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?

Specializes in Oncology, Vascular Access.

This is why I invite you to do the research for your state or any other about which you are curious. I know you cannot know anything about me personally from my posts, other than my spelling and syntax. In response to Nietzche's quote--I am hiding among the monsters.

Up Vote Up Vote ×

People seem to miss the fact that just inserting the PICC is not all there is to a "successful" PICC. What about the maintenance....monitoring lines for thrombus, de-clotting activities such as instilling such drugs as Activase, monitoring patients for catheter migration, monitoring lines for signs of infection, monitoring whether the catheter is in far enough for particular therapies, monitoring if the patient or nurse may have accidentally pulled it out and made it inappropriate for meds of certain ph, monitoring for catheter breakage and the list goes on and on. Medicare is now going to make the facility eat the cost of the PICC if they become infected while in house. How can an RT continue these time consuming tasks while continuing to work simultaneously as an RT? NO ONE can! And to the LPNs, I'm sure many successful PICC insertions are possible, but what are they going to do when an attorney gets them on the stand who has lost an arm due to complications of thrombus or line malposition? They will have a recognized "expert" such as INS to back him/her up stating that this is not "usual" practice of having them insert lines? The facility and the LPN will both be ripped to shreds and may take the rap even if the line was originally fine. Please tell the LPN to make sure she has lots and lots of that will cover her for PICC placements because believe me the facility will not take the full blame. She and her family's future are in jeopardy if this is not usual and customary practice. The same could happen to the RN if these lines are not being closely watched, but she may at least could have gotten some malpractice insurance that covers her.

Up Vote Up Vote ×

Pardon me for texting the attorney lost an arm (LOL!). I meant, of course to say the attorney was representing a patient that had lost an arm. Thought I had proofread that more thoroughly. And please pardon me for the run-on sentences!

Up Vote Up Vote ×
Specializes in Critical Care.
This IS practice at the many facilities in AZ where RTs place and maintain lines. The RTs first aspirate every device when they check patency (during routine maintenance or troubleshooting after insertion). They have to, as intravenous medication delivery is outside their scope of practice. It is believed (by those in charge) that this gets them around scope of practice violations.

I'm still not sure what this refers to. Are you saying that instead of flushing to check patency they have to aspirate then use to aspirate to flush? It's legal for them to flush with saline in states where they are allowed to place PICCs, plus NS flush isn't a medication, it classified as a device.

Up Vote Up Vote ×
Specializes in Critical Care.
I continue to be unclear, I suppose. ANy TECHNICIAN with ethics and a brain can learn to do a procedure and over repetition become successful at the procedure itself. Vascular access is more than that -- this is something no administrators recognize and only some nurses do. The RIGHT device at the RIGHT time is imperative to minimize lifetime scarring and damage. EVEN FOR SUCCESSFUL SHORT TERM IV PLACEMENT. This requires knowledge of infusate properties, catheter risk benefit ratios related to those properties, a host of underlying conditions, illnesses, co-morbidities, etc. THAT is why the RN foundational training is the appropriate one. The comment about LPNs also disturbs me.

I will concede that other disciplines may learn the task, and with an exorbitant amount of additional training, eventually be able to see the whole picture to drive the patient's insertion and care of the right device at the right time. I also believe that with the guidance and oversight of registered nursing or an L.I.P. (again, PA, NP, MD, DO, etc.) an RT can be taught to be an insertion technician. However, each case would need to be reviewed by a Vascular Access Specialist of the above mentioned appropriate disciplines for the right device.

"MunoRN" you keep assuming, which so many others do as well, that the non-specialized RN can make these determinations; or the non-specialized L.I.P. can do so. Vascular Access needs to be its own discipline. And, registered nursing is the only non "advanced" degree with adequate foundational education on overall physiological conditions, medication properties and delivery modalities, etc., prepared to be this specialized. Across the nation, healthcare is by in large doing our patients injustice with anything less.

I would be difficult to replace PICC Nurses with RT's if they actually did all that, but in general this is all done by 'non-specialized' Nurses (if there is such a thing). In every place I've worked and every place I'm familiar with how it works, the process goes like this; order placed for PICC, PICC Nurse comes and places PICC.

Up Vote Up Vote ×
Specializes in Critical Care.
People seem to miss the fact that just inserting the PICC is not all there is to a "successful" PICC. What about the maintenance....monitoring lines for thrombus, de-clotting activities such as instilling such drugs as Activase, monitoring patients for catheter migration, monitoring lines for signs of infection, monitoring whether the catheter is in far enough for particular therapies, monitoring if the patient or nurse may have accidentally pulled it out and made it inappropriate for meds of certain ph, monitoring for catheter breakage and the list goes on and on. Medicare is now going to make the facility eat the cost of the PICC if they become infected while in house. How can an RT continue these time consuming tasks while continuing to work simultaneously as an RT? NO ONE can! And to the LPNs, I'm sure many successful PICC insertions are possible, but what are they going to do when an attorney gets them on the stand who has lost an arm due to complications of thrombus or line malposition? They will have a recognized "expert" such as INS to back him/her up stating that this is not "usual" practice of having them insert lines? The facility and the LPN will both be ripped to shreds and may take the rap even if the line was originally fine. Please tell the LPN to make sure she has lots and lots of malpractice insurance that will cover her for PICC placements because believe me the facility will not take the full blame. She and her family's future are in jeopardy if this is not usual and customary practice. The same could happen to the RN if these lines are not being closely watched, but she may at least could have gotten some malpractice insurance that covers her.

