Respiratory Therapists Inserting PICC Lines

Specialties Infusion

Published

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, midlines, and US guided PIVs. My local INS chapter has not issued an official statement about this and my local AVA chapter is fully supporting this with about half of the members being RTs.

Any thoughts on this? Has anyone seen this in any other State?

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.

How could a busy RT Dept. possibly have the time for troubleshooting and maintenance of say 200 PICCS?

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.
Specializes in Oncology, Vascular Access.

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.

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?

Specializes in Critical Care, Emergency, Education, Informatics.

I'd have to say then that you must have only working in one very small place. I see respiratory or CardioPulonry doing A-Lines, Intubating patients. Assessing and recommending treatment for patients, having face to face discussions on best ventilator mode to use for a patient.

Any argument based on a we're better than they are premise, is missing the boat and degrading to both professions. Yes I used to do all my own breathing treatments, and chest PT, and IPPB machines, and I also used to have a 10-12 patient assignment. Now I have a much smaller assignment but much more to do with those patients. i couldn't do it without reap there to help in their specialty area.

In the last 2 hospitals I worked, One large one, and now a small one, the Bachelor trained RT's act as intensivist and lead rapid response team until I get there. Since a large percentage of crashes on the floor are cardiopulmonary that makes sense.

Can I do everything that they can do. Despite them saying things are out of my scope of practice, when they aren't. I CAN do all the individual skills. But I don't want to. I've got other things to do.

RT's doing PICCs are going to be driven by the market. I've been out of the PICC business for awhile now. It used to be if a nurse put a PICC in an inpatient, you couldn't bill for it. It was included in the basic room rate that included nursing. If this has changed I'd be interested in knowing. Resp can bill = greater reimbursement which equals more money.

This is one are that lindarn and I agree completely on. Until we change how we're reimbursed, nothing is going to change.

Specializes in Oncology, Vascular Access.

I can say no more than I have; I do not wish to reveal details out of concern for institutional privacy and reprisal. What I am warning is that institutions and individuals must check with the professional boards BEFORE "diving in." I invite anyone interested to look at the curricula in their respective states, and to READ their professional practice acts and rules and regulations. This step is imperative before permitting any new skill.

I HAVE ABSOLUTLELY NOTHING AGAINST RESPIRAORY THERAPY AS A PROFESSION. As I stated last time, within their scope, they save lives and are an invaluable part of the healthcare team.

And, no, RTs may not charge for this procedure, any more than nursing can.

Has anyone bothered to check with the Arizona BON to see if this is a protected RN task?

I was just at the latest Scope of Practice Committee for the AZBON. Arizona laws are a bit looser in regards to the medical world. There is no such thing as a "protected RN task" in the State of Arizona.

The Board releases "Advisory Opinions" on nursing matters and shuns giving those opinions on other professions.

I have never heard of, "Bachelors Prepared RTs". I have only known of RT being a two year program at a Community College.

This is interesting if RTs are increasing their entry into practice to a Bachelors Degree, and nursing is still allowing individuals to enter the profession with only a Diploma. What does that have to say about nursing?

I will bet, if RT goes to a four year degree program, there will not be the infighting, like in nursing, whether it should be a requirement or not. I will be that there will not be three entries into practice for RTs, if they increase their educational requirements.

It seems that all other Health Care Professionals are leaving nursing in their dust. If nursing does not get their act together, there will not be a nursing profession for us to fight over.

JMHO and my NY $0.02

Lindarn, RN, BSN, CCRN (ret)

Somewhere in the PACNW

Specializes in critcal care, CRNA.
I have never heard of, "Bachelors Prepared RTs". I have only known of RT being a two year program at a Community College.

This is interesting if RTs are increasing their entry into practice to a Bachelors Degree, and nursing is still allowing individuals to enter the profession with only a Diploma. What does that have to say about nursing?

I will bet, if RT goes to a four year degree program, there will not be the infighting, like in nursing, whether it should be a requirement or not. I will be that there will not be three entries into practice for RTs, if they increase their educational requirements.

It seems that all other Health Care Professionals are leaving nursing in their dust. If nursing does not get their act together, there will not be a nursing profession for us to fight over.

JMHO and my NY $0.02

Lindarn, RN, BSN, CCRN (ret)

Somewhere in the PACNW

There are 4 year and 2 year programs available. There have been 4 year schools for several years now.

Specializes in Critical Care.
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.

You lost me there.

Specializes in Critical Care.

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.

There is a difference between on the job training and foundational theory and practice, but RN programs don't provide any PICC insertion foundational theory and practice except for a relatively small amount of vascular anatomy. Typically, an RN beginning training to place PICC's is at the same starting point as an RT.

Publishing can be very political, although outcomes reporting isn't all that political, but the political nature of publicizing that data is exactly why I would expect to see any evidence that RT's produce poorer PICC outcomes widely publicized by any of the many Nursing groups that would benefit from this, but I have done my homework and there doesn't appear to be any.

In terms of maintaining PICC's, I've only worked in one facility where the PICC nurses actually maintained the PICCs (dressing changes, Tpa, etc), but even then that was only during baking hours.

Don't get me wrong, I'm very disappointed that we've been too inflexible to keep this arrow in our quiver in many instances, but while I'm a proponent of Nursing keeping it's role in healthcare, I'm more of a proponent of good patient care, and I've had too many experiences where a patient couldn't have a PICC line because it's 2:30 in the afternoon, so they have to get a central line placed only to have it replaced with a PICC the next day (so long as the next day isn't a weekend or holiday).

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