Lines and tubes

Advanced Practice Columnist / Guide · Jul 19, 2016

I'm not sure if there is an actual text or manual for providers in skilled nursing facilities as there are for providers in hospitalized settings. I would say your best bet is to look for best practice guidelines that pertain to each of the "tubes" you encounter in the skilled nursing facility.

For instance, there is a multidisciplinary practical guidelines for GI access for enteral nutrition and reading through it, I would say the take home message for your situation is to be aware of late complications of PEG, G, and J tubes (http://www.sirweb.org/clinical/cpg/PIIS1051044311008505.pdf page 1099). It describes the usual site infection, site leakage and irritation, and to me probably the most annoying, is inadvertent tube removal. I would imagine you could get paged in the middle of the night about a resident whose PEG tube "accidentally fell out".

The important reminder here is that freshly placed PEG's that accidentally get pulled (i.e., within 7-10 days of placement) must be reinserted with endoscopic/fluoroscopic guidance because the tract is still immature, hence send patient to nearest ED. There is a case in California from way back where nurses in a facility reinserted a fresh PEG that was accidentally pulled without telling the provider and the tip ended up in the peritoneal space...definitely a no no.

PICC lines are basically central lines and are subject to the same scrutiny in terms of incidence of central line associated bloodstream infections by regulatory bodies. PICC's are also notorious for line-related VTE's. There are multiple guidelines out there in the care of central lines and PICC's in particular. They all have the same theme: prevention of infection and line related DVT which includes strict aseptic technique when handling these lines and removing them ASAP when the indication for having the line is no longer there. There is some disagreement in how to manage PICC related RUE DVT with some advocating for removal stat and starting anticoagulation.

There aren't many guidelines as far as long-term tracheostomy management in the literature. A lot of what's available is in the Respiratory Therapy journals. If your facility admits patients with trach's, your best friend is the Respiratory Therapist. Come up with a game plan with this person in terms of how to approach accidental decannulations and make sure nursing staff is comfortable in these situations. This can be a serious airway emergency in a SNF where there is little presence from staff who can provide an advanced airway. You may also need a policy for planned decannulation for patients who may not need the trach anymore.

Biliary drains are placed as a conservative management of conditions such as acalculous cholecystitis and they tend to be left in for a while. You would have to communicate with the surgeon from the referring hospital about how long they need to be in and when the resident needs to follow up. Again, accidental dislodgement will be you concern as you may get paged for this and the surgeon will have to be made aware if this happens.

I don't work in a SNF but as an ICU provider, many of our debilitated patients with these "tubes" do end up in a SNF at some point.

pro-student · Jul 19, 2016

In my experience, the person who ordered the line/tube is also responsible to write the orders pertaining to maintainance. As an RN, that was who got called if there we questions or problems. The only time, in my experience, that didn't happen, a PICC line was d/c after the course of IV antibiotics were finished. The provider who ordered the PICC and the abx, a surgeon in this case, was furious that she wasn't consulted for the d/c order as she was planning on continuing the abx after reassessing.

I dont know if this is common across the board or more regional. To clarify your responsibility in SNF patients it would probably be best to inquire with either the DON or medical director who would know what official policy as well as the usual practice of providers at the facility. Many facilities have policies/procedures for routine PICC care or g-tube ...

nurselove757 · Jul 19, 2016

I'm not sure if there is an actual text or manual for providers in skilled nursing facilities as there are for providers in hospitalized settings. I would say your best bet is to look for best practice guidelines that pertain to each of the "tubes" you encounter in the skilled nursing facility.
For instance, there is a multidisciplinary practical guidelines for GI access for enteral nutrition and reading through it, I would say the take home message for your situation is to be aware of late complications of PEG, G, and J tubes (http://www.sirweb.org/clinical/cpg/PIIS1051044311008505.pdf page 1099). It describes the usual site infection, site leakage and irritation, and to me probably the most annoying, is inadvertent tube removal. I would imagine you could get paged in the middle of the night about a resident whose PEG tube "accidentally fell out".
The important reminder here is that freshly placed PEG's that accidentally get pulled (i.e., within 7-10 days of placement) must be reinserted with endoscopic/fluoroscopic guidance because the tract is still immature, hence send patient to nearest ED. There is a case in California from way back where nurses in a facility reinserted a fresh PEG that was accidentally pulled without telling the provider and the tip ended up in the peritoneal space...definitely a no no.
PICC lines are basically central lines and are subject to the same scrutiny in terms of incidence of central line associated bloodstream infections by regulatory bodies. PICC's are also notorious for line-related VTE's. There are multiple guidelines out there in the care of central lines and PICC's in particular. They all have the same theme: prevention of infection and line related DVT which includes strict aseptic technique when handling these lines and removing them ASAP when the indication for having the line is no longer there. There is some disagreement in how to manage PICC related RUE DVT with some advocating for removal stat and starting anticoagulation.
There aren't many guidelines as far as long-term tracheostomy management in the literature. A lot of what's available is in the Respiratory Therapy journals. If your facility admits patients with trach's, your best friend is the Respiratory Therapist. Come up with a game plan with this person in terms of how to approach accidental decannulations and make sure nursing staff is comfortable in these situations. This can be a serious airway emergency in a SNF where there is little presence from staff who can provide an advanced airway. You may also need a policy for planned decannulation for patients who may not need the trach anymore.
Biliary drains are placed as a conservative management of conditions such as acalculous cholecystitis and they tend to be left in for a while. You would have to communicate with the surgeon from the referring hospital about how long they need to be in and when the resident needs to follow up. Again, accidental dislodgement will be you concern as you may get paged for this and the surgeon will have to be made aware if this happens.
I don't work in a SNF but as an ICU provider, many of our debilitated patients with these "tubes" do end up in a SNF at some point.

Juan,

I read the whole thing and I understand now what direction I have to take from now on. Thank you so much for taking the time out to explain this to me. It means a lot to me.