Need some advice. My team has been having a recent problem with PICC infections lately. My question is when the cultures are coming back negative are the floors getting excited and pulling PICCs that are only showing a reaction and not an infection and how do we educate them on the difference. (they rarely listen anyway!) I know sometimes the only way to tell is to pull and culture but that is really distressing for the patient.
How long after a PICC is placed is it an infection from being placed? How long after placed is it infection from how the floor manages it or the fact the patient has a severe infection to begin with? We do not go back and do the dressing changes or cap changes at this time. (we want to but our boss wont let us). We also use only one person to start PICCs not 2 like most teams I have read about. Thanks in advance.
Are you saying that the PICCs are getting discontinued b/c of suspected infection and then the tip culture comes back negative or are you just getting a blood culture. First of all there has been tons of research on all types of CVC-related infections,including PICCs and there are some wonderful recommendations from a variety of sources. I want you to go to the CDC website and download the 2002 guidelines for preventing CVC-related infections. Not only will this educate you it will give you some ammunition for taking over the cap and dressing changes on these line. Research shows that when a dedicated team takes full responsibility for the care of CVCs (dressing changes,cap changes and site checks) the overall infection rate is decreased by 25-30%. That is a huge number. The CDC also has this as one of the highest recommendations!!
PICCS have a very low infection rate. So if yours is high or significant there is room for improvement. Early infection (within the first 10 days) usually can be blamed on insertion techniques. Later infections can usually be blamed on improper care. Are you using Maximal barrier precautions,a 2-step chlorhexadine prep,biopatch at site...etc. Also you should push for another PICC nurse for your assistant. An MD never places a CVC without one,why should you. In addition, the assistant can monitor for breaks in technique. It is also a huge time saving factor for the nurse and the patient.
The next thing to look at is the use and maintenance. dresiing should be changed whenever the integrity is compromised. Any dressing with gauze should be left on for only 48 hours,whereas TSM dressing can be left in place for up to a week. Are you changing all caps at least every week?Are the nurses using them performing a good cap scrub every time they access them?
Now for the cultures. In order for it be classified as a CRBSI the same organism must be cultured from the blood and from the distal segment of the PICC and they must be in sufficient numbers (greater than 15 CFUs colony forming units). You also have to make certain the nurses are culturing the tip correctly as skin contamination is common.
I could go on and on as I have been studying this for the last several years. I hope this is a start. Any more info you can give me and perhaps we could pinpoint the problem. let me know
Last edit by iluvivt on Jul 10, '08
Sorry it has taken me so long to get back. Been busy working. I remember from my PICC class(many years ago) that is can be common to have a reaction that can include swelling warmth and redness in the insertion arm in the first 24 to 48 hours after insertion. The recommendation at that time was to observe by measuring bicep every shift and documenting and using ice as needed to help with swelling and discomfort.
We have alot of concerns because we know the nurses on the floor do not even alcohol the caps prior to flushing most of the time and really dont care for the PICC properly after placement but we dont have any concrete proof. We try to document when we get reports from patients that tell us that the nurses dont do this but when we confront and educate they tell us they are doing it and the patient was mistaken or didnt see them do it. Half the time we know they arent even washing their hands when they walk in the room to give care!!!!
At a different hospital my girlfriend (a nurse also) observed the nurses enter and leave the room to get supplies while doing her mothers port dressing change and not even bothering to take their gloves off and put fresh ones on along with not washing their hands. Now talk about spreading germs.
Believe me...we are pushing for 2 to do PICC insertions but keep butting heads with our supervisor. I have gotten alot of information or should I say ammunition from this site!
I will check out the sites you suggested also. Thank you.
As for dressing changes we use a gauze dressing and change in 48 hours. We Chloraprep (which I usually do prior to PICC insertion and again before I apply the dressing just in case I inadvertantly contaminated something). We have asked for the impregnated one but so far havent gotten that either. Some days we feel we are running into a brick wall..literally!
Last edit by JOPICCRN5 on Jul 11, '08
: Reason: additional info