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x-ray for tip placement on re-admission

Does anyone know of a standard...or what are your hospitals using as a standard...as to how frequently CVAD tip placement should be checked radiographically after a patient has been discharged...then re-admitted.  We are trying to put a time period for re-x-ray in our policy, but I've been unable to find one.  The closest thing I've found says, "tip position should be re-confirmed radiographically at established intervals"...who establishes these intervals?

Thanks

Tanya Nauman RN, CRNI

Eugene, Oregon

musicfan_rn
We get another CXR every

We get another CXR every time a patient comes to the hospital with a PICC, whether we placed it or someone else did.  Our thinking is that we have no control over what happens to a line outside, but we can feel okay to start using it if we know it is in good position on admission.

 

Sally RN

lynncrni
I would want a new chest

I would want a new chest xray upon admission for all CVCs also. The INS chapter in Atlanta had this discussion a few years ago and most obtained this xray on admission. 

 

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

www.hadawayassociates.com

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

Chris Cavanaugh
I frequently work with

I frequently work with Nursing homes and Long term care facilities.  I received a call one day from an LPN asking me to come out to look at her patient, who's arm was "all red". 

I checked the chart when I arrived, all the documentation referred to the patient's PICC line, and the patient was receiving Vancomycin.  There was no xray on the chart, no copy of the original xray report on the chart or any placement information.  (This is typical of transfers from hospitals to nsg homes.)

The patient's arm was red from the wrist to the axilla.  He  had the hub of an IV catheter coming out of the vein near the inside of his wrist.  The dressing was labeled "23 PICC (date)"

Yes, you guessed it....I removed a 23 cm catheter that went up from that vein in his wrist.  A simple XRay would have saved this patient complications and the nursing home and nursing staff there from a lawsuit. 

If you placed the PICC, you XRay it to confirm...shouldn't we do this if we did NOT place it?

We all know PICCs can move, I personally would never use any catheter that I did not know where the tip was. 

Chris Cavanaugh, CRNI

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

Glenda Dennis
Do you require a CXR for
Do you require a CXR for patients who come in with a port or groshong as well?
Chris Cavanaugh
Ports get xrayed only if

Ports get xrayed only if they do not flush or do not give a blood return.  If they work fine, no need to xray as ports have much shorter, stiffer catheters attached and do not move as easily as other central lines, especially PICCs. 

As far as groshongs, it depends on what type of Groshong catheter--PICCs and Tunneled central lines, yes, Groshong Ports are treated as above. 

Chris Cavanaugh, CRNI

Chris Cavanaugh, RN, BSN, CRNI, VA-BC

momdogz
We get CXR's of all PICC

We get CXR's of all PICC patients admitted, or readmitted.   We've caught malpositions that could have led to disastrous outcomes for the patient.

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

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

Susan Rainey
Susan Rainey, Olympic

Susan Rainey, Olympic Medical Center

What about patients coming to the hospital for outpatient treatment such as chemo after CVAD placement in another hospital?  We're located in a rural area more than 2 hours away from Seattle with patients coming for therapy post CVAD placement in Seattle.  Generally these patients arrive without information regarding their PICC or port.  We have a process in place that is working, but I'm curious to know what others are doing in similar situations.

Susan Rainey RN, Olympic Medical Center

Cherylob
I think this is a recurrent
I think this is a recurrent problem, where patients come from other facilities or readmitted and the information on the CVAD is scant. Lynn, you state to xray all CVD, but is it necessary for even the tuneled catheters that are sutured? I have a hard time getting the MDs to agree to PICC tip verification on transfers and readmits.  What about in our free standing centers- areas, ie: Cancer Treatment Center, where the outpatient is making periodic trips for chemo? Thanks
lynncrni
It is a fact that all CVCs

It is a fact that all CVCs can have tip migration - the original properly placed catheter tip moves to another vein, most commonly into the internal jugular. This means the infusion flowing against normal blood flow and that the catheter tip is much more likely to cause endothelial damage. Tunneled catheters usually have their sutures removed within several weeks after insertion. A review of the literature on CVC stabilization shows that a manufactured stabilization device performs better than sutures for all catheter outcomes, especially dislodgement where both ends of the catheter is moving. 

I believe that hospital admission requires a documentation of where the catheter tip is located. If your facility thinks this is excessive due to frequency, then  you could establish clinical critieria about when it will be xrayed. This would include a change in the external catheter length, any and all complaints of hearing a running stream or gurgling sound, chest pain, back pain or any other discomfort in the thoracic, catheter leakage, absense of blood return, inability to inject or infuse, a change in blood return when the arm or shoulder position is changed, unusual areas of swelling or redness. I am sure I have forgotten something, so don't take this as a complete list. 

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

www.hadawayassociates.com

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

bsherman
On this subject my facility

On this subject my facility policy for CT with contrast studies is picc tip placement per CXR within 24 hours of power injection, if we already xray on admission and no difficulty with blood return or infusion is this necessary?  don't we want to xray after to determine if injection pressure caused any malpostion?  Probably over thinking.

lynncrni
Having seem animal studies of

Having seem animal studies of infusion-induced catheter movement (IICM) as it relates to power injection through PICCs, I think your approach is a good one. I have questions about why they are waiting 24 hours though. My only assumption is they know that IICM is happening but are concerned about whether a tip remains malpositioned at 24 hours or if the tip has spontaneously migrated back to its original location. My concern would be what is being infused within the 24 hour period and what damage is being done to the vein, if any. I do think we can be so concerned about tip location and malposition that we do too many xrays, exposing patients to too much radiation. I don't think you are over-thinking this at all. 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

bsherman
I apologize Lynn that CXR

I apologize Lynn that CXR within 24 hours of CT is prior to CT not post.  My thought was if line is functioning as it should, and admission or initial insertion CXR has been done on current admission I don't think the CXR prior to CT is necessary however post could be beneficial.  Thanks

lynncrni
Catheter tip migration after

Catheter tip migration after placement does happen. It is sporatic and spontaneous. We really do not have any data on the frequency of this malposition. I am just not sure that an xray 24 hours before a CT is going to be beneficial. I would surmise that the reason is to make sure the catheter is properly positioned for the CT with contrast injection, however the xray before is no guarantee that the catheter will remain in the same place until the CT is done. I have not heard of anyone else with a similar policy, eager to read what others are doing. 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

MarkCVL
  New data to add to the
 
New data to add to the mix.......
 
Clin Radiol. 2011 Nov 7. [Epub ahead of print]

Migration of central lines from the superior vena cava to the azygous vein.

Source

University of Texas, MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 1475, Houston, TX 77030, USA

cbusch
CXR on Readmit

We have an order set that recommends that a CXR is done to confirm the tip location. Initally the physicans were not ordering however the PICC nurse would do an assessment on the picc line when the patient was readmitted and calling them to obtain the order. With the piccs that were found to be displaced, one had migrated out and back down the arm and another had migrated into the jugular, the physicans are ordering them on their own.

Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse

ErikaA
Which facility

Carol Busch and Jahearn- 

Which facilities do you work at that have as part of practice/ policy?

We have at ours as well but have been asked what facilities outside of our organization have as well..  So reaching out

Thanks

Erika

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