Central Line Insertion

[haji]

I need some help with assisting with line insertion. It seems like half the time i assist with this procedure the md gets ****** off because I screw something up. So I thought I would list the steps and if anybody feels like adding anything I would appreciate it.

First I get a copy of our consent, make sure the md talks to the signee, and get it signed if the patient or family are able. Then I get the line cart which has most of the necessary supplies. Next I need to move the patient's ekg leads away from right IJ/SC insertion sites if that is where the line is going. Then grab some wrist restraints if the patient is confused, and maybe some versed/fentanyl as well. Put the patient flat. Wipe off the expected insertion site(s) with chlorhexidine. Get some transducer tubing ready to go with 500ns in a pressure bag.

Where I work the RN is also supposed to wear a sterile gown, mask, gloves and hat. Then the md needs help putting on the sterile gown. Is it acceptable to just tie up the ties on the back of the gown? Sometimes the doctors hand me a card and then they turn around tie it themselves. Which is the correct way to do it?\

they also put on sterile gloves and then pretty much I just hand them the needed supplies as they ask for them. They drape the patient with sterile drapes. Then they get the line ready to go with flushes. Sometimes they ask for me to squirt some saline into a sterile bowl. Then they use lidocaine to numb the area. After the line is placed they usually ask me to flush the lines and then we get chest film to check placement.

If anything here is incorrect or anything was omitted please mention it. thanks

[grandmawrinkle]

IDK where you work, sounds like a private hospital.

IMO you are doing way more than you need to. Attending physicians should be near independent with placing a central line unless the patient won't lie still.

If it's just me and the doc, I will help him locate supplies, position the patient, fasten his gown -- usually they want help with the flushes and the IV caps. Sometimes they will want me to place the dressing at the end which I am fine with. I have never worked anywhere that I have done the sterile prep for the doc. IMO they should be doing that themselves. I have also never worked anywhere that I have had to be sterile. Nurses are not qualified to "assist" during a line placement (I am excluding PICC nurses, etc.) -- just "circulate", which doesn't require sterility. Why are you in sterile gloves if you are doing all of the rest of this stuff? Do you stay sterile? That sounds like a silly policy to me.

I work with residents now. I get their stuff together and they pretty much do their own thing - I don't even stay in the room. The place I worked before I worked with hospitalists. They were really good and just needed minimal assistance like I already detailed -- I usually would stay in the room with them (not sterile) just in case something came up that I needed to do, or something got forgotten. This usually wasn't a big deal because they were in and out of there in 10-15 minutes.

[highlandlass1592, BSN, RN]

Lot of places I've worked are now requiring anyone assisting the doc to be gowned, hat, gloved (assist doesn't have to be sterile) and masked. If I'm not mistaken, TJC guidelines necessary to be in place to reduce risk of BSI.

[grandmawrinkle]

Lot of places I've worked are now requiring anyone assisting the doc to be gowned, hat, gloved (assist doesn't have to be sterile) and masked. If I'm not mistaken, TJC guidelines necessary to be in place to reduce risk of BSI.

This is true -- for the ASSISTANT. And it's not a TJC guideline, it comes from the CDC, the granddaddy of all the infection control people. In my facility (and all the ones I've ever worked in) nurses don't "assist". They circulate. We don't mess with the tray, the prep, the sterile field, or the insertion site. We obviously mask up and wear hats/gloves if appropriate.

It is not true that everyone that walks into the room to bring something in needs to be sterile. This doesn't even happen in the OR.

[meandragonbrett]

I hand them the line cart and say "Holler if you need me!" Not sure why you are having to do the prep? They should be doing their own prep.

Sometimes they might holler if they drop a flush or the biopatch.

My hospital does require EVERYBODY in the room to have hat, gown, gloves, and mask during insertion.

[in2ICU]

You pretty much covered it. As a tech I assisted in hundreds of central line and A-line placements as we do those quite often in my unit. Here are the details:

As for prep, the doc has already gotten consent so I just remind pt what we are going to do and explain it in lay terms. I usually turn the QRS volume to 2 on the monitor, position the bed so the doc can have access both at the side (SC) and from the head (IJ) and after prepping site put pt in trendelenburg. I put the bedside table in a handy spot along with a trash (placement of these also depends on which site the doc is using).

In my facility we have central line kits with everything needed except the triple lumen catheter and extra flushes. I start by putting out an extra gown and a selection of diff sizes of sterile gloves next to the hats and masks that are ready on top of the cart (they grab their own). Doc puts on mask/hat and pre-opens sterile gloves. I'm not sure how your supplies are put together, but I usually gather it all and put it on the bedside table and the doc and I go thru and open it as follows: I open kit and slide contents out on table, she/he opens the folded cover, grabs the gown and puts it on. I fasten the gown at the back of the neck (ties at waist left open) and then doc puts on sterile gloves. Inside the kit (under where the gown was found) everything is sterile and can be handled by doc in sterile gloves. Doc opens table drape, sets out supplies (from inside the kit) and I open the TL catheter packaging and let him/her grab what they need from it. I then sterile drop extra flushes onto the field. The doc gets everything in order, pre-flushes and caps the catheters (except for brown bc that's where the guidewire will come out), then we drape the pt (I only handle the outer edge of drape pulling down to feet). Next we put the sterile sleeve on the US probe (put jelly on probe, doc puts hand in plastic sleeve, I drop probe into that sleeve then pull plastic sheath back towards me to cover the cord where it touches the sterile field). After that, the doc gets started drawing up lidocaine (if using).

At this point, the doc is pretty much on his/her own unless they need additional supplies, adjustment of the US depth, or if the pt needs sedation. I always watch for PVCs when they put the wire in - sometimes they need a gentle reminder to pull it back a bit. The docs flush the lines and place the dressing when they're done.

[simvee]

I've assisted at central line insertion a bunch of times, even before I was an RN (I was an ICU tech), and that's pretty sufficient. As long as you are masked and gowned and protect the sterile field and items, what else do they need? And as everyone else said, a physician should be able to do this alone. Where I work they even expect first-timers to pretty much do it alone.

Also we fill out a tracking form (consent, timeout, guidewire counts, etc).

[dmc_rrt]

I say the Doc's retty lucky to have you there. I place femoral Central Lines and Have to get my own stuff together, and I am usually left alone, unlesss someone wants to watch. Tell him to quit his ********.

[iluvivt, BSN, RN]

In the US Joint Commission (JC) adopted the SHEA guidelines...so now for every central line placement and this includes PICCS ..requires maximal barrier precautions (hat mask gown gloves) for anyone in the room. A full body drape from head to toe must be used. For every CVC a CLIP form needs to be filled . As the assistant you need to verify that the MD has not had a break in technique and should have the power to stop the procedure should any occur..and then have him or her make the correction. The CHG must thoroughly dry before making the first venipunture. and make sure you do at least a 30 second scrub time it....I can get the exact wording for you if you want I have the compendium at work in my files . Yes you can assist as long as you are following all the guidelines