Sherlock 2 provides realtime feedback where Navigator does not. Shelock also immediately identifies any PICC tip malposition where Bavigator cannot identify a PICC in the Azygous vein or coiled PICCs in the SVC. If you are using a Site Rite 5 or 6, the Sherlock 2 can be integrated into the machine which is an incredible advantage. The kicker is that although Shelock 2 only works with Bard PICCs, the stylet is preloaded in the PICC. With the Navigator, you can use any PICC but must load the stylet which is added steps, it can create issues with sterility as well as possible damage to the PICC line itself that may go undetected until after placement.
Thank you so much for your input. I used them both. To me, I really like the Sherlock better than the navigator. But I am new to the picc lines. I just started working in January, 2008. We use SiteRite 5 and Bards picc lines.
I was told to pick either Sherlock or Navigator. I'm not sure if I would make the right decision to choose the Sherlock. If a picc tip is mulpositioned, I won' t have a stylet to check the position again. Moreover, I don't have spared stylets to use in case of the stlylet is coiled up.
But, I hope that the Sherlock would give me the picc tip position confirmation correctly every time which means that I don't have to reposition the picc tip at all.
Again, thank you very much for your suggestions. You make me feel more comfortable with the Sherlock.
One thing to keep in mind with both Navigational systems is that they depend on surface landmarks for final positioning. ECG guidance has superior accuracy and greater reliability in terms of placing the catheter tip at the SVC - Atrial junction (see the article by Chu et. al, at http://www.pacerview.com/index_files/ECG_GUIDANCE_FOR_CVC_PLACEMENT_IN_THE_LITERATURE.htm
and may be complementary to navigational systems. If you find your catheter tips are not where you expected them to be, you may consider ECG guidance.
This is a long standing discussion on this site. Search for either Sherlock or Navagator and you will find MANY threads and opinions. The best way to determine pros and cons for YOUR practice is to have the reps come in, give you a brief lesson and try them to see which works best for your practice.
Glad to hear you have tried both. It is always smart to evaluate all of your options. Just to clear up a few misconceptions though, Navigator does provide exact feedback on tip position as long as you know how to use it. I have used it now for over 6 years, and I can find a PICC in the Azygous vein, a coiled PICC in the arm, or any other vein if happens to coil in. It is not difficult to learn to do all of this with the Navigator. I have used both products and I myself do not like to have to sit anything on my patients chest due to movement and possible breathing or wound complications. I do not know about you, but not very many of my patients lay still while I PICC them unless they are sedated, and I have several that like to sit up while being PICC'ed. The device on the chest must be positioned correctly to get an adequate idea of where your PICC is and if it moves much, it can be very deceiving.
Also, there is no sterility issues with inserting a wire into a PICC. IR does it all the time, and there has never been one good published article or study to support this claim. Almost any PICC you use will be trimmed to fit your patient, and unless you trim the wire, which is a big no no, you are pulling the wire back to trim your catheter which is wire manipulation. Plus, if it still really concerns you, the people who market Navigator (Viasys, now Cardinal) also have a power injectable PICC, and a regular PICC that are pre-loaded with their wire. These PICC's are great, and prices are great too which always helps. I have also heard that Viasys is working with a couple of other companies to possibly package their stylet with other PICC's (not pre-inserted, but packaged together) which would give you more options as Bard only markets Sherlock with Bard products. It kind of locks you in, but if you already use all Bard products and are happy with them, I guess that is not such a bad thing. I like to try new things occasionally so it would not work for me or my team.
Please email me privately if you have any more questions, or like Chris said, there have been many threads on these two products over the last few months. Happy hunting!
Thank you all the experts!! You have given me tremendous information. I really appreciate it. I love the Sherlock II so far. But the Sherlock has just been out in the market. The more I get the feed back from the Sherlock, the better it will help me to make the decision, SherlockII or Navigator.
