Respiratory Therapists Inserting PICC Lines - page 5

Here in Arizona several of the hospitals have started an experiment, they are actively replacing PICC nurses with RTs and calling them "Vascular Access Specialists." These RTs will place PICC lines,... Read More

  1. Visit  respstudent profile page
    0
    Quote from SoldierNurse22
    Right...I get that you guys do ABGs and that sort of thing as well, but that's at least related to RT. PICC line insertion...not so much.
    My conversation was meant to be humorous, although we did actually have a former director of nursing take a bunch of our procedures and protocols and re-assign them to nursing based on a similar argument.

    I do agree that RTs doing PICC and central line placement in general is unusual, and I personally don't want to have to deal with them. I have enough on my plate without having to worry about becoming skilled at yet another procedure with its own host of complications.

    It's not like I have time to learn PICC placement or much about IV therapy with all the Q4 nebs these residents are ordering all the time.
  2. Visit  Vascular Access RN profile page
    3
    So, I will tell you why RTs should NOT be placing lines. It is not within their scope of practice. Period.
    For nay-sayers, here is specifically why:

    1. Review their education process -- vascular access for intravenous medications is not part of the curriculum.
    2. Veins are scarred with every puncture, therefore, the least invasive access adequate to the task should be used.
    * Surprise! The physicians and bedside staff do not always know which catheter is up to the task. Each patient case a vascular access specialist is consulted on should be reviewed, based on patient history, co-morbidities, current intravenous therapy qualities such as pH and osmoality, and length of said therapy (to hit the big ones). NO where is this review possible within the scope of an RT's education and training. However, it is EXACTLY the practice of the vascular access RN.

    What do I believe will happen to WA and AZ et al states where RTs are performing these tasks? All it will take is one mistake leading to a bad patient outcome. Too much or too little catheter, an insertion error, an xray interpretation error on the part of the procedural RT. Any lawyer and legal nurse practitioner worth their salt will not only go after the RT and hospital, but also the State Board of Respiratory Therapist who allowed this practice to start!

    The problem is, that a patient, if not patients, will pay the price.

    That being said, specialized vascular access nurses may also error. However, the difference is they are working within their scope of practice (review nursing education and expectations). Therefore, the nurse's educational background and infusion therapy experience makes these mistakes much less likely, especially if she or he is specialized.

    Also, administrators need to WAKE UP to the fact that the least expensive care is always going to be that care which returns the patient to a functional state of wellness in the quickest manner possible (i.e. the BEST care for their targeted need(s).

    Can I get an AMEN?
    Last edit by Vascular Access RN on Sep 14, '13 : Reason: typo
    shirokuma, Tnbelle56, and lindarn like this.
  3. Visit  MunoRN profile page
    1
    Quote from Vascular Access RN
    So, I will tell you why RTs should NOT be placing lines. It is not within their scope of practice. Period.
    I think I'm missing your point because without additional training, placing PICC's isn't part of the RN's scope of practice either.

    There is some education required, although even when placed by RN's, it's typically the patient's primary RN that does the teaching. While I've had some PICC RN's do some basic investigation into what type of access the patient will need, in the end it's up to the primary RN if the Doc hasn't specified.

    The scope of an vascular access RN only exists due to specific training, it's the same training given to an RT.

    In terms of legal liability, there is no additional legal liability to having RT's place PICCs than having RN's given equal training.

    I do agree that it's unfortunate Nursing is having trouble keeping our monopoly on vascular access, but at the same time it's our own fault so it's hard to feel that any injustice has been done.
    Last edit by tnbutterfly on Oct 4, '13
    chare likes this.
  4. Visit  Vascular Access RN profile page
    2
    Yes, your are missing my point. 1. I have investigated the basic education curriculum for RTs education (in my state). THERE IS nothing close to venous access (even basic), the effects of venous access on the vessel, the effects of infusion therapy on the vessel, and on and on in any course description. 2. This is QUITE the opposite for RN education, with training in all these areas. Since the collegiate foundation is the basis for scope of practice, RT preparation falls sadly short. And, I do not believe it would be very difficult to convince a jury of this, especially with just a few facts.

    Furthermore, it is far less of a reach, based on the above FACTS, to extend nursing specialty in PICC and even CVC placement, than to offer the same to respiratory therapists. Also, I have been placing venous access in challenging patients for well over 20 years. While you may believe that the bedside nurse makes the final determination on the line that the patient will receive based on likelihood of best outcomes, you are sadly mistaken. This would be analogous to the primary care physician having the final say on the best chemotherapy regimen rather than the oncologist. Or, if you prefer, the general medical surgical nurse deciding the safest way to administer that chemotherapy verses the oncology certified, or vascular access certified, nurse.

    Also, do not think I devalue the role of respiratory therapy as a specialty. Their mastery of ventilator settings, patient response, and respiratory care makes them an INVALUABLE member of the healthcare team. I am sorry I did not state this in my initial remarks.

