Did I do the right thing?

  1. Hi all,
    I am a relatively new pediatric nurse. I just have a question about an incident that happened the other night at work. While changing a PICC line dressing on a 1 year old (yes I had help to hold the pt), the line came out maybe 1/2inch. I kept my field sterile and placed a sterile dressing on top, as I did not want to mess with the line further until the dr was notified. (the old dressing at this point had been removed). I notified the charge nurse and a call to the dr. was placed to get a CXR to look at line placement. The ER dr called me (our drs usually aren't in house at night) and told me that the line was "not in the correct placement." I specifically asked her if she recommended using the line, and she told me no. I informed the charge nurse and a call was placed back to the pt's primary dr to let him know. He didn't seem too concerned and told me that I could go ahead and use the line. First off, I felt very uneasy about this due to the fact that the ER dr said do not use the line. I told my charge RN what the dr said and she felt the same way. She told me directly NOT to flush the line or even mess with it.

    She told me at this point it would be wise to start PIV to give the Vanc until the dr could physically come look at the CXR in the AM. She started the PIV and the dose was given through that. When the dr came in the next morning he was livid. Needless to say, I got a call from my supervisor saying that they had to take the line out because it wasn't flushing or drawing since I didn't flush it on my shift. (I don't know how to feel about that either). She also said that my placing a tegaderm without a biopatch could have potentially infected the site..again I'm not sure but it doesn't sound right to me.
    My questions are:
    Was I right in placing the PIV (I went to the charge nurse and this is what I was basically told to do)? It just made me nervous thinking the dr that actually saw the xray told me not to use it. What if the pt had received the Vanc and it infiltrated?
    Is this something that I could potentially be fired for or would it be more of a "correction" type issue?
    Would the board of nursing back me on my decision in this case?

    I am just so scared about all of this. I did what I was told to do and then I got in trouble. I know ultimately it comes down to MY decision, but I took it up the chain of command (the charge nurse didn't call the supervisor at this point to ask her opinion). I just didn't feel quite right going with what the dr told me to do if that makes sense.
    Thanks for listening and thanks in advance for the advice.
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    About PedsRNinTX

    Joined: Jun '09; Posts: 1

    15 Comments

  3. by   EverNurseRN
    u are in the right on this one and I applaud u for sticking to your guns and doing what was best for the pt..u are their advocate. Did u document the er doc's order to not use? If so u should be fine!
  4. by   BrnEyedGirl
    I think you did the right thing, because that's what you were told to do, although I don't see why you shouldn't flush the line?? Even if you pulled a PICC most of the way out,..it becomes a peripheral line and I see no reason not to flush it,...but if the boss says not to then don't!
  5. by   Penguin67
    I've been a nurse for 20 years and many times covered a port a cath or CVL with just tegaderm, as biopatches did not exist then. I do not recall my patient's lines being infected. You did the right thing and I would ahve done the same thing.
  6. by   Keysnurse2008
    did you write the order for the er dr stating " do not use".
    " the order should have read " do not use picc until primary md can view and confirm proper placement"?
  7. by   mommiof2kids
    I would agree with the previous posts. You took the right actions by notifying the CN and the MD. Got an Xray to verify placement. The ER doc technically covers your patients and so that is who makes the decisions for you. As long as you wrote a verbal order stating that the PICC line shouldn't be used you're okay. In theory, the PICC line, if pulled out, does become a PIV. However, you can't gaurantee it's patency especially with Vanco infusing. I would have also started another line and used that until further notice. As for the biopatch...I've worked in facilties that have used them and those that haven't used them. I have not noticed any increased incidence of infection for lack of using. The risk comes from not using proper sterile technique. As for the doctor being "livid" he needs to get over it. You were protecting your patient from the risk of vanc infiltrating. He was not present, did not examine the patient nor view the xray. Don't take any crap from him. You did the right thing!
  8. by   LEM1234
    I think you did the right thing, absolutely. 1/2 an inch is a lot for a one year old's veins. The vanco could have "infiltrated" into the lung, right? That's why you wouldn't even flush it...because the PICC could be leading to the lung and you could fill the lungs with fluid...if my thinking is correct. And I'm pretty sure that if the tegaderm was sterile, then there's no increased risk for infection. I don't think this is going to come down to whether or not the board of nursing backs you up. Your patient remained safe and that's what matters!
  9. by   squirtle
    In my opinion, if you documented appropriately you should be fine. My only thought is that if it is your institution's policy to use a biopatch with a PICC, then you technically didn't follow it... I don't think you would have caused an infection since you did maintain sterile field, but policy is policy as far as they are concerned I'm sure.
  10. by   NurseCard
    I absolutely think that you did the right thing. I would not have felt comfortable using it either. I would have felt safer using a peripheral IV whose patency I could readily view and palpate.

