PICC removal

Published

i work ltc and my job does not allow staff rns to remove picc even if we are iv certified. the md comes and removes them. the doctor came today and removed left upper arm picc from my patient. i gave him all the supplies (gauze, alcohol swabs, etc.) and asked if he needed the measuring tape because i know the catheter needs to be measured and compare with the original length. the doctor said no he does need it and he won't measure it. doctor removed picc and put dressing, and charted and left. then my supervisor came and i told him the picc was just removed by the md. he asked me if i had measure it. i told him no that i asked the md if he needed the measuring tape and he said no. my supervisor said it was my responsibility to measure the catheter and chart it. i told him why when it was the md who removed the picc and not me. plus he was the primary doctor. if i had removed the picc myself, then of course i would measure the catheter. i was not even in the same room with the doctor when he was removing it.

what do you guys think? this is the first time an md came to my shift (3-11) and removed a picc so i didn't know what to do.

thanks,

angel

Specializes in NICU, Post-partum.
I would never just look at the markings on a PICC and say.... Oh, it's all there... Some PICC's start their cm markings at the distal end, whereas others start their cm markings at the proximal end. Did you place 43cm? And is the PICC measuring 43 cm now that it is out? Okay, I'm cool with that. but how do you make sure the "tip is intact" as you put it? If you chart that very thing, you're setting yourself up for a losing lawsuit.

How did you determine that? Was a microscope brought to the bedside and you verified that the tip was intact?

Was the catheter cut at an angle, and now it is straight across...ooopppps.

And, unfortunatly, some of the markings, aren't easy to see, or decipher.

A 3fr IV catheter, has markings so timy, that ya' better have good eyes, or good bifocals to see them, heaven forbid I'm looking at a 1.9 or 2 french line.

For the Groshongs, thankfully they have a black tip which is how you know, it's all there!

The next time you pull one out...look CLOSELY at the tip...you will see that it is slightly rounded...that is how you know the tip is intact. If it is not it will look similar to the tip of an IV catheter...cut off.

No microscope needed.

If you are not checking the tip and just measuring it...then you are not doing your job (and in my opinion, not charting clearly) either because if just the tip has broke off you won't pick up on that if you just simply measure it, as the tip is too small..you have to LOOK at it. :coollook:

We chart the length it was put in, we chart what the length was when we started the removal and look to make sure all the numbers are there and chart, "PICC line secured at 6 cm removed with tip intact." In fact, this is the policy of how to chart it.

You are incorrect that charting "tip intact" sets you up for a lawsuit. The tip is THE END. That is pretty definitive. :nurse:

The PICC lines that we use in our unit, the markings are clear, so there is no question of where it is.

So that is why the MD didn't feel the need to measure it...because the tip condition is visible to the naked eye.

Up Vote Up Vote ×
Specializes in Vascular Access.
The next time you pull one out...look CLOSELY at the tip...you will see that it is slightly rounded...that is how you know the tip is intact. If it is not it will look similar to the tip of an IV catheter...cut off.

No microscope needed.

If you are not checking the tip and just measuring it...then you are not doing your job (and in my opinion, not charting clearly) either because if just the tip has broke off you won't pick up on that if you just simply measure it, as the tip is too small..you have to LOOK at it. :coollook:

We chart the length it was put in, we chart what the length was when we started the removal and look to make sure all the numbers are there and chart, "PICC line secured at 6 cm removed with tip intact." In fact, this is the policy of how to chart it.

You are incorrect that charting "tip intact" sets you up for a lawsuit. The tip is THE END. That is pretty definitive. :nurse:

The PICC lines that we use in our unit, the markings are clear, so there is no question of where it is.

So that is why the MD didn't feel the need to measure it...because the tip condition is visible to the naked eye.

Well, I too believe that the tip should be inspected, BUT, the tip is NOT always rounded my friend. Sometimes PICC's are cut to alleviate extra catheter outside of the IV site. And charting TIP intact is not appropriate.. IN a court of law, they WILL quiz you on how that determination was made. They will say... "and how is it that you were able to tell that the tip was intact?" "Microscope" etc. So, charting, "Tip intact to the Naked eye, tip straight across, or rounded, or angled" (not that angling is done that much) is a better way to chart it.

However, we can agree to disagree. :D

And, the MD didn't feel like he should measure it, because many MD's aren't infusion savy. Sad, but true.

Up Vote Up Vote ×
Specializes in NICU, Post-partum.
Well, I too believe that the tip should be inspected, BUT, the tip is NOT always rounded my friend. Sometimes PICC's are cut to alleviate extra catheter outside of the IV site. And charting TIP intact is not appropriate.. IN a court of law, they WILL quiz you on how that determination was made. They will say... "and how is it that you were able to tell that the tip was intact?" "Microscope" etc. So, charting, "Tip intact to the Naked eye, tip straight across, or rounded, or angled" (not that angling is done that much) is a better way to chart it.