I would like to support Dr. Rothenburg's comments about the benefits of using ECG guidance. I am able to rule out an IJ malposition by using ultrasound on the neck. I can reliably place the PICC tip in the lower SVC using ECG and monitoring the amplitude of the P wave. It's simple and easy to do. If I can't see the ECG changes, I know I have malpositioned contralaterally and can reposition.
WHat is the cost (in general terms) between the ECG guidance. I know that the other two devices basically add $30-40 to the cost of each insetion, it the ECG compariative?
The pacerview device is about $150.00 and is reusable. It is the connector between a leg lead and the grabber which connects to the PICC guidewire. The grabber is $15.00. The cost difference is $15.00 vs the cost of a chest x-ray (about $250-$300. plus the radiologists reading charge). The other issue is time. I don't have to wait for the x-ray to be done which cuts about 1/2 hour off of the time required for each procedure.
I have only one comment if you are not using one of the navigation or ECG/EKG systems you should. This is a great way to reduce manipulating a PICC line that is placed originally under full barrier precautions. Manipulations = infection and I think there is no controversy in making that statement once the original full barrier is gone.
Remember I was an infection control nurse and do not believe in wrapping any arms in sterile towels to re-position later. This goes against the whole idea of full barrier to begin with
Is anyone doing Time to Positivity for CLRBSI? If so does this meet the CDC guidelines for measuring central lines infection rates? And how are some of these hospitals reporting zero infections, I don't get it unless there are different ways of reporting.
Our entire team tried them both and preferred the Sherlock. We did not like all the manipulation required with the Navigator. In addition , we thought it be easier for the insertor when they are alone to have the PICC pre-loaded and not have to scan over the chest with the navigator. We also had a lot of interference with the Navigator and had to chage the wire on several insertion for a variety of reasons. We also preferred the visual aspect of the Sherlock.
Thank you so much again for your input. I really need this kind of information to support my decision to use the Sherlock. I am still very new to the picc lines. My voice might not be counted like the only experienced picc nurse we have in our facility (there are only two picc nurses; myself and the other one) because she uses the Navigator.
If you could provide me more info about how many picc lines you have placed with the Sherlocks, I greatly appreciate it.
I have used the Sherlock 1 and now use the SHerlock 2. I am not familar with the ECG way of doing insertions so I can only comment on the SHerlock 2. We have had greater than 90% success rate with our PICC lines since using the SHerlock 2. The only 2 PICC's we could not insert we patients with subclavin occlusions. I do not know how a PICC team can have 100% success rate with either. I can access 100% of my veins in that I get a blood return when I insert the needle however I can not always advance the cath to truly insert a PICC line.
We inserted or attempted in March 78, April 80 and May 65 PICC lines with 1 or 2 per each month we were unable to advance the catherter.
I have not have any catheters go into the IJ with the Sherlock 2 since we started using it a few months ago. I did have two with the Sherlock 1 that we thought were down and okay but was in the IJ. I am very happy with the Sherlock 2.
And no I do not work for Bard. I am a hospital PICC nurse.
Kevin there are now multuple definitions for defining catheter infections as you pointed out.
CLAB, CR-BSI both differ as one is catheter associated and one is catheter related
I too am concerned that there is no standard reporting methodology for testing. This will mean some hospitals will be reporting higher rates than others based on definitions that are not standarized
The problem I have is one of the members on the central line infection committee wants to transition away from BARD products because we are not at zero. It's a fight for me every month
I am very impressed about your success rate. And thank you for sharing your statistics. It is very helpful. First, I was reluctant to tell my manager that I would love to use the SherlockII because the experienced picc nurse uses the Navigator. Now I feel more confident to say it out loud that I need the Sherlock. Moreover, you don't work for Bard. No bias.
Hope you answer. What does Baptist East want to transfer from? PICC lines in general or Bard PICC lines due to infection. I don't think there is a difference to my knowledge in infection rate of PICC lines so far. To date only one coated PICC is on the market which is Cook's and there is no study on PICC line infection reduction however their acute care clinicals blow away the Arrow acute care lines as far as results go. Now I should clarify in Arrow's defense that the Cook catheter has far less clinical study and therefore that could be a contributing factor as well that Cook looked better on paper.
