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Pamela Zuchowski
Turn around time for PICC line insertions

We are a 200 bed facility that does approx 60-80 PICCs a month. We have two part-time PICC nurses. I am wondering in other hospitals, what the realistic turn around time from a PICC order to actual insertion is. Do doctors and nurses have expectations that PICC lines can be ordered stat and will be placed within a few hours? Do you have regular hours that lines are placed and any new PICC orders have to wait until then? We are having debates with our ICU docs and nurses regarding ordering stat and emergent PICC lines, sometimes with the expectation that a PICC nurse should be available at all hours. We suggest that if the patient is that critical a CVC should be placed and then a PICC line can be inserted in a few days if it is indicated. Thank you in advance to anyone who can share their hospital practices.

kunzerod
PICC turnaround

We are at about the same level of # of PICC per month and hospital size.  Our team is out of the Cardiac Cath Lab and PICC insertions are scheduled 0800 to 1700 daily M-F on SAt. and Sun we place them from 0900 to 1500.  No PICC line is considered emergent only occasionally urgent if the patient's INR is elevated to high to safely place a central line by jugular approach.

Rod D. Kunze RN, RCIS Action Site Manager, Door 2 Balloon coordinator PICC coordinator St Vincent Healthcare 1233 North 30th Billings, Montana 59101  Work    (406) 237-4300 FAX      (406) 237-4390 Beepe

utvolmay
We do not take call for our

We do not take call for our PICCs.  We place them M-F 7-4.  No stat PICC's because you are looking at turn around time of at least 1 hour depending on how fast your rad techs and radiologist read the xray.  If they need access stat then they get a jugular or CVL.

Vascular assessment on admission will likely decrease the need for the stat PICC's

Karen Day
Karen Day's picture
I think you should take each

I think you should take each case individually.  there are times when an urgent/emergent or whatever you want to call it picc line is definitely indicated.  In real time, yes there is a slight turnaround time (approx 1 hour as stated in a previous reply), but unless your physician or resident is standing right there and ready to place a central line, you are looking at the same turnaround time if not longer.  It takes some work, collaboration and communication with your nurses, rad techs, and radiologists but it can be done.  Our hospital has come a long way and through many trials and tribulations, our time from order of those "emergent" lines to use of the line is approx 1 hour - sometimes less.  Our radiology technicians have a fantastic response time and our radiologists read the films very quickly.  We need to preserve our jobs and if we limit ourselves and refuse to do "stats" and "emergent" lines, we will be replaced with someone who will.  Not every picc is a stat, but I think we all posess the knowledge to differentiate those that are and prioritize our placements to accomodate our facility who is our customer just as much as the patient is. 

lynncrni
Patient-centered care

I totally support Karen's comments and applaud her for her serious efforts to quality patient care. The time for arranging delivery of patient care around what is best or appropriate or convenient for the providers is coming to an end. It is time we focus on a system that delivers care in a manner that meets the patients needs - first, foremost and always. There is no room for any other approach. If this approach is not used, the patient suffers, treatment is delayed, cost increases, length of stay is longer, etc, etc. If nurses don't understand this, someone else will be waiting to take over your set of tasks. This is part of my focus for the INS preconference presentation next week in Jacksonville. Lynn

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

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

kathykokotis
Response time

If you heard my AVA lecture it is all about response time

A PICC line is emergent.  Sepsis bundle's are growing in usage making CVC's emergent.  MD's get paid $118 to do a CVC and are not going to come to the hospital in the middle of the night

Respiratory therapy is waiting in the wings 24/7 and can be an adjunct to placement in the future

24/7 will be the new reality as healthcare changes are made.  Healthcare is not run on banking hours

Kathy Kokotis RN BS MBA

Bard Access Systems

RichL1
Emergency PICCs

I can't count the times that I've heard PICC nurses (and administrators) who work 8-4 Mon - Fri say that a PICC should never be considered an "emergency or stat".  The reality of acute care and Sepsis protocols is that while "a PICC is never an emergency" or so some believe, the need for central venous access is and the alternatives to PICC's like femoral lines (or ER docs placing subclavians) are considerably less desireable.  

In the "good old days" PICC's were seen as a pre-discharge procedure to provide access for patients going home (or to SNF's) on long term antibiotics.  Often ordered late on a Friday, the "emergency" was that the patient was likely to stay the weekend in the hospital because discharge planning was poorly communicated.  If the PICC wasn't placed that day, the hospital bore the cost per day (up to $2000 average per day) to house the patient.   With better discharge planning and increased pressure of DRG's, communication has gotten better.

What also dramatically changed is that PICC's became more versatile (multilumen, power injectible, CVP readings, etc.) and accepted for sicker patients. Today in some areas of the country, upwards of 30% of the PICC's are now placed in ICU's and ER's.  

At IV Assist, we provide 24/7, 4 hour response time to acute care hospitals who recognize the value of having a multilumen central line placed quickly and efficiently for patients who need cvp monitoring and more than one lumen for drugs and fluids.  Depending on the distance we are often on site in an hour.  We certainly see the need for 24 hour availability.

Kathy is absolutely right, "24/7 will be the new reality as healthcare changes are made.  Healthcare is not run on banking hours."  Well said.

 

 

Rich Lewis, RN
CFO
IV Assist, Inc

www.ivassist.com
Ph:  (510) 222-8403

anna liang
I also agree that it is not

I also agree that it is not the doc/staffs' expecations but pt's need that urgent picc insertion is justified.

quick picc respond is essential for your service's survival

our numbers have doubled compared to 5 years ago -- one reason is that our service repsonds fast

 

Rhonda Wojtas
stat PICC's

I often have been called to urgently place a picc in pts in the ICU because a patient is not doing well. This PICC does take prioty on a pt that already has access and I will do it "stat".  I do PICC's in the order of need not neccessary in the order they were received. I can place a PICC much safer than blind subclavin or IJ stick. I am not on call nor do I get call pay for the weekends. However if the hospital calls me and I am available I will go in to do a PICC on the weekend. My hope is some day we will get some type of call coverage for the weekends becasue it is such a valuable and needed service.