    Finally, while nursing sadly lacks cohesion as a profession, it is foolish and incorrect to assume that "it's our own fault." IF you are a RN who has had to fight political and administrative battles for the sake of patient safety, then you are aware of just what we are up against. I thought long and hard before posting my previous comments. I have valid reason to believe that the current course of events is a jeopardy to patient safety, and thus have stood up in what I believe to be a calculated risk.

    There comes a point where the individual interested in pursuing new avenues, especially within the broad scope of healthcare, must receive additional foundational training to be prepared to take on far reaching new challenges. Respiratory therapists do not receive the foundational training necessary to adequately choose appropriate venous access for a patient. Should the individual RT decide that he or she wishes to place venous access, they should seek the collegiate foundational training first, visa via, return to school in a discipline that does have such a foundation (licensed independent practioner-that is, PA, NP, MD, DO, etc. or yes, nursing school.)
    shirokuma and lindarn like this.
  5. Visit  manusko profile page
    0
    I'm sorry but its a skill and I could not tell you all the foundational training we received on IV access. We had a lab day and practiced on each other. I think I attempted 5 in nursing school and another 5 on my ICU. I really learned how to do IV and look for appropriate access during anesthesia school were I did well over 600 IVs. Now in my new job they want some of us to become PICC line certified. It's not OJT and required a certification. I do not consider specialty training of this type exclusive to nurses.
  6. Visit  MunoRN profile page
    1
    Quote from Vascular Access RN
    Yes, your are missing my point. 1. I have investigated the basic education curriculum for RTs education (in my state). THERE IS nothing close to venous access (even basic), the effects of venous access on the vessel, the effects of infusion therapy on the vessel, and on and on in any course description. 2. This is QUITE the opposite for RN education, with training in all these areas.
    Education on the initiation of IV therapy is actually often quite minimal in Nursing schools, particularly BSN programs which may not cover IV starts and other aspects of initiating IV therapy at all. You'll find numerous threads on this site about this subject.
    Just as some Nurses will need more education on this subject than others, so will RT's, but it's by no means insurmountable.

    Quote from Vascular Access RN
    Since the collegiate foundation is the basis for scope of practice, RT preparation falls sadly short. And, I do not believe it would be very difficult to convince a jury of this, especially with just a few facts.
    I'm still not sure what these "facts" are? Just like many RN's, RT's need significant training for starting PICC's, so long as that is done there's no real argument to be made unless you can show that there are more adverse outcomes when RT's place PICCs. RT's have been placing PICCs for many years, certainly there'd at least be a legal opinion you could refer to.

    Quote from Vascular Access RN
    Furthermore, it is far less of a reach, based on the above FACTS, to extend nursing specialty in PICC and even CVC placement, than to offer the same to respiratory therapists.
    For the many Nurses who received no training on starting PICC's or even IV's in school, it's the same amount of reach.

    Quote from Vascular Access RN
    Also, I have been placing venous access in challenging patients for well over 20 years. While you may believe that the bedside nurse makes the final determination on the line that the patient will receive based on likelihood of best outcomes, you are sadly mistaken.
    I have worked in numerous facilities and every PICC Nurse I've worked with has deferred to the primary RN or MD regarding the type of access required. If you take a more active role, that's great, but you're one of the few. For most PICC Nurses I know, what they like about it is that it's essentially a well paid tech job.

    Quote from Vascular Access RN
    This would be analogous to the primary care physician having the final say on the best chemotherapy regimen rather than the oncologist. Or, if you prefer, the general medical surgical nurse deciding the safest way to administer that chemotherapy verses the oncology certified, or vascular access certified, nurse.
    It's not like treating cancer; order for PICC with proper indications for a PICC, place a PICC.

    Quote from Vascular Access RN
    Also, do not think I devalue the role of respiratory therapy as a specialty. Their mastery of ventilator settings, patient response, and respiratory care makes them an INVALUABLE member of the healthcare team. I am sorry I did not state this in my initial remarks.

    Finally, while nursing sadly lacks cohesion as a profession, it is foolish and incorrect to assume that "it's our own fault." IF you are a RN who has had to fight political and administrative battles for the sake of patient safety, then you are aware of just what we are up against. I thought long and hard before posting my previous comments. I have valid reason to believe that the current course of events is a jeopardy to patient safety, and thus have stood up in what I believe to be a calculated risk.
    While I don't always agree with all of Lynn Hadaway's views, she is typically referred to as an expert in vascular access, and her view is also basically that it's our own fault. We've seen a growth in demand for all-hours PICC placement, yet Nursing has resisted that. Given the combination of union rules and the fact that most PICC teams are made up of high seniority Nurses, many facilities have found it near impossible to expand PICC services to after hours and weekends, which is one of the main reasons facilities have looked to RT's to meet these changing needs.

