PICCs in LTC

CoffeeRTC, BSN, RN · May 11, 2006

What is the staff saying is the cause behind them flling out? Is it the staff...poor dressing change technique, poor management of them? Or is it the residents them pulling them? Sometimes no matter how hard you try to keep them up, the demented res will pull them.

Seems like a lot to go thru for the line placement etc and having them be pulled out. What about a midline cath? or evaluating the need for the med in the first place.

Whats the average length they are kept in?

Trust me..I work with some very difficult residents...it can be very frustrating, huh?

CritterLover, BSN, RN · May 11, 2006

what is the staff saying is the cause behind them flling out?

oh, usually i'm told that the resident pulled the picc out. though one lady's roommate told me that it had been therapy, not the patient, who had pulld the line out. i know one resident in particular pulled her's out, because she told me she was going to do so ("if that thing hurts my arm, of course i'm going to take it out")

of course we'll never be able to keep them all in....but i think that i've had 3 not come out, and that is getting pretty frustrating. not to mention that they are much harder to place the second time around.

my thoughts are that it is a multi-faceted problem: therapy and ancillary staff arn't used to the piccs, and i'm sure some come out during bathing/dressing and therapy exercises, plus the lack of restraints allowed in most ltc places (not that lack of restraints is necessarily a bad thing...), and the relative long duration of therapy that most ltc picc patients have (6wks or so of abx).

Ms.RN · May 11, 2006

what are the health risk of picc line pulled out unintentionally? are there a life threatening risk? i had a patient whose picc line was partially pulled out, about three centimeters? does it have to be pulled out immediately?

CoffeeRTC, BSN, RN · May 12, 2006

Sounds like these nurses and cnas need some inservicing. These things just don't pop out and throw themselves on the floor. Poor transfer, bathing and dressing technique is how it looks. Restraints are totally not necessary.

Daytonite, BSN, RN · May 14, 2006

Our IV team used to tape and secure the lines to the upper arm rather than the forearm when this was happening. Seems like IV's taped on the forearms of careless patients/caregivers are less likely to get yanked out when they are hidden on the upper arm. You could also try taping the tubing more toward the medial side of the arm rather than the lateral side for more protection.

wooh, BSN, RN · May 14, 2006

Are you using stat locks with them? We use them on kids, and they work great. Staff might also need to make sure they're using two people for dressing changes, makes it a lot easier (of course in LTC, it's hard to find two free staff members at a time isn't it?) I'd recommend stat lock, taping up towards the upper arm as was said above so they aren't constantly in the pt's line of vision, then covering with stockinette.

But as was said above, LTC patients as a rule aren't known for their compliance!

CritterLover, BSN, RN · May 16, 2006

what are the health risk of picc line pulled out unintentionally? are there a life threatening risk? i had a patient whose picc line was partially pulled out, about three centimeters? does it have to be pulled out immediately?

in general, there are few health risks to accidental removal of a picc. the worst possible complication would be picc fracture, meaning that the picc broke apart and not all of it came out. this can cause a mechanical pulmonary embolus. slim-to-no chance of this if the catheter comes out easily. otherwise, mostly just complications from the picc being pulled without pressure being held at the site to control bleeding (hematoma, bruising), if there is any bleeding to begin with. most of the time, there are no complications.

if a picc is partially removed, it is always best to not remove the rest of it. leave it in place and get an xray. if the tip is still in the svc, it can still be used without problem. if it is no longer in the svc, let the person who placed it know so they can come assess it. with a few exceptions (such as the groshong picc, which has valves at the end), piccs that have been partially remvoed can be replaced using a wire exchange, which means the patient doesn't have to be re-stuck.

in general, piccs are very safe, which is why you are seeing so many of them in ltc.

CritterLover, BSN, RN · May 16, 2006

are you using stat locks with them? we use them on kids, and they work great. staff might also need to make sure they're using two people for dressing changes, makes it a lot easier (of course in ltc, it's hard to find two free staff members at a time isn't it?) i'd recommend stat lock, taping up towards the upper arm as was said above so they aren't constantly in the pt's line of vision, then covering with stockinette.
but as was said above, ltc patients as a rule aren't known for their compliance!

yes, we are using statlocks....sometimes i even use two. i always secure the picc to the inside of the upper arm (this is also almost always where i place them -- basilic vein of the upper arm, which is in the inside, usually about 3 inches or so above the ac space). do you thing the staff at the nursing homes are changing the securement to the forearm?

sometimes i wish we were suturing them in place, instead of using the statlock. i bet we'd have alot less problems with them coming out. but i really don't want to be the one sewing them in....

anniev · May 16, 2006

I work in LTC 99%,Resident pulls out themself confused, dementia , combative we will wrap, use hand mitts ,what every the Dr allows but we are restraint free facility, it is the state of Ohio laws so we can't tie down an arm to prevent it but when you have 25+ residents to take care of and if you are lucky 2 STNAs for your shift you can't be there with that person the whole time we don't like it either I hate putting the poor little confused fragile lady thru the PICC either but it is usually after many attempts with peripherals that will not stay either it's a last attempt to help them. I would love to see them last also .

indigo girl · May 16, 2006

The biggest problem I see is not staff being careless, it's patients, primarily, the demented, pulling on them.

TBLPN, LPN · May 20, 2006

PICCs have become a popular item in the LTC facility I work at these days. One lady in particular, just had hers replaced, because it occluded, but she is also a retired nurse, confused, and thought she would help us out a bit, by pulling and tugging on it herself. She informed the staff that she was capable of caring for her own line............although, in the next few minutes she was wrapping her IV tubing around a plastic cup. You know, because it was the right thing to do. As far as PICCs just "falling" out in LTC setting, rarely the case. I will admit, the CNA issue in transferring and daily care plays havoc with a PICC. They don't know the meaning of the word "easy" putting on that sweater.............I also think that the lines aren't flushed properly when we aren't running anything............therefore, occlusion. I also work in a restraint free facility, and keeping some of these older folks from pulling and tugging is almost next to impossible.