Published Aug 17, 2001
I work as a Home IV nurse as well as on a Hospital IV team. I frequently find that my home care patients are discharged without any information on the PICC ie length & tip location.
I have been careful not to initiate home IV therapy until I have verified tip placement with the hospital. I do this because occasionally I come across a line that wasn't x-rayed, I also have found lines that were x-rayed but the tip is in the atrium and no intervention was done. However, I recently was pressured by my supervisor that I need not insist on verification at home because if therapy was initiated in the hospital they would have checked placement, and the standard is to check placement prior to initiating therapy or if malposition is suspected.
I disagree with her rationale. I personally know of nurses who have no clue that placement must be verified prior to use. They ASSUME placement is correct when the patient returns form the procedure. I am not willing to risk my career on a misplaced tip.
Another part of the issue is what therapy is being given. If it is an irritant not a vesicant, or just long term therapy, how much does it matter? ie line does not need to be a CVC, midline would be appropriate.
Please give me your thoughts on the issue. I am seriously considering leaving home care because I feel a lack of support, and am put in situations I feel put patients at risk.
P.S. anyone who knows of any articles on this issue please let me know.
hoolahan, ASN, RN
Hi IVRN, I am not on the IV team at work, wanted to be on it, but they never gave me the orientation.
Anyway, I have used PICC lines in the hospitals, and central lines in critical care, and as far as I am concerned, you are correct. If placement wasn't important, why would cxr even be necessary? Obviously it is important! Though, I will say this, in the open heart unit I worked in, caring for infants after congenital heart defect repair, we gave all meds into a direct Right atrial chest wall line, which as the name implies is placed in the RA. We gave AB's, inotropes, everything, in codes all drugs went through that line, and if it was safe in babies, I assume it is safe in adults. These lines were extremely flimsy and delicate though, not like a larger line meant for large vein placement, so not sure if it is actually the tip that is the concern, irritating the atrial walls, or puncturing through the septum, etc...
If I were you, I would write to the IV nurses association. It's probably listed on this site under associations or just try http://www.ins1.org They would be the experts to consult. Sounds to me like your agency is just like any other agency, the bottom line for them is money. Time is money and doing all these safety checks costs them time, that you could do another case no doubt. Start keeping a log of all the referrals you get w/o x-ray placement.
BTW, is your intake dept asleep on the job? Why aren't they requesting a copy of the x-ray report along with the referral? They could save you nurses a lot of time by getting the info that is needed to expedite your job. NRSKaren has a good intake dept, maybe she can shed some more light on this for you.
Stick by your instincts, they are usually right, until you are proven wrong, with literature by clinical experts.
thanks for the feedback.
Regarding placement in the RA, the catheter is considered malpositioned if placed there. In adults this can cause arrhythmias, although reports of it are rare. I do not have much experience with babies, although I am getting more here and there.
As for the intake people; I work for a large HMO and all referrals go to a central intake team who forwards all IV referrals to the IV pharmacy where 1 person coordinates staffing for all IV cases, even if we subcontract the nursing. There is constant frustration related to miscommunication or delayed information, on the pharmacy end. And believe me that is well chewed on bone. I think bureaucratic bull is the culprit. So I have no idea how that could be fixed. I sometimes get called on the road to pick up a case and only have a name and an adress, with the expectation that the orders arrive with the drug delivery.
When I complain (which is often) nothing ever seems to come of it. I have already told my boss she is fairly close to losing an employee. The compensation is crap, and I'm killing my truck.
I tell you, I have already changed my specialty once to avoid quitting nursing altogether. I am no longer willing to tolerate bullshit for very long.
All I can do is voice my concerns and follow my principles, at least I have no problem with refusing to do something I feel is unsafe.
I will contact INS, I am a member, actually plan to sit for the CRNI exam soon. I also know a nurse who gives lectures on legal issues related to IV therapy, I took a class of her's once, I'll try to contact her as well.
NRSKarenRN, BSN, RN
Welcome IVRN94! Homecare can be frustrating when you don't have the information you need at your fingertips in the home.
From my 12 years of home infusion including several years subcontractor for different company's and 2 years taking referrals, my suggestions.
1. Does your intake IV forms have information space on it for insertion date, who placed line, verified by Xray with tip placement located where___ and PICC length. If not, suggest that it be added or the intake staff be given a crib sheet of questions to be asked re IV therapy referrals: Include flush information, catheter repair orders, declotting instruction and anaphylaxis kit,if first dose given already, needed labs Vanco/Genta/Tobra levels, SMA12 for TPN, etc. Does patient have a WILLING caregiver to assist in IV infusion? SAFE home environment with adequate refrig storage, electricity and running water?.
2. Look at Picc: was is placed in fluroscopy with large lumen or was it placed by RN's and steri stripped? If PICC placed less than 24 hrs before discharge would have more concerns re potential for problems than if placed 3 days ago. Ask PATIENT was continuous infusion or intermittent occurring prior to discharge? Answers to this questions will make you want to pay closer attention or get more info. If dissatisfied in any way, CALL REFERRAL SOURCE, but be aware you will most likely not get an answer after 4:30 PM!