    I agree, the doc just needs to get over it.

    There was no harm done. What about the patient's parents? Are they angry or anything?

    As for the biopatch.... I have no idea what that is. Where I used to work as a med-surge nurse, we had something that went on our PICC lines besides just the tegaderm, and I'm having a hard time remembering what it was called.. but it wasn't a biopatch. It was something that helped hold the line in place.
  11. by   Mulan
    Quote from LEM1234
    I think you did the right thing, absolutely. 1/2 an inch is a lot for a one year old's veins. The vanco could have "infiltrated" into the lung, right? That's why you wouldn't even flush it...because the PICC could be leading to the lung and you could fill the lungs with fluid...if my thinking is correct. And I'm pretty sure that if the tegaderm was sterile, then there's no increased risk for infection. I don't think this is going to come down to whether or not the board of nursing backs you up. Your patient remained safe and that's what matters!

    Why would it be in the lung? I don't understand what you're saying.
  12. by   wooh
    Actually have had this happen very recently. I finished the dressing change as normal. Because if it's in place, don't want to pull the dressing off just to finish it and risk pulling it out more. Besides, as long as it's possibly in place, I want to make sure that I do everything to prevent infection, and that includes the biopatch (if your hospital policy includes them.)
    I then went ahead and flushed it. If it gets pulled out some, it can still be used as a peripheral IV. You can give anything through it that you'd give through a PIV, and that includes flushing.
    Get a CXR, confirm placement. If it's not in place, confirm with the MD or whomever checks placement if it can be used as a peripheral line. The answer should be yes if it wasn't pulled almost totally out of the arm.
    Rule of thumb is do everything possible to keep that line in place and useful for as long as possible. Think through each thing you want to do or not do and think is the risk of harming the patient greater than the risk of losing the line?
  13. by   BrnEyedGirl
    I'm confused about how a PICC would be in the lung also,......perhaps the doc was upset because if you had flushed the line and kept it patent, the PICC could have been advanced and saved the kiddo another PICC placement. You were told not to use the line, so you didn't,...he needs to chill!
  14. by   mama_d
    Ah, the ages old nurse in the middle and getting all the blame scenario.

    I would have done the same as you did. I would have probably used the biopatch, although to be honest, if you maintained your sterile field the chances of infection from not using one, especially given that the dressing was likely to be removed in the near future and replaced if the line needed to be advanced, were probably slim.

    As far as it not working anymore, was that before or after they tried to manipulate it back into place? If they just left it in the same place, I would suspect that that could be the reason why it wasn't working, given that the ED doc said it was not in proper placement. Either way, the doc who actually looked at the CXR for placement is the one whose opinion I would defer to. Unless the other doc viewed the film from home before giving the go ahead to use the line...but I would hope he would have told you that he had looked at it before making the decision.

    In this situation, it might be in your favor to drop an email or other written account of what occurred to your NM, in an emotionless and factual way. Like instead of saying "dr. was angry" put something like "MD objected to the decision to not utilize PICC line despite prior orders from ED MD to not use line until CXR viewed by primary to maintain patient safety secondary to questions regarding placement of PICC." Be sure, if you do do this, to include all steps that you took regarding the decision and to maintain patient safety in this manner.

    Ultimately, yes, the kiddo did get another line. However, they also got their abx into them, and in a way in which there was no question as far as delivery into the right place. We are in no position to judge the risk vs. benefit of what the ultimate outcome was, which is why you deferred to a MD and then used that information to make your final decision, and why the docs need to take it up with each other if there's a discrepancy in opinion.

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