PICC removal - page 4

by agldragonRN | 17,560 Views | 58 Comments

i work ltc and my job does not allow staff rns to remove picc even if we are iv certified. the md comes and removes them. the doctor came today and removed left upper arm picc from my patient. i gave him all the supplies (gauze,... Read More


  1. 0
    Quote from MunoRN
    Sealing the site with an ointment is not a "standard". A standard is something that has universal agreement, where examples of the standard not being followed are very hard to find and constitute true legal negligence. As you'll notice in this thread, use of an ointment is not universal, there are also professional practice sources that don't advocate the use of an ointment (for instance: Mosby's, http://www.medscape.com/viewarticle/508939_8, and others).


    http://www.ncbi.nlm.nih.gov/pubmed/2241775


    Our issue with the ointment is that decreases the ability of the occlusive dressing to do what it is intended to do; occlude. I agree that AE should be avoided as effectively as possible, which we believe consists of an occlusive that has not been compromised by a lubricant which will negate the seal, but you seem to overestimate the probability of an AE related to PICC removal, what is the incidence of AE following PICC removal?
    Hello... That article is NOT r/t Removal. Ointment DOES NOT decrease the ability of the TSM.. It enhances it.
    It is "standard," to seal with ointment. If you were called into a court of law because your pt suffered an AE, would they go by your own standards, or would they check out INS standards. It will BE INS.
  2. 0
    Quote from xtxrn
    And just because you use this in your area doesn't mean that all other nurses (and I've done plenty of IV/central lines/PICCs-- don't have to agree with you to have 'savy' ) are going to contribute to someone croaking because they didn't use a dab of goop Each facility has their own procedure manuals (and lawyers) and decides what data they use to make those procedures You follow different procedures- whoopee for you It's not the cornerstone of the continuation of mankind!! It must s**k to have so many idiots to have to explain things to

    You're kinda wishing I'd been sued, so I'd understand how deeply you feel about this, huh? I HAVE been sued (along with 3 other co-workers including the DON and admin) for something totally unrelated -- and it IS horrible, and I've gotten very bent out of shape over some of the issues related to that situation. It hurts to be involved in legal action, and colors views on the accusations they used.

    I had my Hickman taken out last week...a much bigger hole leading up through the tunnel to my jugular vein...no goop. 2x2s and Tegaderm.... and 6 days later, I'm still kicking
    Wow, didn't know I was talking to an idiot, but rather a fellow medical professional, but hey, thanks for enlightening me.
    Never, did I say that I wished you were sued, what I said was that I'm glad you haven't been privy to a lawsuit involving a AE. Don't take it out of context. In addition, just because they removed your Hickman catheter and didn't use "goop" doesn't mean that they shouldn't have used it. The size of most Hickman catheters along with the tunneling of the catheter, provides a long tract in the SQ which without "goop" could be a direct migratory pathway for air. Thank God you're still "KICKING"
  3. 0
    Quote from IVRUS
    Wow, didn't know I was talking to an idiot, but rather a fellow medical professional, but hey, thanks for enlightening me.
    Never, did I say that I wished you were sued, what I said was that I'm glad you haven't been privy to a lawsuit involving a AE. Don't take it out of context. In addition, just because they removed your Hickman catheter and didn't use "goop" doesn't mean that they shouldn't have used it. The size of most Hickman catheters along with the tunneling of the catheter, provides a long tract in the SQ which without "goop" could be a direct migratory pathway for air. Thank God you're still "KICKING"

    Yeah, the doc talked to me about the tract going into my jugular, and that some bruising may show up dependently from the jugular, but slapped a couple of 2x2s on with a Tegaderm (I can't have the foam tape for a stronger pressure since the adhesive literally causes blisters full of serous fluid wherever the tape touches- still have a funky flaky scar from April 2010 from foam tape at a PICC site). You would have been mortified when he accidentally clipped the Hickman in half trying to loosen the cuff...had enough to grab, and it all came out fine --it's SO nice to be rid of that thing

    I worked at places that did not use ointment with PICCs or other central lines when they're removed. And the only cleanser for dressing changes with my PICC and Hickman was chloro-prep makeshift preps (Medicare doesn't cover Chloro-preps, and they're too expensive for out of pocket- had to make due with an OTC antiseptic with chlorohexi-something ...I don't remember the whole name- it's quite late, or early - LOL..... and got my own dressings; did all of my own Hickman care). It all worked out.

