central lines protocols

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Just wanted to know how your protocols, practice, or experience is regarding central lines. What type of documentation do you get or expect after the line is inserted in order to safely start using it? Is it any different when it is a central line or a peripherally inserted central line PICC?

Do you get documentation about which vessel was used, the size of the catheter, how much heparin was used, and so on in both types of central lines? Do they write an order saying, "line ready to used" in either case and whether it is inserted at especial procedures department or at the bedside?

:confused:

Thank you for your feedback,

wrkoutg

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Specializes in Oncology.

The inserting doctor/PA rights a note saying which vein it's in and a brief account of the procedure, "After obtaining informed consent, left neck area numbed with lidocaine and a triple lumen temporary central line was inserted in the L IJ under sterile technique." Just that sorta thing. If u/s guidance was used, they'll include that picture. They right the order saying it's ready for use, and typically write ordered for it to be flushed with saline q12h and orders for TPA as needed. Each shift the RN just documents how the dressing looks and if the patient is experiencing any redness or pain at the insertion site. Central lines typically include a patient id card, which is stored in the patient's chart and sent with the patient when they're discharged if they're discharged with the line.

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piccs or central lines must have a chest x-ray after insertion. it is then read by either the ordering md, radiologist, or house md. then an order that it is alright to use is given.

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Thank you so much for confirming my expectations, my practice, and my arguments. I had a patient coming back from special procedures with a new TLC and no documentation what so ever!!!!!!

I was first "instructed" by my assistant manager and almost degrading my demands, expectations, and refusal to use the line until I got proper documentation and orders stating, "TLC ready to be used" I was told with a "funny" smile, "it is a TLC you don't need an xray, only when it is a PICC" I argued and argued pretty much what you guys responded. After I insisted on this the assistant manager "kind of" changed the response and starting calling the department but they were gone for the day.

In efforts not to endorse "the issue" to the next shift, I had the operator page the interventional radiologist on call. Boy, he told me off... well, he tried to. "It is understood that the line is ready to be used..., I have been here for 30 years and this is the first time I get a phone call like this..., do you do an x-ray or need an order when you start an IV line??????"

I insisted that he "allowed" me to write an order saying, "central line ready to be used". He agreed to it but showed to be very annoyed. I wrote the order and endorsed it to the incoming nurse and left it to his discretion.

I told my assistant manager the day after that if this is what our protocol is, it needs to be revised and changed...

Thank you so very much for your responses, wrkoutg

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Specializes in CCU MICU Rapid Response.

Well... I'd have a cxr done... you never know when one in the IJ snakes up instead of down!

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Specializes in Oncology.

I can't believe in my earlier post I put they "right" an order. Gah! Sorry, OT.

Ours done under ultrasound guidance don't typically require an x-ray, I believe. Most of them do get x-rays, though. I could be wrong. Our patients frequently get chest x-rays for other reasons, and the CVLs are commented on in those.

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PICCs should def have xrays if inserted by a PICC nurse. We used to have a PICC nurse insert at our hospital but now Interventional Radiology does that so I'm not 100 % sure about policy now. Reason being, among other reasons, for the xray, placement and mid-line PICCs can't be used for TPN (and other things I'm sure but I don't know offhand). TLC's I'm sure need an x-ray, but now that I'm thinking about it, I'm not sure about that either!!! I need a policy and procedures refresher!!

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Thank you again for your replies guys. I understand that it all depends on who inserted the line and where, at the bedside, x-ray must be done for heaven's sake or at special procedures, us guided, no x-ray needed. I am comfortable and opened to that concept. The problem I have with this is that nobody called me with report, there was N0THING written on the progress notes, no electronic or written orders, and no post insertion of central line form filled out, nothing, nothing, nothing, and nothing.

the nurse from special procedures brought my pt back and told me that they did a tlc instead of a picc because the pt's BUN and creat were iffy and the radiologist usually want to protect the arms in case the pts eventually need to go to dialysis. That was the only report I got.

I understand that if they did the procedure fluoroscopic guided they do know that the cath is in the right place, but I don't and I need some info. Would you not agree?

The day after when I charted my assessment of the TLC I felt unprofessional when I said, "right neck" as the site of the TLC instead of IJ or whatever.

Regards to all and thank you for your feedback.

Wrkoutg

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You are totally right. There should definitely be an MD order "tlc ok for use", "picc ok for use". I wouldn't have used it either without an order and I would have called the doc to for an order. Don't feel unprofessional saying right neck tlc instead of IJ or whatever....not a big deal!!! Kudos to you for doing the right thing.

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Specializes in Medsurg/ICU, Mental Health, Home Health.

I just wanted to add that during a code, you're not going to wait on that chest x-ray!

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Well, in a code it is totally different. To push drugs in a code you have an MD ordering what to push and when, so the order to "use the line" is right there during the code.

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Specializes in Vascular Access.
You are totally right. There should definitely be an MD order "tlc ok for use", "picc ok for use". I wouldn't have used it either without an order and I would have called the doc to for an order. Don't feel unprofessional saying right neck tlc instead of IJ or whatever....not a big deal!!! Kudos to you for doing the right thing.

I would not accept the Radiologist, or Rad. tech calling and saying, "Okay to use" that is NOT acceptable.

The main reason why this is not appropriate is that for many doctors of radiology, "okay to use" for them may be with the tip of the catheter in the right atrium. This is NOT acceptable according to Infusion Nurses Society (INS). The reading of the tip, and its blood vessel in which it dwells needs to be spelled out: PICC with tip in distal 1/3 of SVC/Cavoatrial junction (This is ideal placement). Or, tip in the SVC (middle or top) (Less ideal, but it happens). This is what a nurse needs the order to say.. anything else is unacceptable ie. tip in rt. atrium or if the tip stopped short and is in Brachiocephalic or subclavian..etc

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