UnbrokenRN09

Can anyone give me some guidance on policy writing? I work for a small infusion company. We previously had a DON and now no longer operate with one since we only have 3 FT nurses. I discovered some of our policies are lacking. What are policies based on and where would find this information? I have never held a position where writing policies was one of my job duties so I don't really know what I'm doing or where to start.

My boss read a case study about a patient with an arterial PICC and that particular patient had symptoms that were similar, although it didn't make much sense to me.....I would tend to think the symptoms would be instant with an arterial placement. I was more concerned about a sensitivity to materials in the line itself or infection. The line was not arterial. I confirmed that with US. It was clearly in the basilic. Pt was only flushing the line for maintenance at that point which is why we opted to remove it.

Just wondering if any of you have ever taken care of a patient that had a picc line inadvertently placed in the artery and what symptoms the patient had, specifically when flushed or during or after an infusion? I don't honestly see how this can happen, but I know it does happen and we have a patient on our services right now that we are suspecting might be an aterial placement because of the bizarre symptoms that are occuring with the pt. (We didn't place the line on this one!!) I've been doing search after search trying to find a case study or anything helpful to explain this pt's symptoms that occur 1-2 hours after the line is flushed. (chills, rigors, headache, nausea/vomiting, coldness in extremities, fever, runny nose, and sometimes chest pain). I've been a picc nurse for 4 years now and I have not heard of or seen anyone experience these symptoms before. I'm going out today to remove the line from this patient and I'm going to look at it with my US before I pull it out of curiosity.

You actually want to decrease your tourniquet time to reduce the risk of blood clots. I undo it after I've marked my spot, then I set up my field and I re-tighten just before gowning up. I also suggest adjusting your contrast on the US to a lighter setting, or just play with different settings until you find what you like best. Some people prefer it dark, but I feel like it's easier to see your needle on a lighter setting. Something that helped me with the US is thinking of the probe like it's a flashlight. You can't see the needle if you aren't shining the "light" on it. Keep rocking it back and forth until you find your needle, don't advance if you haven't found it. Your needle is in the skin at at angle, so your probe needs to be angled too. if your angle is more shallow than steep, your probe needs to be farther back from your needle, so you don't end up with the needle behind the probe. Hope that helps. It gets better, you just have to stick with it.

I would say you’re more than qualified. Unless they want the 2 year minimum to ensure you’re dedicated? I would look for something else honestly. lol. I don’t think I’d stick around for 2 years waiting to train. You have clearly mastered the US already, not letting you progress with training at this point seems silly. Not to mention the technique for accessing for PICCs is a different needle and a steeper angle, so there’s really nothing else you can learn just by placing more US PIV’s

I think it just depends on the needs of your particular facility ?‍♀️. Most ads I see for PICC nurses require experience. It’s a highly specialized skill. I didn’t have to be on the team x number of years to get trained, just demonstrated interest and capability with the site rite. We place lines 24/7, but only 2 night nurses are picc certified. I guess what I’m wondering is why you got a position on a vascular access team and they aren’t automatically training you for PICCs? That’s the whole point of having a team. But every hospital is different on how they approach this. I’d just talk to my direct supervisor about it.

At my hospital we learn to place USG PIV’s first, then start placing midlines. After so many successful PIV’s and midline placements, you start on PICCs. It’s definitely easier to learn PICCs if you already know how to set up sterile field and access veins with US.

We do wire exchanges fairly regularly at my facility. Not a single one of them has resulted in a Clabsi. When proper sterile technique is followed the risk of infection is not much different than an initial insertion. That being said....we don’t exchange if the site has drainage or just looks bad, proper care/maintenance of the line is questionable, they went home with it and came back, etc.

If you ever have trouble drawing blood from a picc you shouldn't force it. Sometimes it's positional and you just need to move the arm a bit, there could be a small clot inside, or there's a fibrin flap over the catheter opening that's being sucked in preventing blood aspiration and the line just needs cath flo to break up the clot/fibrin flap. If all of these measures fail, you should get an X-ray to see where the tip of the picc actually is. If you continue to try and aspirate blood inside the lumen and it sits there long enough without moving you can clot the entire lumen off and the picc is basically ruined at that point and would need to be replaced. As far as there being air in the line, I think that was simply from the suction of the syringe separating the blood into sections because it wasn't easily flowing. I doubt you were pulling free air from the line....that would be a sign the catheter is no longer in the vein, but since the other lumen drew easily, it clearly was still in the vein.

That's a very interesting point cxbf and I will bring that up to our head picc nurse. Our catheters are reverse tapered and only come in 1 length. Our facility only allows for 6 cm to be exposed. Our piccs are 55cm so, on average you would have 8-15cm exposed if you put the whole thing in. That just seems to me like a disaster waiting to happen as far as infection risk and accidental malpositions with dressing changes. Having piccs in different lengths makes perfect sense to me if it's a tapered catheter. I have recently heard that bard is trialing a 4fr double lumen picc. That would definitely be more ideal for a lot of the patient population I deal with. Personally, I think the groshong piccs make the most sense because they're trimmed from the outside after the picc is inserted to the correct depth, but I've been told this type is more difficult to place because it is very flimsy and they have a tendency to clot off easier. I suppose each type of line has its pros and cons. But regardless....being as accurate as possible with your measurement leads to less overall trauma and complications for the patient which is what I'm going for here.

We use statlocks to secure our PICC's, and they hold it in place great, but it's difficult to change the dressing and lock, especially if you have more than 3 cm exposed. That's why I personally don't like having more than 3 out. But yep I'm in total agreement about going deep and pulling back rather than being too short. My last few measurements have been spot on so I'm feeling better about it. Appreciate the feedback.

