~*RN*~

If anyone wants further info on how I made this work for an LTACH, both EJ peripherals & IJ PICCs, feel free to contact me Thanks.

Bob, I am also trying to find out what other companies are charging but am having a hard time. I will email back soon with pricing that I have found so far in my extensive searches. Liz Holowasko BSN, RN, CRNI

The LTACH I work at is great because of it being so small change can occur quickly. My other place of work, the University of Michigan Health System is HUGE and it takes almost 2 years just to get a policy read by the appropriate committee. So I truly value the intimacy of a small institution and being able to provide evidenced-based best practice shortly after it has been deemed to be best practice. So, when the position papers came out I brought everything to the medical director and she saw how this absolutely was best practice especially for our patient population and she told me to come back after the policies and procedures were written. I did that, revised our forms to include the EJ and IJ as vessel options as well as education materials, etc. She serves as my champion physician. After reviewing everything and making sure I was knowledgeable re: A & P, complications and interventions, etc (everything that was already laid out in the very long policies and procedures with numerous references) I was off to place my first EJ PICC. It went well but I definitely felt the valves! Then AVA's statement came out and it was like DUH! THIS is definitely best practice! So instead of the tortuous and valved EJ, PICCs were to be placed in the IJ for patients with chronic kidney disease or impending (i.e. verified by BUN, Creat, GFR, etc). I have now placed 8 of these and I have followed every single one like they were my own child. I am the only one who changes the dressings and if there are any issues I am immediately paged and notified so I can troubleshoot or do what I have to do. They have been a huge success! Patient's state they can't even really feel that anything is there except for right after the dressing change it can sometimes be tight. Each one has been treated as a "case study" for me as I have someone photograph the insertion and then I take pre/post PICCs with dressing changes and upon removal of the IJ PICC. Again, they have been exceptional for those patients requiring vessel preservation in the upper extremities and it feels great to be truly practicing cutting-edge evidence-based practice which more important than anything is best for the patient. As for the external jugular, it's an option for peripheral access in the right circumstances. After reviewing much literature it was made obvious that the IJ is by far preferred for PICCs over the EJ but that the EJ is an excellent option for peripheral access, again in the right circumstance and in the right patient. I give IJ PICCs a thumbs up.:)

Yes, sometimes those little buggers with end up in the Azyous vein which is not appropriate placement for a PICC since the Azygous vein is not "central" it;s like a bifurcation off the SVC. It looks like a check mark on the CXR. So yes, sometimes the PICC tip does end up in the Azygous vein and we have to readust is minimally to get it out of there and into the SVC.

Since the INS position paper re: EJ cannulation, came out in July/August 2008 in the Journal of Infusion Nursing once policies and procedures are in place and in accordance with your state nursing laws you are good to go. I do have a policy of the actual insertion steps...let me try to find it.

I would love to hear more about your PICC business as I am extensively looking into to starting my own in Mi. Any tips would be much appreciated. Thanks!

per the INS July/August 2008 V 31, n 4 edition of Journal of Infusion Nursing, the external jugular vein has been deemed "peripheral" as it does not break the intrathoracic cavity at the point of entry. Even better yet, as I am sure you are already aware of, AVA published their position paper re: the internal jugular vein and is appropriatness in certain situaitions (i.e. vessel preservation in patient with chronic kidkey disease, etc) and too being a peripheral approach at a central catheter. A small LTACH I work at I have implemented this program and it truly has been awesome to be able to place what is BEST for the patient. Educating them about their poor renal function and that I have no business traumatizing the upper arms veins (no matter how good you are...it's is still damage) because they may be needed for an AVF someday. It has been much more fluent of a transition than I thought,

I too an looking extensively into starting my own PICC consulting company. In order to order medical equipment it is necessart to start accounts with vendors (i.e. cardinal, bard, etc). They will look at your credit, negotiate a contract (i.e. you promise to give x amount of dollars to Bard in one year's time) and then quote you prices. So it is accounts through each vendor that are necessary for you to acually purchase medical equipment.

Yes, I work at a small LTACH in Lansing, MI and I have started a program which allows for the insertion of IJ PICCs (by me, BSN, RN, CRNI). These are small bore lines (4-5 fr and brought out to the clavicle making it much more comfortable and the dressing stays on well for the seven days. This is a small institution so change is able to take place faster. I brough the evidence-based articles from INS and then AVA and after writing the policies and procedures, proving that I had head & neck anatomy...I was off. These was instituted for patients with chronic kidney disease as a means of vessel preservation. I have inserted about 8 of them now, photpgraphing each and getting all the consents signed so that if I wanted to publish as case studies I could. This is what I am curently working on. It is a great option and doing cutting edge procedures which ultimately are in best interest of the patient is awesome!

Triple lumen PICCs are awesome! If I walked out of the ICU placing a single or double rather than a triple I would definitely get attacked by the nurses. They would be furious!:angryfire As you can imagine, the three lumens are great in patient who have a ton of meds running. I remember the first time I placed a Bard 6Fr TL PICC...the introducer scared me (it was so big). Now I have placed hundreds of them! Go get 'em!