    Quote from Vascular Access RN
    There comes a point where the individual interested in pursuing new avenues, especially within the broad scope of healthcare, must receive additional foundational training to be prepared to take on far reaching new challenges. Respiratory therapists do not receive the foundational training necessary to adequately choose appropriate venous access for a patient. Should the individual RT decide that he or she wishes to place venous access, they should seek the collegiate foundational training first, visa via, return to school in a discipline that does have such a foundation (licensed independent practioner-that is, PA, NP, MD, DO, etc. or yes, nursing school.)
    So RN's who also didn't get this foundation in school have to go back to school to be a PICC Nurse? What school would they go to?
    Last edit by tnbutterfly on Oct 4, '13
    lindarn likes this.
  7. Visit  classicdame profile page
    1
    Has anyone bothered to check with the Arizona BON to see if this is a protected RN task?
    lindarn likes this.
  8. Visit  lindarn profile page
    1
    I have seen programs advertised in CEU flyers, that offer, "PICC Training". Nurses can learn it, and have their own business, placing PICC lines in hospitals, nursing homes, private homes where patients live.

    Hospitals really do not want nurses to be independant contractors, and have control over anything. They would rather train RTs to do a procedure that they should not be doing, to undermine nurses, yet again.

    Nurses were not, "socialized", to be. "business people", like other health care professionals are. The older nurses who resisted being on call to place PICC lines, were just not used to that mentality. I cannot believe that there were NO nurses in the hospital setting that were willing to be on a PICC team, if they were paid more for it. That is probably more the issue.

    This is especially true, as when RTs do an ABG, they fill out a charge slip, and charge the patient. If nurses do ABGs, it is a freebie.
    Go figure!

    JMHO and my NY $0.02
    Lindarn, RN, BSN, CCRN (ret)
    Somewhere in the PACNW
    Tnbelle56 likes this.
  9. Visit  Tnbelle56 profile page
    1
    Being a longtime PICC Nurse who works at a large inner city hospital, I believe anyone can be taught any type of procedure, including how to perform some minor surgeries.....IF things go smoothly. BUT, with people as sick as they are when finally hospitalized, many times things DO NOT go smoothly. Perhaps some life threatening arrhythmia, venous system anomaly, improper selection of device, malpositioning of line, incorrect interpretation of xrays, not knowing how to troubleshoot etc.....could cause a poor outcome. I think being a PICC Nurse, on close examination, is an art that requires hundreds of hours practice. Many think that if they can just imitate the procedure that they are a true PICC Professional. This is a fallacy. A good portion of my time is spent troubleshooting/maintaining existing PICCs on the floors. We have a less than 1 percent infection rate and great PICC outcomes.
    lindarn likes this.
  10. Visit  Tnbelle56 profile page
    1
    How could a busy RT Dept. possibly have the time for troubleshooting and maintenance of say 200 PICCS?
    lindarn likes this.
  11. Visit  chare profile page
    0
    Quote from classicdame
    Has anyone bothered to check with the Arizona BON to see if this is a protected RN task?
    Excellent question. I wondered when someone would bring this up. As a matter of fact, this was addressed by the Arizona Board of Nursing’s Scope of Practice Committee during their 7 June, 2005 meeting. The following is copied from the minutes of that meeting, which are available on line:
    The committee reviewed a request from ***** to develop an advisory opinion relating to respiratory therapists and the role of the RN in teaching respiratory therapists. After discussion, the committee did not feel a need for an advisory opinion on this matter as the Respiratory Therapy Board has approved this procedure to be within the SOP of a respiratory therapist, and nurses are frequently involved in instruction of other health professionals.
    Last edit by chare on Sep 24, '13 : Reason: Removed name.
  12. Visit  Vascular Access RN profile page
    1
    The comments regarding the nursing board response are correct; however, that is AZ. I am not in that state, and I am the ONLY person from my facility who contacted the RT board in my state when rumors about a blanket conversion arose. The RT board would not back the position of RT placement of venous lines. And, our team HAD formally asked for a night shift year after year. And, our team has had outcomes that would make any facility jealous for at least 7 years (that is how far back the data collection goes.)

    No, RTs may not charge for the procedure, although this may have been a theory in the past, upon further investigation they may not. And, though they may "flush a device" (NS for the purpose of patency is not considered medication by the FDA, they may not administer any IV medication. So, if they plan to maintain patency, they aspirate first, always. If not, they are reaching outside their scope of practice.

    The RT programs were complete take overs at many facilities. The RNs were showed the door.

    To MunoRN, do your homework. I have. There is a big difference between "on the job training" and foundational theory and practice. Please don't throw outcomes at me either. Publishing is a very political deal. And valid outcomes should be collected and interpreted by both internal and outside review. That is, end results reviewed and verified both by the department involved and another (quality, infection control, etc.) Also, outlying high risk or poor outcome incidences should be mentioned.
    lindarn likes this.
  13. Visit  chare profile page
    0
    Quote from Vascular Access RN
    The comments regarding the nursing board response are correct; however, that is AZ. I am not in that state, and I am the ONLY person from my facility who contacted the RT board in my state when rumors about a blanket conversion arose. The RT board would not back the position of RT placement of venous lines.
    I posted the link from the Arizona Board of Nursing as that was the state where the incident under discussion occurred. You have made several references to respiratory care education and scope of practice in your state; however have not identified which state that is. How are we to respond to your claims if you don’t provide this information?
    Last edit by tnbutterfly on Oct 4, '13

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