picclineman

Thanks for the passionate response. I definitely appreciate it. I see where you are coming from. I am just trying to understand where a non IV nurse come from, how they rationalize there actions and so i will know how to help them. I respect their reasoning. There are a lot of policies that just doesnt make sense just like a lot of other nursing policies are purely out of this world. I would like to discuss this issue further, because i can see where the nurses come from. If we can make sure that the 15 second scrub is followed we can make sure then that the hub is clean and so looping would be okay. how about we do a research!! I can see why not!! When a nurse disconnects the IV tubing from the PICC, cleans the hub of that IV tubing vigorously, 15 20 secs, leaves it to dry and loopes it, that would clean that site. Wouldnt this be same as disconnecting the IV tubing, cover the end with a sterile luer lock and the next time the nurse accesses the hub of the PICC, clean it with 15 sec scrub and reconnect. The issue then is the nurse cleaning the hub vigorously , leaving it to dry before reconnecting it.. I have observed amongst nurses myself, and my observation is huge and varries with type of nurse because i see nurses at general hospitals, nurses at acute long term hospitals like ventilator hospitals, nursing home nurses. There are a few nurses that scrubs the hub of the IV tubing or the hub of the venous access before they connect a syringe or an IV tubing. I think the issue is cleaning as opposed to where it is connected. Otherwise if the issue is disconnecting and reaccessing again, and not sure if the nurse scrubs the hub,then the solution is use IV tubing one time and discard. This way , the nurse does not have to worry about contamination. This is a huge issue!!! wouldnt you agree? I do not easily give up.. I will continue to research on this issue. i read lynn's site and she says the same reason why looping is not favorable. She is afraid nurses dont clean the hub vigorously. IVnet had something about the topic but has the same reasoning. I hope you dont shy from sharing your ideas in the future. Thanks a million...

I think i also know what you have just lectured me on. I have a CRNI certification and familiar with the INS Guidelines. I appreciate your lecture. What i was looking for was a rationale why looping would not be acceptable if the nurse does the 15 second or whatever second scrub rule, is used. If you really think about the whole practice of infection prevention, we are trying to implement a system that would achieve the goal of eliminating infection amongst central line. What you are telling me is YOUR preference. My nurses are asking me these questions and i kind of understand them. I always assume that there are more intelligent people than me out there even if they were not IV nurses. Again i will ask you, do you know of any research that proved that using the sterile end cap has a lesser infection rate than cleaning the hub of the IV tubing using the 15 second scrub rule then immediately attaching the male luer of the same IV tubing. If i can show this to them, i would have a more convincing rationalzation. Just because i am a certified infusion nurse, member of so and so organization, to me does not mean i know everything, i might know a lot but not all would be convincing. Just like what you are telling me now. I do not mean to argue with you on these points. The help I am asking out there is IF THERE WAS OR IS A RESEARCH ABOUT USING THE END CAP VS LOOPING AS AN EFFECTIVE WAY OF LESSENING INFECTION AMONGS CENTRAL LINE. I have read an article oN the site of LYNN HADAWAY ( I am convinced she is an authority on Infusion Nursing) and she mentions that "looping" is unacceptable HOWEVER, she also does not give a rationalization as to why looping is not acceptable. BRAUN company also suggests use of sterile end cap and i undestand why they would want it. Its more sales for them. Again, to all the nurses who would like to help me out on this topic, i appreciate all your help. What I am looking for is a research.

I realize it is an unacceptable practice, however i have not found a good rationale why it is unacceptable. When nurses clean that injection site using the 15 seconds scrub, leaves it to dry before flushing it and it is found acceptable, why not looping,if the same injection site is thoroughly cleaned before the male luer of the same tubing is attached. It has the same reasoning, right? You know of any research done on this area? I also realize that we IV nurses being in this field for a long time have a lot of bright ideas, however they remain ideas until it is proven correct by a research and is written as a policy. I am a hospital contractor doing PICCs for 8 hospitals and nursing homes. I do teaching too. I have so many ideas but no research so my ideas remain as is. As you know registered nurses are intelligent people and i find it hard to just tell them to follow. There is a common rationale they tell me.. " it is my license" and me being an outsider and have business interest have to be really careful i dont offend anybody. Thanks for you input..

i need some help from the expert infusion nurses. There is a habit i notice from a lot of nurses regarding IV tubings. After disconnecting the IV tubing from the access, i.e PICC, the tip of the tubing is reconnected to one of the hubs of the same IV tubing. I have read this in the infusion nursing book, in an article and forgot the name of it. Can you please help me out.. Thanks a lot..

You can use a sterile glove to cover the transducer with gel on it.. You also use saline flush vs sterile gel, it gives you the same clear picture of your veins...

Has anyone taken the Vascular Access, Board Certification exam? Were the questions really for a board certified vascular access professional?