I don't know of any facility where PICC Nurses are soley responsible for maintenance. Maintenance needs to happen at all hours of the day and week and usually can't wait to be first on the list tomorrow, which is why it's typically part of the primary Nurse's worklist.

No INS expert is going claim that it is negligent to have a properly trained RT place PICC lines. Lynn Hadaway is an INS "expert", and testifying in court is a big part of what she does, here is her view:

...I can not confirm that it is happening in 28 states but I do know that respiratory therapists are placing PICCs, other types of CVADs and have been doing arterial lines for a long time. If there state board or governing body in their state has indicated that it is within their scope of practice, then yes, it is legal. Radiology technologist are also doing PICC insertions. They would be required to follow the same Joint Commission requirements for competency validation as any others doing these procedures. This is happening because respiratory therapists were willing and able to meet the business need and nurses were not. Simple matter of who stepped up and said I will accept this role. RTs did in these situations and nurses did not. I do not think this should mean a competition between RTs and nurses. The group that is able to meet the needs of patients 24/7/365 and produce a track record of good outcomes is the group that should be doing it. Many times nurses have not been willing to do this. Or hospitals have not been willing to "allow" nurses to do this. Will a group of RTs that are employees of the hospital be more effective and produce better outcomes that a contracted service? This is yet to be determined. What impact will the new healthcare law have on these services? Yet to be determined. This can be a lesson though for many nurses on teams. Be willing to do the complete job at all hours. Don't leave until the correct tip location is confirmed and the job is finished. Track your outcomes, not just productitivy. In other words, know your rates of all complications, not just how many PICCs you are placing. Be able to support your practice with good outcome data. Or some other group who is willing to be there at all hours for all patients and keep the needed records could step in and take over. As you can see, it has happened. Lynn

—

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

Up Vote Up Vote ×

That is very true, the care should be ongoing, unfortunately not happening all the time. Ex: reported to critical care one am and nurses wanted lines activased on 2 vent patients that had been coughing quite a deal. I had the nurses obtain orders for a cxr on both and found they had both flipped up the neck. The staff and docs did not know this was possible. Both pts were on pressors and TPN. Strange things can happen.

The issue with RT should be a non issue if this is usual and customary.

But just wondering what kind of risk the LPNS in Indiana are taking.

Up Vote Up Vote ×
Specializes in Emergency Nursing.
That is very true, the care should be ongoing, unfortunately not happening all the time. Ex: reported to critical care one am and nurses wanted lines activased on 2 vent patients that had been coughing quite a deal. I had the nurses obtain orders for a cxr on both and found they had both flipped up the neck. The staff and docs did not know this was possible. Both pts were on pressors and TPN. Strange things can happen.

The issue with RT should be a non issue if this is usual and customary.

But just wondering what kind of risk the LPNS in Indiana are taking.

What risks would u be referring to when all three RN, LPN, & RT are inserting PICC lines? What advanced sterile/aseptic technique might be so far beyond a licensed professional's grasp?

Up Vote Up Vote ×
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I have worked in Indiana....while the LPN scope of practice for IV has essentially No specific laws defining scope. Nurses can "perform function that they are trained to do and those in which the facility allows them to do." I know of no acute care facilities that have LPN"s inserting PICC lines nor respiratory therapists.

Up Vote Up Vote ×
Specializes in Emergency Nursing.
I have worked in Indiana....while the LPN scope of practice for IV has essentially No specific laws defining scope. Nurses can "perform function that they are trained to do and those in which the facility allows them to do." I know of no acute care facilities that have LPN"s inserting PICC lines nor respiratory therapists.

Does not mean they are not out there. I never knew of any either until last year either. It is very nice to know someone can actually cite Indiana practice. It has been a huge uphill battle to convince governing bodies that LPNs can do so much more than they allow, given the chance.

PS- I absolutely love LOVE your doggy pictures. They have filled me with so much joy over the last year or two!

Up Vote Up Vote ×

Libran, I personally feel that an LPNs PICC technique, with practice, can be just fine. It's all the complications that can occur later such as massive thrombus, etc... We have such a litigious society. The attorneys would be combing through the chart for anyone's name associated with the PICC trying to blame someone. I would be very afraid for myself it was not usual and customary for my job grade to be inserting the PICCs. There are those here that are much more knowledgeable than me on this issue that hopefully can answer this question for us.

Just a couple of questions....how far in are the PICC tips placed by the LPNS...and who would administer Activase if needed?

Up Vote Up Vote ×
Specializes in Emergency Nursing.
Libran, I personally feel that an LPNs PICC technique, with practice, can be just fine. It's all the complications that can occur later such as massive thrombus, etc... We have such a litigious society. The attorneys would be combing through the chart for anyone's name associated with the PICC trying to blame someone. I would be very afraid for myself it was not usual and customary for my job grade to be inserting the PICCs. There are those here that are much more knowledgeable than me on this issue that hopefully can answer this question for us.

Just a couple of questions....how far in are the PICC tips placed by the LPNS...and who would administer Activase if needed?

That, my friend, is something you'd have to ask of someone else. The actual care for them is handled by the unit nurses after placement from my understanding.

I'm sorry if I come off as combative or defensive at times. I'm sure this happens much more than I mean it to.

Thanks for the replies. We are making great conversation.

It has also been my experience that people or lawyers, rather, go for the highest money maker when doing law suits. If a law suit were to arise from a placement, the RN/LPN/RT would/should have all the correct documentation to cover their behind. The only thing I can see is if it were trended that this nurse/RT had a reoccurring history or PICC infections . Then, given closer examination, the legal system could possibly point him/her out as having poor practice (as is my understanding).

Up Vote Up Vote ×
+ Add a Comment