    I've found different protocols in the same city for some things (like one place counted Phenergan with the narcs....one facility let LVNs start IVs but not give push meds, and another wouldn't let them start IVs, but could give IVPBs- both could maintain the fluids...Here, the LPNs aren't allowed to do much of anything, even though they've been nurses for ages, and know a lot.

    Oh well.... JMHO
  4. 1
    Quote from IVRUS
    Hello... That article is NOT r/t Removal. Ointment DOES NOT decrease the ability of the TSM.. It enhances it.
    It is "standard," to seal with ointment. If you were called into a court of law because your pt suffered an AE, would they go by your own standards, or would they check out INS standards. It will BE INS.
    That article, as I pointed out earlier, documents the effect (death) of vaseline entering a vein, putting vaseline in an open tract that communicates with a vein clearly presents some risk. The question then is if the risk is justified based on the severity of the threat and lack of other, safer options. The incidence of post PICC removal AE is zero, there are no documented cases of this ever happening. In terms of other options, a tegaderm by itself is both safer and more effective. An occlusive dressing, which relies on adhesion to the skin surrounding the site, is not enhanced positively by a lubricant that negates the adhesive abilities of the dressing. Less adhesion = more likely seal will not be patent.

    Legally, Nurses are expected by courts to follow their facility policies and the Standards of Care. I think you may be getting confused by the INS's use of term "standard" when referring to their practice recommendations. Standards of care and practice recommendations are not the same thing. Some of the INS's practice recommendations could be considered Standards of care, but that doesn't mean that all of the INS recommendations are therefore Standards of care. When an issue arises in court where facility policies and Standards of care don't apply, they may then defer to practice recommendations, where a Nurse's expectation to follow those recommendations would be considered based on the strength of the recommendation and if it's reasonable to expect that the nurse would have been aware of the recommendation. The ointment recommendation is not only not based on strong, unequivocal evidence, it's based on absolutely no evidence at all, and the recommendations are not publicly available.

    Are you suggesting that the best way for a Nurse to protect themselves legally is to defy their facility policy to instead follow a poorly substantiated practice recommendation?
    xtxrn likes this.
  5. 0
    Quote from MunoRN
    That article, as I pointed out earlier, documents the effect (death) of vaseline entering a vein, putting vaseline in an open tract that communicates with a vein clearly presents some risk. The question then is if the risk is justified based on the severity of the threat and lack of other, safer options. The incidence of post PICC removal AE is zero, there are no documented cases of this ever happening. In terms of other options, a tegaderm by itself is both safer and more effective. An occlusive dressing, which relies on adhesion to the skin surrounding the site, is not enhanced positively by a lubricant that negates the adhesive abilities of the dressing. Less adhesion = more likely seal will not be patent.

    Legally, Nurses are expected by courts to follow their facility policies and the Standards of Care. I think you may be getting confused by the INS's use of term "standard" when referring to their practice recommendations. Standards of care and practice recommendations are not the same thing. Some of the INS's practice recommendations could be considered Standards of care, but that doesn't mean that all of the INS recommendations are therefore Standards of care. When an issue arises in court where facility policies and Standards of care don't apply, they may then defer to practice recommendations, where a Nurse's expectation to follow those recommendations would be considered based on the strength of the recommendation and if it's reasonable to expect that the nurse would have been aware of the recommendation. The ointment recommendation is not only not based on strong, unequivocal evidence, it's based on absolutely no evidence at all, and the recommendations are not publicly available.