However, we can agree to disagree. :D

And, the MD didn't feel like he should measure it, because many MD's aren't infusion savy. Sad, but true.

So how many times have you been sued over a tip? Just sayin'.

I only have to be responsible for the PICC's used in MY unit that I remove....not every PICC manufactured on the market. All of the ones in our unit have the rounded tips.

Intact...has a meaning. Intact means it is in it's original state. So if it comes out rounded out of the package and then comes out of the PATIENT in the same condition...that is the definition of intact.

Up Vote Up Vote ×

I've been blessed a lot with the health issues i've had, even though several have been life threatening.... but a PICC line, while being a central line, isn't major surgery to insert OR remove....it's not rocket science :) I've had nurses who removed mine be appropriately careful. I'm much more concerned about air emboli while the line is still in. It takes a lot of air for an air emboli...always been taught (for a LONG time) that it takes close to a full IV tubing (without extensions) to pose a serious risk.

With the PICC being as long as it is (vs a subclavian line), there's a lot more space with fluid in it (flushes, IV fluids, etc), and that's going to help with any tiny amount of air that COULD be in the hub of the PICC, during removal. My sites have always been covered and pressure held....never had a problem. A clot, then scab, forms pretty quickly. Unless I picked it off, pried the insertion site open, and blew with a tiny hose, my risk wasn't any big deal.:)

When I've removed PICCs, our protocol never included any type of ointment or goo to 'seal' the area. Ointments don't totally seal anything- just lube things up, or make a mess- lol.

Facilities I've worked for abandoned the antibiotic ointment after line removal (or during routine care) a long time ago, since the goo is just one more thing on the site that messes with any natural seal formed by the body. JMHO based on MY experiences.

Up Vote Up Vote ×
Specializes in Vascular Access.
I've been blessed a lot with the health issues i've had, even though several have been life threatening.... but a PICC line, while being a central line, isn't major surgery to insert OR remove....it's not rocket science :) I've had nurses who removed mine be appropriately careful. I'm much more concerned about air emboli while the line is still in. It takes a lot of air for an air emboli...always been taught (for a LONG time) that it takes close to a full IV tubing (without extensions) to pose a serious risk.

With the PICC being as long as it is (vs a subclavian line), there's a lot more space with fluid in it (flushes, IV fluids, etc), and that's going to help with any tiny amount of air that COULD be in the hub of the PICC, during removal. My sites have always been covered and pressure held....never had a problem. A clot, then scab, forms pretty quickly. Unless I picked it off, pried the insertion site open, and blew with a tiny hose, my risk wasn't any big deal.:)

When I've removed PICCs, our protocol never included any type of ointment or goo to 'seal' the area. Ointments don't totally seal anything- just lube things up, or make a mess- lol.

Facilities I've worked for abandoned the antibiotic ointment after line removal (or during routine care) a long time ago, since the goo is just one more thing on the site that messes with any natural seal formed by the body. JMHO based on MY experiences.

I too would be worried about air-emboli while in-situ, because if you had a non-valved IV catheter and the injection cap "accidentally" came off, or was removed when the syringe was removed, air emboli is a problem and concern. However, depending on the size of the PICC, or any CVC, their could be a track through the skin into the vein that stays open once the catheter is removed. That is why it should be immediatly covered with a gel to seal the track shut. The is not only common sense, it is an Infusion Nurses Society (INS) standard.

It should NOT, however, be used at the site for routine care.

If you didn't follow this standard and your pt suffered an air embolism as a result of this neligence, a successful lawsuit with you being the loser will result.

Up Vote Up Vote ×
Specializes in Vascular Access.
So how many times have you been sued over a tip? Just sayin'.

I only have to be responsible for the PICC's used in MY unit that I remove....not every PICC manufactured on the market. All of the ones in our unit have the rounded tips.

Intact...has a meaning. Intact means it is in it's original state. So if it comes out rounded out of the package and then comes out of the PATIENT in the same condition...that is the definition of intact.

Here is the defintion of Naivete: Lack of experience; Gullible.

Here is the defintion of Litigious: Subject to lawsuits.

Up Vote Up Vote ×
So would your boss have preferred you to dig through the sharps container looking for the PICC after the MD deposited it there???

Not blaming or anything, but next time, she might want to stay with the MD during removal or a procedure on her patient, especially as this is LTC. Doctors are few and far between, so just to keep up with the going-ons on your patient. And I'm sure the doctor would not have minded if you had requested he keep the PICC line so you could measure it.

It's team work, sometimes all this, "he should, you should, they should", Not my fault, not my responsibilty just bugs things down.

It should be " what can I do to make things better?"HOw can I help to make life easier?' It's more of the attitude.