But back to PICC line is it the idea of a PICC line and infection or the idea of a Bard manufactured PICC line and infection?
As long as all factors are the same, i.e. lumens, insertion technique would find it extremely difficult to believe that BARD has a higher infection rate than any another manufacturer, would look at insertion technique, care post insertion, etc rather than manufactures as the culprit.
3M has a nice Tegaderm CHG dressing that would be worth looking at as well, http://tinyurl.com/ynkpuc
There has been a trend at many hosptials to move more toward PICCs and away from subclavian or jugular central lines. IMHO, it should be up to the patient to decide, that is, what does the patient truly need? Does he need access for more than 30 days? If so, consider a PICC. Does he have CRF, high GFR? if so, consider a subclavian central line. Does he really need 3 or 4 lumens? Can his arm support that large of a catheter? The right line for the patient should be determined upon admission, as changing of lines, even from a Central line to a PICC, puts that patient at higher risk of complications. Placing PICCs because they are "easier", "cheaper" or "can be done at the bedside by an RN" are not good reasons to place a PICC.
Infection rates of both lines are similar when placed similarly and cared for similarly.
An antimicrobial treated central line will have lower infection rates than a PICC, but dwell time is limited.
All things should be considered prior to choosing the right device for your patient.
How does your hospital define a catheter infection. Some hospitals are now using CLAB which means if you have a patient with a blood stream infection and a catheter they are related but that might not be true
You might want to break down a day specific rate as PICC lines dwll longer than traditional CVC's to see what day they become infected
What organisms they are so one can arrange an educational program to reduce those transmissions. Are they skin, water etc
What time period do they occur in: close to insertion within 7 days of insertion or after 7 days and related more to care
Do you use full barrier, biopatch, chlorhexidiene, a swabable needleless system etc
Look for causative factor and design an educational program around those
Look for articles by Harnage as she has zero infections with PICC lines. There is one published in the JVAD and RN for May 2008
Sherlock 2 provides realtime feedback where Navigator does not. Shelock also immediately identifies any PICC tip malposition where Bavigator cannot identify a PICC in the Azygous vein or coiled PICCs in the SVC. If you are using a Site Rite 5 or 6, the Sherlock 2 can be integrated into the machine which is an incredible advantage. The kicker is that although Shelock 2 only works with Bard PICCs, the stylet is preloaded in the PICC. With the Navigator, you can use any PICC but must load the stylet which is added steps, it can create issues with sterility as well as possible damage to the PICC line itself that may go undetected until after placement.
Hope this helps.
Thank you so much for your input. I used them both. To me, I really like the Sherlock better than the navigator. But I am new to the picc lines. I just started working in January, 2008. We use SiteRite 5 and Bards picc lines.
I was told to pick either Sherlock or Navigator. I'm not sure if I would make the right decision to choose the Sherlock. If a picc tip is mulpositioned, I won' t have a stylet to check the position again. Moreover, I don't have spared stylets to use in case of the stlylet is coiled up.
But, I hope that the Sherlock would give me the picc tip position confirmation correctly every time which means that I don't have to reposition the picc tip at all.
Again, thank you very much for your suggestions. You make me feel more comfortable with the Sherlock.
Ann
One thing to keep in mind with both Navigational systems is that they depend on surface landmarks for final positioning. ECG guidance has superior accuracy and greater reliability in terms of placing the catheter tip at the SVC - Atrial junction (see the article by Chu et. al, at http://www.pacerview.com/index_files/ECG_GUIDANCE_FOR_CVC_PLACEMENT_IN_THE_LITERATURE.htm
and may be complementary to navigational systems. If you find your catheter tips are not where you expected them to be, you may consider ECG guidance.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
Ann,
Glad to hear you have tried both. It is always smart to evaluate all of your options. Just to clear up a few misconceptions though, Navigator does provide exact feedback on tip position as long as you know how to use it. I have used it now for over 6 years, and I can find a PICC in the Azygous vein, a coiled PICC in the arm, or any other vein if happens to coil in. It is not difficult to learn to do all of this with the Navigator. I have used both products and I myself do not like to have to sit anything on my patients chest due to movement and possible breathing or wound complications. I do not know about you, but not very many of my patients lay still while I PICC them unless they are sedated, and I have several that like to sit up while being PICC'ed. The device on the chest must be positioned correctly to get an adequate idea of where your PICC is and if it moves much, it can be very deceiving.