Rhonda Wojtas, RN VA-BC

momdogz
We are quickly working toward 24/7 coverage.

PICCs are placed days and evening shifts.  Haven't had a call for one on nights yet - and we still need to figure out how to staff in order to be able to that.  We do have per diem staff of which one would be willing to come in on a night shift.  We'll be training resource staff to be PICC assistants (competency training and assessment) for arm prep (observed by PICC RN), assistance with set up, and completing the checklist while sterile procedure is in operation so that we have an assistant available at all times.

PICCs are at times emergent lines, and often are urgent lines, and we triage them as such.  Most of our MDs rely on this service, and would rather the pt. have a PICC line than an IJ or subclavian or femoral (if a central line is truly needed - sometimes they are not).  

We place them in the OR if we're called there, we'll place them in the ED, we'll place pedi lines in a procedure room under conscious sedation if that is required.

We provide consults for MDs on vascular access, and have been teaching vascular access to med students and residents for the past 2 years.  Every chance we get - we are advocating for patients, patient safety, and for the success of our team.

 

Mari Cordes, BS RNIII VA-BC
Vascular Access Department
University of Vermont Medical Center

JackDCD
"STAT" PICC's

The reason for urgent PICC's is not founded on good practice data. I've been doing PICCs, bedside with US, for 6 years now. I worked in a large PICC program (5 PICC nurses) doing 3-4,000 PICC's a year. So, my take on this whole arguement is that you can't promise urgent service. I don't disagree that a PICC could be needed urgently, however, unless you have a large staff that support that kind of service, it's just not practical. An example: if patient A needs a PICC "STAT" from the ER. If I'm involved with a difficult access well it could be 20-30 minutes before I get there. Now, I put the PICC in ...say 15-20 minutes. Xray ordered. I read the film..and not all PICC nurses can clear a line for use. Radiologists reads the film. In the IJ...now I have to reposition. Xray again, tech has to come RIGHT back now it's across in the contralateral brachiocehalic. Have to fix again...tech come s RIGHT back..fixed SVC ready to use. That is by no means STAT. That's about 1.5 hours. Remember, a central line may need xray but the chance of malposition with an IJ or Subclavian is less than a PICC. So, it's a quicker turnaround.

I agree with the notion we need to make our profession more valuable to a hospital system. But we need to be smart and not set the bar so high we can never achieve what we promise.

Things we can and should do: 1) Get yourself approved to read the films to confirm placement.

                                             2) Be ready to be more than a PICC nurse, be a Access Specialist

                                             3) Know your craft!!! Be the expert!!!

                                              4) Develop relationships with the MD's, nurses, 

   And Remember, knowledge is power the more you know....the more they want you!

 

        Jack Diemer

         Coordinator, Access Intervention Team                                             

achoosa1
Try Sherlock for Bard. No

Try Sherlock for Bard. No more hectic with the PICC tips malpositions!! You will love the tip location system. You will know where the line is going by looking onthe screen and hearing from the sound. Once it goes to CAJ you will hear the high pitch sound. It gives me 100% accuracy by far. It is the best system I have ever used.

 

Glenda Dennis
Faster PICC insertions

A technique that significantly saves time is to use ECG guidance.  It eliminates the need for chest x-ray and the waiting time for that whole process.  You will know immediately if you need to reposition.  It can reduce the procedure time to 1/2 hour. 

Teresita Pasalo
Expert PICC RNs

With Sherlock , a picc RN can troubleshoot in real time.  Each picc RN learns on her own pace.  We, have an RN from ICU and applied as picc line nurse and always delay the picc placement and as I can observe, still a neophyte even working for almonst 3 years.  With this exposure to patient, we have to try to learn from our mistakes.  If you encounter mistakes and do not try to research what could be the cause of the mistake, then that nurse will stagnate and create more failed insertion in the future.  And that is what I am seeing on this nurse.  The supply cart has lots of unopened statlock and tegaderm which means , she opens new ones coz of frequent failed attempts.  We do not know how to approach a solution to this case.  I hope someone will give us an advise. Could be to observe and do peer review on this nurse?

kerry taliaferro
ECG guidance significantly

ECG guidance significantly reduces the frequent repositions post insertion - we have been using it for over a year and can have a line released in an hour (uncomplicated) from referrral, We have a team of 2 - and always priorititse on patient need first - organisational second. To lenthen our hours we stagger start times so can offer 8.30 to 6pm Mon to Fri (working on getting weekend cover when the hospital recognises the need) As the CNC - charge of the team I will take calls from 7.45am as we have cell phones for contact, Our KPI's are 4 hours max to assess, 24 hours to insert/clear line. We achieve this 97% of the time.

 Like Teresita I have concerns re the oncology PICC's as they have a high failure rate on insertion compared to our team of 95 - 100% success per month, and high post insertion complication rate (thrombosis etc) I know they insert the majority in the cub fossa or below - occasionally just above.  I am working on irrefutable evidence to present that the RN's there do not provide best practice - don't insert ultrasound guided despite the CNC stating they do, don't use fully body drapes or full barrier precautions. I don't want to stop them inserting just educate and help to provide a better patient experience and outcome.

This I will take to our Hospital National  Standards meeting to improve practice - I have said for my team credentialling - then recredentialling every 3 years is required and we want to bring it in hospital wide - happy for them to recredential me as I know I am practicising the latest in evidence based best practice! And  we have had external recredentialling in the past 12 months.

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