You also got into trouble not because you were wrong, but because you did not follow policy. Each and every hospital has their own policy, when there is a policy, you should try as best as possible to follow it. There are rules to live by.

Up Vote Up Vote ×
Specializes in Wound Care, LTC, Sub-Acute, Vents.
well, you were truly "blessed" not to suffer an air embolism s/p removal if a 2x2 and bandaid is all they put on it!

well, this is what pretty much the doc did, 2x2 and paper tape.

Up Vote Up Vote ×
Specializes in Wound Care, LTC, Sub-Acute, Vents.
not blaming or anything, but next time, she might want to stay with the md during removal or a procedure on her patient, especially as this is ltc. doctors are few and far between, so just to keep up with the going-ons on your patient. and i'm sure the doctor would not have minded if you had requested he keep the picc line so you could measure it.

it's team work, sometimes all this, "he should, you should, they should", not my fault, not my responsibilty just bugs things down.

it should be " what can i do to make things better?"how can i help to make life easier?' it's more of the attitude.

you also got into trouble not because you were wrong, but because you did not follow policy. each and every hospital has their own policy, when there is a policy, you should try as best as possible to follow it. there are rules to live by.

nurses are spoiling the doc too much. everything is on the nurse yet the doc is the one who is making tons of money. i offered him the measuring tape and he told me he did not want to measure it and i'm expected to collect the catheter and measure and chart it? it's like some of the nurses at work who chase down the cnas to tell them a patient wants something when it could have taken half the time if that nurse just did that something for the patient.

Up Vote Up Vote ×
Specializes in Wound Care, LTC, Sub-Acute, Vents.
not blaming or anything, but next time, she might want to stay with the md during removal or a procedure on her patient, especially as this is ltc. doctors are few and far between, so just to keep up with the going-ons on your patient. and i'm sure the doctor would not have minded if you had requested he keep the picc line so you could measure it.

it's team work, sometimes all this, "he should, you should, they should", not my fault, not my responsibilty just bugs things down.

it should be " what can i do to make things better?"how can i help to make life easier?' it's more of the attitude.

you also got into trouble not because you were wrong, but because you did not follow policy. each and every hospital has their own policy, when there is a policy, you should try as best as possible to follow it. there are rules to live by.

i really didn't get in trouble. i was just given an "advice." and sometimes this supervisor does not know the p&p himself so i have to take his advice with a grain of salt. i looked at the p&p and there is no mention of removing a picc as staff rns are not allowed to remove it at my facility. i get the point. it is for patient's safety but if the md himself seemed not interested with the measurement why would it fall on the nurse. oh well, that's nursing!

Up Vote Up Vote ×
Specializes in Critical Care.
I too would be worried about air-emboli while in-situ, because if you had a non-valved IV catheter and the injection cap "accidentally" came off, or was removed when the syringe was removed, air emboli is a problem and concern. However, depending on the size of the PICC, or any CVC, their could be a track through the skin into the vein that stays open once the catheter is removed. That is why it should be immediatly covered with a gel to seal the track shut. The is not only common sense, it is an Infusion Nurses Society (INS) standard.

It should NOT, however, be used at the site for routine care.

If you didn't follow this standard and your pt suffered an air embolism as a result of this neligence, a successful lawsuit with you being the loser will result.

There seems to be this wave of fear-mongering lately on behalf of the INS, which strikes me as desperate attempt to force some credibility by threats where it hasn't been earned . Even worse, none of the threats seem to have any basis in reality.

Negligence is doing something that no reasonable person in that situation would do. There are many practice recommendations, particularly from the INS, where there is no overwhelming consensus and policies may vary from one hospital to another, which means there is no basis for negligence because you followed your facility protocol rather than a moderately influential practice group's poorly substantiated recommendation.

My facilities policy not only does not say to apply a gel after PICC removal, it specifically prohibits it. Applying a gel does not provide an occlusive seal. Imagine if you have a leak in a tire, would putting some vaseline on it seal the leak? Probably not. Another issue is safety; If there is an open track to a vein where the vein is exerting negative pressure into that track, is it a good idea to put vaseline in the track? Absolutely not, this (vaseline emboli) has been attributed to at least one death. Is the threat of air embolus following PICC D/C significant enough to support such a risk? Nope, there has never been a reported case of air emboli following removal of a PICC. Are there safer and more effective options? Yes, an occlusive dressing is far more likely to successfully occlude the opening, and it's unlikely that the dressing could be pulled into the vascular system. Occlusive dressings can be placed in one motion with removal of the PICC resulting in minimal time between removal of the line and occlusion of the tract. We don't allow vaseline soaked dressings either, these just make it more likely that the occlusive dressing will fail and provide no advantage over an occlusive dressing alone.

Up Vote Up Vote ×
+ Join the Discussion