Also, there is no sterility issues with inserting a wire into a PICC. IR does it all the time, and there has never been one good published article or study to support this claim. Almost any PICC you use will be trimmed to fit your patient, and unless you trim the wire, which is a big no no, you are pulling the wire back to trim your catheter which is wire manipulation. Plus, if it still really concerns you, the people who market Navigator (Viasys, now Cardinal) also have a power injectable PICC, and a regular PICC that are pre-loaded with their wire. These PICC's are great, and prices are great too which always helps. I have also heard that Viasys is working with a couple of other companies to possibly package their stylet with other PICC's (not pre-inserted, but packaged together) which would give you more options as Bard only markets Sherlock with Bard products. It kind of locks you in, but if you already use all Bard products and are happy with them, I guess that is not such a bad thing. I like to try new things occasionally so it would not work for me or my team.
Please email me privately if you have any more questions, or like Chris said, there have been many threads on these two products over the last few months. Happy hunting!
Heather Nichols RN BSN CRNI
[email protected]
Thank you all the experts!! You have given me tremendous information. I really appreciate it. I love the Sherlock II so far. But the Sherlock has just been out in the market. The more I get the feed back from the Sherlock, the better it will help me to make the decision, SherlockII or Navigator.
Thank you again for your time and your expertise.
Ann
HI Glenda,
WHat is the cost (in general terms) between the ECG guidance. I know that the other two devices basically add $30-40 to the cost of each insetion, it the ECG compariative?
Cheryl Kelley RN BSN, VA-BC
Kathy Kokotis
Bard Access Systems
I have only one comment if you are not using one of the navigation or ECG/EKG systems you should. This is a great way to reduce manipulating a PICC line that is placed originally under full barrier precautions. Manipulations = infection and I think there is no controversy in making that statement once the original full barrier is gone.
Remember I was an infection control nurse and do not believe in wrapping any arms in sterile towels to re-position later. This goes against the whole idea of full barrier to begin with
Kathy Kokotis
Kathy Kokotis
Bard Access Systems
Kathy,
Is anyone doing Time to Positivity for CLRBSI? If so does this meet the CDC guidelines for measuring central lines infection rates? And how are some of these hospitals reporting zero infections, I don't get it unless there are different ways of reporting.
Kevin
Hi Mary Ann and PJ2008,
Thank you so much again for your input. I really need this kind of information to support my decision to use the Sherlock. I am still very new to the picc lines. My voice might not be counted like the only experienced picc nurse we have in our facility (there are only two picc nurses; myself and the other one) because she uses the Navigator.
If you could provide me more info about how many picc lines you have placed with the Sherlocks, I greatly appreciate it.
Ann
I have used the Sherlock 1 and now use the SHerlock 2. I am not familar with the ECG way of doing insertions so I can only comment on the SHerlock 2. We have had greater than 90% success rate with our PICC lines since using the SHerlock 2. The only 2 PICC's we could not insert we patients with subclavin occlusions. I do not know how a PICC team can have 100% success rate with either. I can access 100% of my veins in that I get a blood return when I insert the needle however I can not always advance the cath to truly insert a PICC line.
We inserted or attempted in March 78, April 80 and May 65 PICC lines with 1 or 2 per each month we were unable to advance the catherter.
I have not have any catheters go into the IJ with the Sherlock 2 since we started using it a few months ago. I did have two with the Sherlock 1 that we thought were down and okay but was in the IJ. I am very happy with the Sherlock 2.
And no I do not work for Bard. I am a hospital PICC nurse.
