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I certainly appreciate your concern.  I use my PacerView to confirm tip location with EKG.  It is easy to do and there is no charge to the patient and you can absolutley be certain that the tip is in the low SVC.  That said, PacerView is not available anymore.  I think it is seriously not a good idea to use a PICC that you do not know where the tip resides.  Extravasating medications or power injecting can be very dangerous to the patient.  Until tip location can be confirmed by some means, I would start a peripheral IV and not use the PICC.

 I agree with Glenda about the issues with using any CVAD without knowing where tip location was orriginally placed and if it is stil in that location. I would work toward a facility policy about this situation. Depending upon the therapy prescribed and the patiient's vein status, a PIV would have been a very good alternative until you could take this up the chain of command for this patient. Unfortunately though this would mean the patient "looses" due to being stuck again. If there were no signs and symptoms of tip malposition, I might have used the PICC but would certainly take this to medical QI on Monday morning! Lynn

We do have in policy that all CVAD's coming in to the hospital must have a CXR prior to use on the in-patient floors, in ED we will assess for blood return and flush and use accordingly however we will get the CXR when pt is stabilized.  We have found some that were no longer SVC but up the neck.  Very valuable tool in the essence of safety for your patients, I urge you to take this to evidence based nursing practice council or your policy writers and incorporate it into your practice.

We do require a CXR when a patient is admitted to the hospital with a 'temporary' central line in place.  We've really struggled to get this done; it was too often overlooked.  The issue finally went to Med Exec and from that meeting we discovered that the docs want to be involved in the process. 

We have adapted our EMR.  During the admission assessment piece when queried 'does the patient have an IV in place' and the nurse checks 'yes', it queries 'Is this a central line?' and if yes, there is a drop down box which says, "Patient may require a CXR for tip placement; notify physician."

We are only abour 2 weeks into this so I'm not sure how it's going to go.  Our physicians did not want the CXR ordered without their input so that is why we did it this way.

Not perfect, but leaps and bounds ahead of where we were.

Alma Kooistra CRNI