In the 15 years i have done PICCs and midlines, i have used PICC catheters and trim them to become midlines per INS definition. The PICC catheters are trimable catheters , so i do not see any reason why not. Of course, your rep is going to tell you not to trim their PICC catheters because they need to have more sales... Except if you use a groshong double lumen you cannot trim the catehter. If there is any research out their, i have not encountered any. How are my patients, i have had no adverse report so far. I know, once i had a discussion with another nurse who told me that i should not be trimming the PICC catheter becase she says her rep told her to order midline catheters. She told me that the label of the PICC catheter says PICC Not midlines and this will cause nurses to mistakenly use the line for a vesicant. I said then the nurses should make sure they look at at the kardex or the nurses notes of the person doing the procedure for the tip position or better yet, look at the chest xray film..

That is an inservice in and of itself. Thanks

The pharmacy that provides IV infusion products usually have their own IV nurses as employees. They earn a salary much like working in a hospital. Most hospitals have their own vascular access team. It is extremely difficult for us registered nurses to get a contract with a hospital.My experinece is that you have to be known to some doctors who can recommend you to the hospital administration of the hospital. If the hospital is big enough, they will tend to form their own vascular access team. The injection business that you are doing now, are you an employee or doing it as a contractor? Going into business has a lot of downside but is rewarding too. If you hate hospital work as i do, you will love it. If you expect money every two weeks like working as an employee, dont do it. I would advice you to do it part time. Keep a full time job and do your business on the side until you grow your census and survive on your own. Keep one foot in the hospital cause you might loose all your contracts and it is difficult to get back once you are out. I hope i am able to give you an insight of someone already inbusiness.

I think the best way to do it is to take the nurse practitioner program and concentrate on interventional radiology where your internship will be in interventional radiology and concentrate on IR proceudres which would include vaccular access.

As long as the line is placed contralaterally to the pacemaker, i guess is okay and i do it all the time. Cardiologists can give you an order but if it is your policy not to do it then i guess you are right. You should have shown the cardiologist the written hospital policy and i would guess he will go along with you. I have asked around if there is a published article on this subject matter and i have yet to find it.

i was given a memo from navigator that says it is not contraindicated for pacemaker. I did try it on a patient with pavemaker and the aptient was ok. So update your info.

AAchoa1, It is good that you are able to identify the tip in the azygous vein but other bard users say that the sherlok does not identify when the tip is in the azygous vein. I do not doubt that you know what you are doing but as far ar Bard is concerned and the whole community of PICC line nurses your technique becomes questionable. I own a small company that does 400 PICC a month and i have revised the PICC insertion upside down based on how INS trained me 18 years ago. I have 15000 patients worth of data but does these data hold any proof , no because i have not published them. Same as yours If you have the data to prove it works you should sell it to bard. I think it is great that you are an experienced user of sherlock. By the way the last time i spoke to the regionl manager and sales rep of bard in my area, they told me it does not identify when the tip is in the azygous vein so i encourage you to come up with a research to prove your tehnique is correct and dependable. It could make you a millionaire. And also convince them to standby their product by convincing the medical community especially the rads that the findings of sherlock and navigator are worth using. I use the navigator and each wire cost me 41 bucks. It helps me with my time management coz i am able to see more patients and not wait for a chest xray. Once in a while i have this azygous tip placement but my machine says it is in the direction of the SVc region. I prefer to use the navigator coz i service 9 hospitals and 250 nursing homes and they use 5 different catheters. The navigator is universal in use whereas bard sherlock is not. In truth, 98 % of my PICCs will go the direction of the SVC region. The other 2 % is either you cannot get to the SVC because ethey have history of multiple subclavians, or their is a dialysis catheter blocking the inominate/SVC region and in these cases you cannot place the tip in the SVC so what use is the sherlock and navigator. It would be good for us PICC nurses if the report that sherlock/navigator gives will be acceptable to the medical commubity. Could you believe i do not have to wait for the rad techs which by the way sometimes takes a little while. I would love to hear more from your experience and if were in my area i would love to hire you. picclineman NOT piccman

it depends on where the tip of this PICC was originally. If the tip was SVC/RA junction and it migrated 3 cms, you still will be in the SVC area. If you were left sided PICC and the tip was proximal SVC 3 cms will place your tip in the innominate vein. So check the xray first and see where the tip was originally. The PACs usually has a measuring device which will aid you in determining where the tip could be. It would be nice if the catheter does not migrate at all.