No I haven't heard of that particular organization but sounds like something I need to check into! Glad to finally see another fellow okie here lol. Anyways, my hospital has a really big picc team so I've seen lots of different measurement methods. After studying the X-ray closer, my preceptor pointed out to me that the tip actually could've been 2 cm further, so I guess adding 2 to the measurement made it more accurate because I add 1-2 for vein depth also. I think from now on if I'm not going by 3CG I'll just insert it to zero and then pull back if necessary. Our picc's have a good 2 cm in front of the zero to allow for the biopatch.

At my facility RN's can remove transvenous wires but not epicardial. Personally, I feel like removing epicardial wires is too much liability for an RN. I don't want to be responsible for removing wires placed by a surgeon. What if the surgeon used faulty technique and the removal lead to an emergent situation (tampondade)? I feel like the surgeon or his PA owns that liability, not me. Just my 2 cents!

I'm a brand new picc nurse. I'm a perfectionist lol....and never want any of the picc exposed. Is it realistic to measure so accurately that this can be done on most patients? I know with some patient's anatomy you can't be spot on with the measurement. I've been measuring and adding 1-2 cm to make sure I don't end up short, but I'm always 2-3 cm long. I'm just afraid to be too short knowing I can always pull more back but can't put more in. Just wondering if this is just something that comes with time and experience once you're comfortable and consistent with your measurement method. My last one would've been perfect if I had just trimmed to my measurement instead of adding wiggle room. I measure from my planned site that I mark with a sterile skin marker to the shoulder just above the axillary area to the right clavicular head and then to the third intercostal space. If I have to change sites I just add or subtract the distance between them rather than re-measure once they're draped and have the Sherlock on.

Sometimes they can flip into the IJ after insertion, particularly if they are on a vent or coughing a lot. You can try to power flush with them sitting straight up, hoping that gravity will pull it back down. But at our facility we usually just end up doing a wire exchange and placing a new PICC so long as the insertion site looks good with no suspicion of infection. Or if the PICC is no longer really necessary, we just do a wire exchange with a new midline. We never use a PICC as a midline so there is no confusion about what type of line it really is. Some nurses see the double or triple lumens and would automatically think it's a PICC, so we just eliminate that.

Most PICC jobs are filled from within, not outside. I worked at my hospital 9 years before i finally got the opportunity to train for PICC. I was a baby nurse when I started, which is partially why it took so long in my case. Just pick a good hospital with a strong PICC program and get your foot in the door, but make sure your supervisor knows what your goals are. Once you prove yourself they may consider you for the team. But as stated by the other commenters, it's very difficult to get this type of position and even more difficult to become good at placing the lines. It's a highly specialized skill and very few are up for the challenge. Good luck to you! If this is really want you want to do, just keep chasing that goal knowing it will take time.

It was the basilic. This was a very sick patient and there had been multiple failed IV attempts and the ones we got, didn't last. It was nightshift, I'm midline certified, so I chose the best vein that I was able to find. We cannulate a vessel as long as it occupies

That makes a lot of sense. The catheter occupied around 42% of the vessel by my ultrasound measurement at the insertion site but it was much smaller farther up. Another nurse later was able to do a wire exchange for a picc through the midline I placed, so that confirmed I was in the vein, which made me feel better.

So I put in a midline this morning and ran into an issue I havent encountered yet. Got access easily and guidewire slid in like butter. There was very minimal blood, it didn't drip out of the needle like it normally does. I put the introducer in, which also went in easily, didn't even have to nick the pt. I threaded the catheter in and couldn't get any blood return but it flushed very easily. I flushed several times, never saw any sign of infiltration and the patient didn't have any pain with flushing. This Pt was very petite, and had very poor vessels. Drawing lab has been a nightmare....you just can't hardly get the blood to flow even with a butterfly attached to a syringe. I went ahead and left the line in place but had a more experience PICC nurse take a look at it too. I'm just confused as to how everything went as smoothly as it did without getting blood return. I am absolutely positive my guidewire was in the vein because it glided smoothly like it should, so I don't see how the introducer could have been out of the vein? Any thoughts are appreciated, I'm still new to this.

I never stick these areas unless they have a very prominent palpable vein and there isn't anything else. If they require long term access, vesicants or irritant medications then they should have a midline or picc as soon as it's feasible. I dont think these "standards" are laws, but they should be taken into consideration in non urgent situations.

Our facility doesn't require a physician order for a midline and we use the bard power midline product, which is basically a short picc line and is put in the same way. The reasoning behind that is it's not entering the central vasculature, so risks are similar to that of a regular IV. We also don't use them to infuse vesicants long term and never tpn. If they end up needing a PICC later we do a guidewire exchange as long as there are so s/s of infection of thrombosis.

My preceptor pulls the catheter back a bit and then pulls several cm of the guidwire out of the line and then flushes it while advancing it. Makes the tip flimsy so it will drop instead of going up.

From what I've heard you kinda have to just get a job in a hospital with a picc team to "get your foot in the door" and then get on the picc team. That's what I had to do. I'm now mid-line certified and hoping to move on to piccs asap. It's very expensive to get independent picc training and the hands on experience is lacking. I think the certification process varies by facility. I was required to watch 3 and then successfully do 3. I recommend getting comfortable with the ultrasound machine beforehand because it's very frustrating to struggle with getting access while also maintaining a maxi-bari sterile field.

We have very specific protocols for air removal from our bands. But transporting patients with partially deflated bands is not an issue, provided protocol was being followed during deflation process. I find it odd that RN's aren't transporting cath lab patients?? That just seems strange to me, we require 1 RN with every transport

I just laugh when doctors are rude. And make snarky sarcastic comments back. And then I report them for being disrespectful. I don't lose sleep over a-holes that never matured past the angry, temper tantrum stage....