3. Having taken IV infusion referrals, if can be like pulling teeth to get needed info from MOST referral sources...usually 2-3 calls minimum to get case started. HOUND the Nsg supervisor for her to make sure intake staff get info...my standard line was" If I dont get the info I need (including NAME of antibiotic/infusion, dose and frequency) then YOUR patient won't be accepted. Once you play hardball with your referral sources a few times, they get the picture and start having the needed info on first call OR they can choose to go elsewhere. Remember, they need YOU to get that patient quickly out of the hospital
Tried to get PICC standards online but unable to locate. Your concerns are valid...but the ideal. Often the referral source is unable to get the info as notes missing/absent especially if fresh line.
To solve problems, my one agency came up with standard form that was sent to Major referral sources with required info noted in BOLD type for them to fill out and fax to us or use as referral guide. If any doubts about patency/location, your judgement is BEST NOT TO INFUSE, even if it means return trip to ER.
Never forgot after I became supervisor at my last agency, my former boss known for her brief notes was subcontractor RN. She called up and chewed me out re patients home conditions for Q 8hr IVPB med----home was so filthy dog excrement covered entire kitchen and BR flooring---including the tub. PT. pronto back to ER and her documentation ONE page re home conditions. Hospital unaware... 2 sons in home oblivious!LOL.
Hope this helps.
Dear IVRN94, it's very difficult to work in homecare. I am a home care RN in Ontario, Canada! I have been doing this type of work for 7 years and I love it, but it can be very frustrating.
I have worked with PICCs. We do not receive any info regarding tip placement, ie x-ray, etc. Sometimes we might get some text telling us where it was placed and when! We generally get them long after they have been in use, but I do understand your point. We are told to always check for migration by measuring and of course we always check patency before use. This of course is not perfect. Because we live in a small rural town, most of our PICCs are inserted at a larger hospital 2 hours away - tracking down a doctor therefore is very difficult. You should never do anything that you are not comfortable with though.
I get concerned when they are left in just in case they might be needed then we end up spends months just maintaining the line! Once they're in, its hard to convince a doctor to take it out!
I once had to go and assess a PICC that the patient said was leaking. When I got to the home, the IV medication was leaking at the insertion site and collecting under the tegaderm. I immediately sent her to the Emergency department, where the doctor got upset for me being concerned and told me to continue using the line!!(?) I refused, but there were other nurses who did continue to use that line.
I agree with confirming placement, perhaps that could be a discharge criteria. I do not agree with a midline being adequate if the patient is not recieving vesicants. Midlines are good for 7 to 10 days only, and after the first couple of days it is not uncommom for them not to draw blood.
We deal with the odd PICC line in our Hospice work too. Thanks for all of your responses as I found them VERY informative. :)
Your supervisor would be changing her tune very quickly if a nurse didn't verify that placement has been checked and a pt had a negative outcome because the PICC was used anyway.
I only recently started home care. At my orientation I asked if we had to have positive proof of proper placement before using a PICC line. Oh no I was told. We don't give the first dose so if they used it at the hospital it must be okay. I come from the world of long term care where facilities get cited for using a PICC without a copy of the xray report stating the PICC is in the proper place and we never gave the first dose there either. I would not be comfortable using a PICC line unless I knew where the tip was.
From the other side of the bed pan: I was sent home with a PICC line because I was going to need IV antibiotics for 10 days total and I refused to stay in the hospital that long. I knew the tip was in the proper place because I asked to see the report before I was discharged, but when the nurse came from the VNA, she never asked about it. She assumed it was OKAY...mind you I hadn't had anything through the PICC line. They placed it at the hospital and sent me home. So, not only was she willing to give the first dose, she didn't apparently care where the line ended.
Needless to say, I informed her that I did have a copy of the fluroscopy report. Takes all kinds, doesn't it. (I can only imagine what she told her coworkers about me )
at the agencies i have worked with, the IV pharmacy obtains the xray report on all PICC's before they will send out the meds
DPH just exited my agency for survey. PICC lines were an issue for several reasons:
1.No documentation of correct placement
2.No documentation of how much if any the catheter had migrated out
3.No reconciliation of the length of the catheter that went in with the length of what was pulled out (doc. said 50cm cath....dc note said 40!)
4.No consistently written flush orders
5.Documentation of the site itself not consistently documented...
so.....there you have it
I just placed a PICC today and felt it went right in. I had absolutely no problems. An xray was ordered and to my dismay the PICC had been curled in the axillary vessel. I feel all PICC insertions must be determined by xray especially if your doing it without US guidance. I have placed PICC's for approximately 15 years and have never had this happen. I had left the hospital and was on my way back when the physician pulled the PICC with research I found you can reposition the PICC if you use sterile technique. Now the patient has to go through the procedure all over again.
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