    Are you suggesting that the best way for a Nurse to protect themselves legally is to defy their facility policy to instead follow a poorly substantiated practice recommendation?
    Wow, "poorly substantiated practice recommendations".. Hmm.. You must think that INS has a bunch of uneducated "boobs" working and writing the standards. Sad. But you are wrong.
    The INS standards represent the scope of practice and offer evidence based criteria essential to the delivery of safe and competent care.
    Practice recommendations and standards of care are different, truly, but remember standards which read in part that the nurse "shall" carries a greater weight (Remember the 10 commandments?) than saying a nurse should do something. In a court of law, did the nurse comply with the standards, or didn't she/he? Without exception, these are the standards by which nurses are held to.
    Though reported cases of AE s/p PICC removal may not be published, that only doesn't mean it Hasn't happened, or couldn't happen. Remember that if a catheter's been dwelling for a long period of time, a fibrin sheath can become well defined. There is a documentated case of a CVC being removed and then 30 minutes later the man went out to smoke, with his first drag, deep inhalation of cigarette smoke, he also "sucked" in an air embolus which extended from the insertion site of the now removed PICC , to his lungs all along a strong fibrin sheath.
    A TSM is NOT sufficient in and of itself to seal the site and prevent an air embolism. You need a complete seal around the site, which is why a gel, and a TSM is needed.

    But, hey Muno, thanks for the lively discussion and WE can agree to disagree.
  6. 1
    OK. My since having just had a Hickman removed (yes, I know they're different since the Hickman is tunneled, but the tract is more significant with a Hickman- the PICC goes directly into the vein- or has a minimal tract to get through the SQ tissue, fat, and muscle- at least 3-4 I had...don't know of any tunneled PICCs) , with a very defined tract to my right ext jugular....and the cuff of tissue having to be cut out to remove the catheter. The surgeon told me that the tract would collapse very quickly, and be permanently 'shut' within minutes, as long as I didn't strain w/lifting-. Also said that the opening to the jugular would self seal- they didn't have to put a tourniquet around my neck . He stuck 2x2s and Tegaderm, and told me to leave it alone for at least 48 hours- then it was a done deal. He cut the edges of the entry site (essentially a stoma at that point) to approximate them. His concern was bleeding (I'm on Pradaxa for PEs) and asked me to please not bleed enough to have to go to the ED that night .

    If the jugular (and tract) were at risk for AE, it makes sense that there would be some oozing if the vessel was open enough to allow for an AE...

    With a PICC, the entry site is right at the skin. The nurses taking my PICCs out have always been more concerned about holding pressure- and thus sealing the site- than with any glop application The biggest rationale I've heard for not applying anything gooey is that it's another way to introduce bacteria--- yes, it should be kept from any bacteria from the dressing and antibiotic properties of the ointment of choice, but the skin around the area isn't sterile...and aren't antibiotic ointments bacteriostatic, not bacteriocidal- colonization can turn to infection????

    JMHO
    Altra likes this.
  7. 0
    Quote from xtxrn
    OK. My since having just had a Hickman removed (yes, I know they're different since the Hickman is tunneled, but the tract is more significant with a Hickman- the PICC goes directly into the vein- or has a minimal tract to get through the SQ tissue, fat, and muscle- at least 3-4 I had...don't know of any tunneled PICCs) , with a very defined tract to my right ext jugular....and the cuff of tissue having to be cut out to remove the catheter. The surgeon told me that the tract would collapse very quickly, and be permanently 'shut' within minutes, as long as I didn't strain w/lifting-. Also said that the opening to the jugular would self seal- they didn't have to put a tourniquet around my neck . He stuck 2x2s and Tegaderm, and told me to leave it alone for at least 48 hours- then it was a done deal. He cut the edges of the entry site (essentially a stoma at that point) to approximate them. His concern was bleeding (I'm on Pradaxa for PEs) and asked me to please not bleed enough to have to go to the ED that night .

    If the jugular (and tract) were at risk for AE, it makes sense that there would be some oozing if the vessel was open enough to allow for an AE...

    With a PICC, the entry site is right at the skin. The nurses taking my PICCs out have always been more concerned about holding pressure- and thus sealing the site- than with any glop application The biggest rationale I've heard for not applying anything gooey is that it's another way to introduce bacteria--- yes, it should be kept from any bacteria from the dressing and antibiotic properties of the ointment of choice, but the skin around the area isn't sterile...and aren't antibiotic ointments bacteriostatic, not bacteriocidal- colonization can turn to infection????

