Central line insertion

[pet2012]

I recently worked with a nursr whose patient was having a central line placed by a resident. The nurse was not in the room during the procedure, nor was anybody else for that matter, except for the NA, who was in for a few minutes. Don't most hospitals have a policy, or is there a standard policy, that there should another person (like, a nurse) at the bedside to monitor the patient and assist with sterile technique during the procedure? I'm working on a brand new PCU that just opened two months ago, all new staff to the hospital, and the particular nurse is a new grad nurse (this is her first job) and apparently has not been on "orientation" for the past month that i have been there. Opinions?

[iluvivt, BSN, RN]

Yes! for best practice another licensed person should have been in the room. This person should have documented training on file verifying that they are capable of verifying that maximal barrier precautions have been followed and are educated on central line insertion procedures. A CLIP (central line insertion procedure) form should then be filled out that confirms that the 5 key aspects of max barrier have been followed. This individual is an empowered observer that has the authority to STOP the procedure if a break in technique should occur so corrective action can be taken. Are you in the US? I can tell you where these guidelines come from if you are interested. IT is also a good idea to have someone in the room to assist with the actual insertion,comfort the patient if needed and be present in case a complication occurs!

[CraigB-RN, MSN, RN]

Would have been a good idea to have another person in the room, but not a necessity. Having another person who can get things when needed, or help if things go wrong would be very beneficial. It's hard to to set up by yourself and to maintain aseptic tech by yourself.

As to being required. well the depends. There may be a hospital policy that spells out who should be in the room, but there is no law, or anything else that mandates. The last couple of hospitals I worked at didn't specific the number of people who needed to be present. A health tach could be the other person.

The above poster is talking about her hospitals implementation of the central line infection policy. This came out of the work from Dr Peter Pronovost at Johns Hopkins. It's the ideal, and by following this concept hospitals have been able to decrease their catheter related infections. One of the consistent things among the different implementation is a QI tool that collects data on the insertion. Documents content, tech, aseptic tech, etc.

Check out your hospitals policy and if you don't have one, take the bull by the horns and get one started.

[Penelope_Pitstop, BSN, RN]

When I did MICU, I was always present in the room during a central line or A-line insertion. We had an electronic checklist to complete (it was a CLABSI prevention initiative) and were also there to act as "circulator." As far as it being in "the rules," good question.

[Corey Narry, MSN, RN, NP]

I place central lines and arterial lines in the ICU. There was a time when most hospitals went on board with the recommendations of Dr. Pronovost's work as Craig mentioned and had strict implementation of RN checklist that makes sure that the sterility of the procedure technique is upheld. Some hospitals do not have that checklist anymore in their policy.

Typically, I request for RN presence when I place lines because one, time out's are required and must be documented in the procedure note and two, I sometimes need assistance with positioning of the ultrasound equipment and applying the probe cover. I don't insist that the RN is present the whole time I'm doing the procedure if they are busy. Whoever places the line must honestly write in their procedure note that handwashing was done and maximal barriers were used during the procedure.

[Here.I.Stand, BSN, RN]

Where I work, the resident is responsible for finding an observer; usually it's another resident. If they can't, I'll stick close to help position the sterile field, pouring sterile NS into the tray, and with thd u/s probe cover... but I don't completely interrupt my own nursing duties. If my other pt needs something I go to my other pt.

[PANYNP]

That would be the day that I would let *any* provider, resident or advanced practice provider, carry out an invasive procedure on one of my patients without my presence at the bedside!!!

What about sterile technique?! What about maximal barriers? What about attending to the patient during a procedure that carries the potential for injury (dropped lung), discomfort (numbing injection, covered with sterile drapes), etc and so on.

Talk about depersonalizing the patient. Talk about trusting a resident to know what s/he is doing!!? Geeze.

[bgxyrnf, MSN, RN]

Where I work, it's not strictly required. I'm always there at the outset but if the patient is alert, oriented, and cooperative - and the doc has everything they need, I don't just stand there waiting. That's not a value-added expenditure of time.

[KelRN215, BSN, RN]

We place central lines in the OR in children or sometimes in the ICU on sedated children so in those cases, someone else is always in the room. PICCs are placed by the IV RN without anyone else in the room for patients who do it awake or with just oral ativan.

[PANYNP]

You are under-estimating your value-added nursing presence for the patient.