Central venous catheter placement in the ED

[iluvivt, BSN, RN]

What does your ED do? We are a small IV team at a 320 bed hospital. We place 150-200 PICCS per month in addition to difficult starts,port access,all PICC dressing changes and issues,verify and confirm PICC tip placements,administer and read skin tests,draw blood if others unable can not,and any and all things related to infusion therapy, We have three nurses on per day in staggered shifts and two are always placing PICCs. The third nurse has the entire house and takes all new orders and does all the rest of the work. We also place all the PICCs in outpatient infusion and help them with any and all IV issues. we have one ultrasound unit Somehow ED expects instant PICC service.We all believe as does our director that they have access to an MD that can place CVCs. We take the order of course and then place the line when we can when they arrive to their unit or floor. It is also difficult to control the environment down there and to maintain maximum barrier precautions. What do other EDs do. Do you not place a CVC when you cannot get any other access and the pt will be admitted. They are even reluctant to place an EJ. W still can only do one at a time and the reality is that their patient is not always the most ill...bu they think b/c they are the ED they come first...even over critical care areas. How do other EDs deal with this......just curious...tx in advance

[WalkieTalkie, RN]

Our docs insert central lines in the ED.

[kmoonshine, RN]

We do our best to get a line in the pt.

We'll even go so far as to use an ultrasound machine to place a peripheral IV.

If a pt is stable but needs an IV and we're unable to get access, we'll send for a PICC. This rarely happens. We recently had a pt who needed IV fluids and had been throwing up at home. She needed a line for fluids and antiemetics, but no one could get a line (they tried for a good 2 hrs and whipped out the ultrasound machine too). So, we sent her for a PICC. She was stable enough to wait and her condition wasn't urgent that would justify attempting a CVC. There's all sorts of fun complications with CVC insertion, such as pneumothorax, cardiac dysrhythmias, etc. A PICC was a better option for her.

If they're sick, screw a PICC - we're going CVC. IF they're really sick, you know you'll be measuring CVP, giving meds to increase BP, etc.

[BrnEyedGirl, BSN, MSN, RN, APRN]

There is no such thing as an Emergency PICC placement where I work. If it's an emergency pop in a central line.

[iluvivt, BSN, RN]

Tx so much for your replies...my thinking exactly. It is simply a matter of volume......we do not have the nurses just waiting around to place instant PICCs. We are getting anywhere from 10- 14 orders per day. We are pretty fast for the actual insertion...but you have to add in good pre-insertion evaluation,pt consent and teaching and pre-scan the veins and then set up and do post procedure orders and clean-up. By the way we place a lot of triple lumens that are power injectable and capable of being used for CVP monitoring. I hate the fact nurses think we are lazy or asking too many questions...we are swamped and will not be getting help soon...we just triage and hang in there and we get caught up eventually...sometimes it takes us 2 days though. So why are the nurses so unreasonable and nasty when they are not first. The reality is we have limited resources...just like everyone else. I say if you want that kind of service you are going to have to have more IV nurses. So we look for the areas with other resources besides have everything dropped on our plate. If the patient going to OR and nurse can not get the line in and I am putting in a PICC by myself.....why can't anesthesia do it? Nurses have been rude all week and demanding. Same in ED why can't they help with getting lines in their patients? I think hospitals should have full vascular access teams with enough staffing to respond in a timely manner....vascualr access can be challenging and time consuming....let us have the help and staff to do it.....a little disgusted today!!!!!

[C-DIFF PHIL RN]

i've come to realize that doc's will try to pass off issues like that to other healthcare personnel if they can, unless there is sometype of decent reimbursement for it. but for the mostpart if they pt really needs a line jugular or central placement is done in the er, but if the pt is stable and say they just need fluids or antibiotics you have to pull their teeth to come try an attempt.

[kmoonshine, RN]

BTW: In the past 6 months I havent had a pt in the ED go for PICC placement. The other pt I spoke of (vomiting, needing antiemetics and IV fluids) was being taken care of by another nurse and is the only pt that I've seen go for PICC placement in the past 6 months during my work shifts.

Most of the nurses I work with are pretty skilled at IV access and we'll try to get at least something until a more reliable line can get placed. For example, we had a pt come to the ED for "seizures" by ambulance, and the pt had a witnessed seizure while in the ED. She had NO veins, and 4 other nurses had tried to get a line. I was the 5th nurse to attempt IV access and after 2 tries, I got a 24g in her upper forearm. Not ideal, by any means; but it was patent and worked just fine. We'd be able to use it to give ativan (or something similar) should the pt seize again, but I told the primary nurse "I woudn't give fosphenytoin through it". It was a temporary fix until something more permanent could be placed - the pt would probably need a PICC eventually, but not STAT.

We don't have an IV team at our facility. Difficult IV sticks on the floor call the ED for help. I love putting IV's in and I'm glad that I've had experience with hard sticks on a regular basis (I used to work at a facility where pts with ESRD on dialysis would come to the ED daily, or sickle-cell pts that had little veins left, etc). I love the challenge of putting in IV's!!! The only time I struggle with IV access is in peds pts; but for the most part, we (nurses) are self-sufficient with IV access in our ED.

[litbitblack, ASN, RN]

If the policy is that PICC's are not emergent how can they argue. IF they need iv access quickly and its emergent then they need to get a peripherel to work until a picc can be placed or the doc can place a central. Is there a doctor that is over the picc team. We had the trauma surgeon over the picc team and he agreed and they had there backup on that. They were also more than willing to come and use the doppler if none of the people that were usually able to get them could get them