    JMHO
    The application of gel, is not to prevent infection, but rather as a seal over the tract made with the catheter's removal. Has the "gel or ointment" just come out of a tube or a jar in your patient's room? No, I can't imagine that it did. Usually an individual packet of gel is ideal, but if it is a tube which you just purchased because you're in home care, that will work too.
    And yes, the track usually closes, but what about the time the MD is in a hurry and just removes it, and "slaps" a 4x4 and tape over it... R U at risk? YES. That's why there are standards for pt care.
  8. 0
    Quote from IVRUS
    The application of gel, is not to prevent infection, but rather as a seal over the tract made with the catheter's removal. Has the "gel or ointment" just come out of a tube or a jar in your patient's room? No, I can't imagine that it did. Usually an individual packet of gel is ideal, but if it is a tube which you just purchased because you're in home care, that will work too.
    And yes, the track usually closes, but what about the time the MD is in a hurry and just removes it, and "slaps" a 4x4 and tape over it... R U at risk? YES. That's why there are standards for pt care.


    OK.

    Dead horse is now drawing flies, and maggots are eating its flesh.....

    Is there a problem with different people having different experiences? Or is it more important to be right? We're not all living the same thing, in nursing or personally

    Even if the ointment is not to prevent infection, the minute it hits the skin, it's contaminated and kissing up to impaired skin integrity. Even if it comes from a sterile container.

    Are all of the healthcare facilities in the US being negligent if they don't do what your employer endorses??? You guys (and the INS-- the beloved and omniscient INS) are the only ones who can absolutely do the best job? Even with no AEs on record to prove/disprove this? What about the people who didn't get some seal who are just fine? They don't count either ???

    It's not a competition. If it will make you feel better, I'll chew up a wad of gum and slap that puppy on my Hickman site

    Passion is a good thing- preaching- not so much
  9. 1
    Quote from agldragonrn
    nurses are spoiling the doc too much. everything is on the nurse yet the doc is the one who is making tons of money. i offered him the measuring tape and he told me he did not want to measure it and i'm expected to collect the catheter and measure and chart it? it's like some of the nurses at work who chase down the cnas to tell them a patient wants something when it could have taken half the time if that nurse just did that something for the patient.
    you don't have to over-analyze it and you are not responsible for supervising the physician in any way.

    this is what i would chart: picc removed by dr. jones.

    then chart how the site was dressed. i might write a couple of words if the site appeared to be red, the amount of bleeding, etc, but since you did not remove the picc, you are not responsible for how it was removed any more than you would be responsible if you were an or nurse of how a surgery was performed.

    dr. jones is responsible for charting his own procedures, not you.
    agldragonRN likes this.
  10. 0
    Quote from IVRUS
    Wow, "poorly substantiated practice recommendations".. Hmm.. You must think that INS has a bunch of uneducated "boobs" working and writing the standards. Sad. But you are wrong.
    The INS standards represent the scope of practice and offer evidence based criteria essential to the delivery of safe and competent care.
    Practice recommendations and standards of care are different, truly, but remember standards which read in part that the nurse "shall" carries a greater weight (Remember the 10 commandments?) than saying a nurse should do something. In a court of law, did the nurse comply with the standards, or didn't she/he? Without exception, these are the standards by which nurses are held to.
    Though reported cases of AE s/p PICC removal may not be published, that only doesn't mean it Hasn't happened, or couldn't happen. Remember that if a catheter's been dwelling for a long period of time, a fibrin sheath can become well defined. There is a documentated case of a CVC being removed and then 30 minutes later the man went out to smoke, with his first drag, deep inhalation of cigarette smoke, he also "sucked" in an air embolus which extended from the insertion site of the now removed PICC , to his lungs all along a strong fibrin sheath.
    A TSM is NOT sufficient in and of itself to seal the site and prevent an air embolism. You need a complete seal around the site, which is why a gel, and a TSM is needed.

    But, hey Muno, thanks for the lively discussion and WE can agree to disagree.
    Evidence based Practice Recommendations supported by no evidence would have a level of evidential support fairly described as "poor".

    That case of the smoker wasn't a PICC.

    Why is it you don't believe a TSM seals 360 degrees around the site?

    I'm still not clear if you're suggesting that Nurses should go against their facility's policies?
    Last edit by MunoRN on Jul 29, '11


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