There was an article about blood draws from the INS magazine about changing the caps first prior to blood drawing. Part of the reason wasm the old cap could be harboring bacteria. But yes i think drawing with the use of ten /twelve cc syringe is a better way. Better yet if you can clean the hubs with chlorascrub/alcohol, draw your specimen then apply a new cap after flushing willbe a good practice.

you will still know when your tip is in the jugular vein WITHOUT sherlock or naviagtor. Use your ultrasound. So the sherlock/naviagtor is really useful to help identify your line is in the rpojection of the SVC RA region/contralateral/retrograde. This is also useful for me in cases where i dont want to readjust lines such as combative /confused/severly anxious/ cases where you opnly have one arm to work on.This is probably in my experinece 1% of my population. If not for this and the fact that i have to cater to several hospitals, i probably will not use it. I just got frustrated over one of my cases thw other week where two times i used the naviagtor and it was in the azygous vein. Thanks for your opinion.

How does the sherlock show when the tip of the PICC is in the azygous vein. This is my question. As far a effectiveness, it depends on who pays for it. If i were to pay for it, i will not use it. If the hospital pays for it, i go for it. The only time that this equipment will be totally and convincingly be useful is if its result is acceptable to the medical community. Its a good help in terms of time but not financially helpful. Thanks for your opinion.

I would like to ask the opinion of the PICC experts out there. How does the sherlock system manifest/show when the tip of the PICC is in the azygous vein. I am under the impression that the tip locating machine are directional in nature, in other words it tells you the direction of the tip as opposed to where exactly the tip is. I use the Corpak Navigator Bionavigation System and i have encountered a case where the machine indicated the tip of my PICC to be projecting towards the SVCregion however the chest xray shows the tip is in the azygous vein by approxximately 2 cms. I adjusted this line, but before i retracted the catheter, i used the navigator to see how it would look like ( directional wise). It showed the same as the first time. I proceeded to adjust it and used the navigator which again indicated the tip to be directionally positioned in the SVc region. second xray showed the same with a little difference,but the tip was not too deep n the azygous vein. I have come to a conclusion that the machine cannot really identify when it is in the azygous vein. Hope to hear from somebody. Thanks for your opinion

my point is is it worth spending 99% to solve a one percent problem? You can look at it from different angles. I agree with you that problems happen when you least expect it. But what i am trying to drive at is if the sherlock or corpak wire technolgy or navigation technology is used, the company should back up it s claim. otherwise, if you just keep on spending without really getting your moneys worth t is not practical. I am trying to share my experience with you not to compete with you. What i am urging everybody is to encourage sherlock or corpak to do a study and present it to the medical community so this technology becomes a standard, because in my humble opinion, if it is not acceptable to the medical community, it is not worth the money spent on it.

If we as nurses or bard and corpak cannot use the PICC after insertion with use of the sherlock or corpak, what is the point of using this product. this becomes just an additional expense to the already high expense for inserting a picc. My experience is 99 % of my picc end up in the SVC as long as they advance to my intended lenght. My 1% is azygous, contralateral, coiled on itself. With this situation can i justify spending more for a 1% non SVC placement? The only way i can justify the use of sherlock and corpak is if the report from it can be used as an official report meaning i dont need an xray. I cannot understand why sherlock will sell a product but cannot stand behind its report. It is similar to them (sherlock) saying i want you to use this product but i cannot support you if something goes wrong. i chalenge sherlock and corpak to do a 10,000 patient study, present it to the mdical community and i am convinced they will take this study seriously and hopefully agree to use its report. HOW ABOUT THAT!!

I have started to use the corpak electromagnetic CVC tip placement device. This is by the way a competition to the shelock system.The device is wonderful. It is one hundred % accurate. I tested all the patients i saw with a chest xray to confirm tip placement. I used this device with a measurement technique that i have developed and it works wonderful. Personally, i am comfortable using the line and comfortable convincing a physician to use the line even without a chest xray to confirm placement. I tried selling this idea to a nursing home saying with this method, tip confirmation can be done without a chest xray. The first question thrown to me by the DON was does the machine ( corpak) print anything that says the tip is in the SVC ( which is required by INS/AVA standards)? I said NO. The question i want to ask the sherlock users are as follows: 1. Are u able to use your PICCs after sherlock confirms the tip is pointing towards the SVC? ( Does shelock print out a report that states the tip is in the SVC ? 2. Is there anybody out there ( hospitals ) that allow the use of the PICC post insertion using sherlock or corpak without doing a chest xray to confirm tip pacement ? 3. If there is, can you share with me how you convinced the hospital? This device is wonderful and can be equated with a flouro or a chest xray as far as i am concerned. I beleive that we as nurses will be proactive about the use of this device, we may be able to convince everybody that sherlock or corpak is the way to go. I have asked both companies through their sales rep that their company should take the bold step to formally state that their product can compete with a chest xray tip conformation. This way, if we use the product in lieu of chest xray, then WE PICC nurses can do this work more efficiently and be trusted 100% by our collegues. Patricip R. Collera BSN CRNI PICC Line Specialists