Rhonda Wojtas, RN PICC Team
Lowell MA
Rhonda Wojtas, RN,BSN, VA-BC
Kathy Kokotis
Bard Access Systems
Kevin there are now multuple definitions for defining catheter infections as you pointed out.
CLAB, CR-BSI both differ as one is catheter associated and one is catheter related
I too am concerned that there is no standard reporting methodology for testing. This will mean some hospitals will be reporting higher rates than others based on definitions that are not standarized
Kathy Kokotis
Kathy Kokotis
Bard Access Systems
Kathy,
The problem I have is one of the members on the central line infection committee wants to transition away from BARD products because we are not at zero. It's a fight for me every month
Kevin
Hi Rhonda,
I am very impressed about your success rate. And thank you for sharing your statistics. It is very helpful. First, I was reluctant to tell my manager that I would love to use the SherlockII because the experienced picc nurse uses the Navigator. Now I feel more confident to say it out loud that I need the Sherlock. Moreover, you don't work for Bard. No bias.
How many picc nurses do you have in your team?
Ann
Kathy Kokotis
Bard Access Systems
Kevin:
Hope you answer. What does Baptist East want to transfer from? PICC lines in general or Bard PICC lines due to infection. I don't think there is a difference to my knowledge in infection rate of PICC lines so far. To date only one coated PICC is on the market which is Cook's and there is no study on PICC line infection reduction however their acute care clinicals blow away the Arrow acute care lines as far as results go. Now I should clarify in Arrow's defense that the Cook catheter has far less clinical study and therefore that could be a contributing factor as well that Cook looked better on paper.
But back to PICC line is it the idea of a PICC line and infection or the idea of a Bard manufactured PICC line and infection?
Kathy
Kathy Kokotis
Bard Access Systems
As long as all factors are the same, i.e. lumens, insertion technique would find it extremely difficult to believe that BARD has a higher infection rate than any another manufacturer, would look at insertion technique, care post insertion, etc rather than manufactures as the culprit.
3M has a nice Tegaderm CHG dressing that would be worth looking at as well, http://tinyurl.com/ynkpuc
The central line infection committee has a critical care nurse specialists that thinks we should move away from piccs, especially Bard products
She really challenges my A.D.D.
Kevin
There has been a trend at many hosptials to move more toward PICCs and away from subclavian or jugular central lines. IMHO, it should be up to the patient to decide, that is, what does the patient truly need? Does he need access for more than 30 days? If so, consider a PICC. Does he have CRF, high GFR? if so, consider a subclavian central line. Does he really need 3 or 4 lumens? Can his arm support that large of a catheter? The right line for the patient should be determined upon admission, as changing of lines, even from a Central line to a PICC, puts that patient at higher risk of complications. Placing PICCs because they are "easier", "cheaper" or "can be done at the bedside by an RN" are not good reasons to place a PICC.
Infection rates of both lines are similar when placed similarly and cared for similarly.
An antimicrobial treated central line will have lower infection rates than a PICC, but dwell time is limited.
All things should be considered prior to choosing the right device for your patient.
Chris Cavanaugh, RN, BSN, CRNI, VA-BC
Kathy Kokotis
Bard Access Systems
Kevin at Baptist East
Find out the facts on your PICC infections
How does your hospital define a catheter infection. Some hospitals are now using CLAB which means if you have a patient with a blood stream infection and a catheter they are related but that might not be true
You might want to break down a day specific rate as PICC lines dwll longer than traditional CVC's to see what day they become infected
What organisms they are so one can arrange an educational program to reduce those transmissions. Are they skin, water etc
What time period do they occur in: close to insertion within 7 days of insertion or after 7 days and related more to care
Do you use full barrier, biopatch, chlorhexidiene, a swabable needleless system etc
Look for causative factor and design an educational program around those
Look for articles by Harnage as she has zero infections with PICC lines. There is one published in the JVAD and RN for May 2008
Kathy
Kathy Kokotis
Bard Access Systems