes say for RT's with regards to precepting and placement of CVAD's

You will note that the RT must perform placement of a line under medical direction.  I am not sure what medical direction actually means.  If the MD has to be present in a room, in the hospital, be the medical director of the department, or have the blessing of the medical staff.  This leads to the question of preceptorship outside of one's system.  What is medical direction?  Bottom line the Arizona Borad of has endorsed the placement under medical direction.  I have also attached a position of the Arizona State Board of Nursing which indicates that a nurse is not under the direction of a physician but a qualifief LIP must be available to manage complications.  When working through this process one must understand the Board requirements for supervision


Position Statement of the Arizona Board of Respiratory Care Examiners

March 19, 2009

As previously established, central line insertion is considered part of theRespiratory Care scope of practice based on interpretation of the law, given thepractitioner has received appropriate advanced training, participates in timelycontinuing education/skill reevaluation and is performing under medical direction.Preceptorship, after a Respiratory Care Practitioner has met the training andcompetency standards as previously stated, is at the discretion of hospital policy.After discussion, Board Member David Sanderson, M.D. moved adoption ofthe proposed statement. Board Member Jim Love seconded. The motion passed


Arizona State Board of Nursing

4747 N. 7th Street, Suite 200

Phoenix. AZ 85014-3655

Phone (602) 771-7800 Fax (602) 771-7888

E-Mail: [email protected]

Home Page:





DATE: 11/09

Within the Scope of Practice X RN LPN




It is within the scope of practice for a Registered Nurse (RN) to insert a central line if the following requirements are met:


A. Qualified physician or LIP in the facility for complication management.

B. A written policy and procedure to include competency, scope, and supervision requirements is maintained by the employer/facility.

C. Completion of an instruction program including:

• Advanced vascular access/insertion including Peripherally Inserted Central Catheters (PICC) insertions

• Ultrasound technology for vascular access and central line insertion

• Supervised clinical practice in ultrasound guided central line insertion

• Securement, which may include suturing

• Management of central lines

D. Documentation of education, proctored clinical practice, and validation in vascular access ultrasound technology is on file with employer/facility.

E. Vascular access experience.

F. Central lines are placed using ultrasound technology.

G. Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS) course completion for age specific population.

H. If interpreting x-ray for tip placement has completed an instructional program and has supervised clinical practice by a qualified LIP to interpret placement and interventions for mal-positioned tip, as recommended by PICC advisory opinion.

I. If placing femoral catheters, education and validation to include insertion, maintenance, complications, removal of femoral sheaths.


A. Anatomy and physiology of the vasculature and adjacent structures of the neck, chest, femoral artery, veins, nerves and groin area structures.

B. Indications and contraindications

C. Sterile technique

to include, but not limited to:

An advisory opinion adopted by AZBN is an interpretation of what the law requires. While an advisory opinion is not law, it is more than a recommendation. In other words, an advisory opinion is an official opinion of AZBN regarding the practice of nursing as it relates to the functions of nursing. Facility policies may restrict practice further in their setting and/or require additional expectations related to competency, validation, training, and supervision to assure the safety of their patient population and or decrease risk.




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