PICC reaction vs infection

mrsbratmom · Jul 9, 2008

That is a hard one. We pull all of our lines, piccs, cvl's, etc. not the nursing staff so we get to assess the line. I would think infection form placement would happen within a few days but infection can be introduced at any point. With cultures being negative, why would they think a line infection???

JOPICCRN5 · Jul 9, 2008

Because in our hospital we are the easiest to blame and no one else wants to take the blame. It is a sad situation really and very frustrating. We have been trying for 2 years to get our team up and running. We average about 40 PICCs a month with 5 members on our team. But there is a big mistrust because we come from homecare and are not "hospital" employed. It has been a real struggle. :banghead:

mrsbratmom · Jul 9, 2008

Wow! I am sure that must be hard. We have had a team since 1973 so there are no issues with boundries for us. 40 piccs per month !! good job

iluvivt, BSN, RN · Jul 10, 2008

Are you saying that the PICCs are getting discontinued b/c of suspected infection and then the tip culture comes back negative or are you just getting a blood culture. First of all there has been tons of research on all types of CVC-related infections,including PICCs and there are some wonderful recommendations from a variety of sources. I want you to go to the CDC website and download the 2002 guidelines for preventing CVC-related infections. Not only will this educate you it will give you some ammunition for taking over the cap and dressing changes on these line. Research shows that when a dedicated team takes full responsibility for the care of CVCs (dressing changes,cap changes and site checks) the overall infection rate is decreased by 25-30%. That is a huge number. The CDC also has this as one of the highest recommendations!!

PICCS have a very low infection rate. So if yours is high or significant there is room for improvement. Early infection (within the first 10 days) usually can be blamed on insertion techniques. Later infections can usually be blamed on improper care. Are you using Maximal barrier precautions,a 2-step chlorhexadine prep,biopatch at site...etc. Also you should push for another PICC nurse for your assistant. An MD never places a CVC without one,why should you. In addition, the assistant can monitor for breaks in technique. It is also a huge time saving factor for the nurse and the patient.

The next thing to look at is the use and maintenance. dresiing should be changed whenever the integrity is compromised. Any dressing with gauze should be left on for only 48 hours,whereas TSM dressing can be left in place for up to a week. Are you changing all caps at least every week?Are the nurses using them performing a good cap scrub every time they access them?

Now for the cultures. In order for it be classified as a CRBSI the same organism must be cultured from the blood and from the distal segment of the PICC and they must be in sufficient numbers (greater than 15 CFUs colony forming units). You also have to make certain the nurses are culturing the tip correctly as skin contamination is common.

I could go on and on as I have been studying this for the last several years. I hope this is a start. Any more info you can give me and perhaps we could pinpoint the problem. let me know

iluvivt, BSN, RN · Jul 10, 2008

by the way what are you referring to when you say reaction...do you mean phlebitis?

JOPICCRN5 · Jul 12, 2008

Sorry it has taken me so long to get back. Been busy working. I remember from my PICC class(many years ago) that is can be common to have a reaction that can include swelling warmth and redness in the insertion arm in the first 24 to 48 hours after insertion. The recommendation at that time was to observe by measuring bicep every shift and documenting and using ice as needed to help with swelling and discomfort.

We have alot of concerns because we know the nurses on the floor do not even alcohol the caps prior to flushing most of the time and really dont care for the PICC properly after placement but we dont have any concrete proof. We try to document when we get reports from patients that tell us that the nurses dont do this but when we confront and educate they tell us they are doing it and the patient was mistaken or didnt see them do it. Half the time we know they arent even washing their hands when they walk in the room to give care!!!!

At a different hospital my girlfriend (a nurse also) observed the nurses enter and leave the room to get supplies while doing her mothers port dressing change and not even bothering to take their gloves off and put fresh ones on along with not washing their hands. Now talk about spreading germs.

Believe me...we are pushing for 2 to do PICC insertions but keep butting heads with our supervisor. I have gotten alot of information or should I say ammunition from this site!

I will check out the sites you suggested also. Thank you. :nurse:

As for dressing changes we use a gauze dressing and change in 48 hours. We Chloraprep (which I usually do prior to PICC insertion and again before I apply the dressing just in case I inadvertantly contaminated something). We have asked for the impregnated one but so far havent gotten that either. Some days we feel we are running into a brick wall..literally!

JOPICCRN5 · Jul 12, 2008

iluvivt.. i need to give you more info but am just really tired right now and not thinking clearly. I will try to gather more info and get back to this post. I work the weekend so it may be Monday. Thanks for your info.

iluvivt, BSN, RN · Jul 13, 2008

To JOPICCRNI I will also direct you to to the IHI (Institute for Health Improvement ) site. There you will find the save 100 thousand lives campaign/ A lot of their recommendations are based on the CDC recommendations. Believe me,I know how sloppy some nurses can be with vascular access devices. We leave a little cheat sheet on the Kardex of every patient that we place a PICC in . There are instructions on how to properly care for these lines. We also periodically audit a variety of these issues,including hand hygiene. We report offenders to the management team. The nurses must know you are serious. Also please join iv.therapy .net or peak in (I am Mary Ann on that sight) If you would like I can send you a sample of the cheat sheets I designed for the Kardex. Also.one study be Maki,showed that approx 40% of the infections from CVCs in that study were from the cap. So scrub the hub campaigns are just as important as hand hygiene. Educate the patient as well when you put the line in. If they are reporting to you that the caps are not getting scrubbed,they are telling you the truth. Any other questions just fire away and I can help or direct you to an answer.

iluvivt, BSN, RN · Jul 13, 2008

JO PICC. the reaction you described is a sterile phlebitis. I hope you are using Ultrasound to place your PICCs as this will virtually eliminate this complication. This is an insertion related complication and usually occurs early in the life of the PICC (ie.first 10 days). If you would like a copy of the cheat sheet...send me a private message with your E-mail and I will send thatto you

JOPICCRN5 · Jul 15, 2008

Thank you so much for your information. We are beating our heads against the wall with docs pulling our lines and not getting proper cultures. We even had one say he didnt care what the cultures came back as he still considered it a PICC line infection. :banghead: I do know all our tips we have been able to get cultures on have been negative. Yes we use ultrasound to place our PICCS. I wouldnt place one without it.. and when I first started we used to place without ultrasound. Nothing like poke and hope you didnt hit the artery. I am going to check out the websites you have given me and will also e-mail you for the cheat sheet. The nurses on the floor try to give good care but we are in a situation where we are expected to do more with less and it is frustrating all around. Thanks again. I have read alot of your posts and value the information you give. :nurse: I have directed some of my coworkers to this website also. Hope to see them on here.

As far as the maximal barrier thing I have not seen them come home from Iowa City, Des Moines, or even Mayo with one of those so would be curious to know who out there is using them and is it just for the first week or more?

accessqueen · Jul 21, 2008

When trying to differentiate if a PICC is infected, there is a test called time to positivity. BLood is drawn from the PICC, and also directly from a vein. Then the time to positivity is measured. IF a PICC is infected the time to positivity is faster by 120 minutes on the PICC culture. Unfortunatlely, it takes a special machine to do this and not all facilities have this machine. You may want to inquire if your facility can do this test.