Respiratory Therapists Inserting PICC Lines

Anna Flaxis, BSN, RN · May 16, 2012

No, no, nnnnnoooooooooooooo!!!!!!!!!!!!!!!!!!!!!!!

MunoRN, RN · May 16, 2012

RT's have been placing PICC's in Arizona since at least 2009 and have also been placing them in my State for a couple of years, along with IR techs and CV techs. Personally, I'm fine with it. As hospitals have identified a growing need for 24/7 PICC placement, other disciplines have stepped up in a way that Nursing hasn't; you snooze you lose.

Asystole RN · May 16, 2012

RT's have been placing PICC's in Arizona since at least 2009 and have also been placing them in my State for a couple of years, along with IR techs and CV techs. Personally, I'm fine with it. As hospitals have identified a growing need for 24/7 PICC placement, other disciplines have stepped up in a way that Nursing hasn't; you snooze you lose.

What state are you in?

I am not sure that it is fair to say that nurses have not "stepped up." Unless it is terribly different in other states the PICC position is rather coveted and the demand for PICC positions far outweighs the supply. The determination to not have 24/7 PICC nurses is a leadership decision, not a nursing decision.

Having IR and CV techs place lines within their disciplines makes some sense however.

The nature of how some of the PICC teams have been treated would point to a fiscal motivation rather than a staffing need.

MunoRN, RN · May 16, 2012

I'm in Washington. IV-Therapy.net has a number of threads on the topic, many of which repeat the issue of how it's been more difficult to make 24/7 PICC placement available when RN's are used as compared to other disciplines. I can't speak to why that is specifically at other institutions, but I know at mine our PICC Nurses strongly resisted after hours or weekend coverage and also resisted being available for other tasks when not placing lines (Most of our PICC Nurses went into PICC placement to get a M-F 8-5 schedule and to get away from bedside Nursing). We currently use RN's for most daytime/weekday PICC's with CV techs doing the off-hour and weekend PICC's. There are already plans in place to phase out the PICC RN's and replace them with RT's when the next round of departmental restructuring occurs. Aside from being non-union which makes things easier, our RT department jumped at the chance take this on, while when given the opportunity to fill a need, Nursing basically ran in the opposite direction.

Asystole RN · May 17, 2012

I'm in Washington. IV-Therapy.net has a number of threads on the topic, many of which repeat the issue of how it's been more difficult to make 24/7 PICC placement available when RN's are used as compared to other disciplines. I can't speak to why that is specifically at other institutions, but I know at mine our PICC Nurses strongly resisted after hours or weekend coverage and also resisted being available for other tasks when not placing lines (Most of our PICC Nurses went into PICC placement to get a M-F 8-5 schedule and to get away from bedside Nursing). We currently use RN's for most daytime/weekday PICC's with CV techs doing the off-hour and weekend PICC's. There are already plans in place to phase out the PICC RN's and replace them with RT's when the next round of departmental restructuring occurs. Aside from being non-union which makes things easier, our RT department jumped at the chance take this on, while when given the opportunity to fill a need, Nursing basically ran in the opposite direction.

I understand what you mean. Would it be possible that the resistance of those particular nurses to work off hours could originate from the fact that M-F nurses were hired in the beginning? You cannot take a M-F group of employees, of any profession, and easily transition them to 24/7. This principal is clearly evident in the fact that there are day nurses and there are night nurses. Very few nurses can easily switch between the shifts.

Inability to find staffing is simply an excuse, a clear and obvious one at that. If presented with the option of termination or working weekends I am sure that many would opt to work the off hours. To state that there is an inability to staff a 24/7 PICC team full of nurses simply because they cannot recruit the staff is as silly as the "nursing shortage" that is widely proclaimed. If there was truly an inability to recruit PICC nurses then one would see the addition of RTs to PICC teams, not the removal of RNs in place of RTs.

If this situation was objectively evaluated the fact that there is often a $10hr pay difference between the professions should be noticed.

MunoRN, RN · May 17, 2012

I do agree that Nursing could have made more of an effort to hold on to this source of hours for Nurses. But I've long since learned that at least ANA unions will gladly sacrifice what's best for patients, what's best for all Nurses, and what's best for Nursing as a profession in order to make a relatively small group of Veteran Nurses happy.

We could have chosen to adapt to the changing needs of our patients, and in the process not only kept the FTE's we already have but actually add to them, although the way things are set up the best option for our PICC Nurses is to just surrender the role to another discipline. As it stands, when the PICC RN team is dissolved, this will require a restructure, which according to our union rules will have to include multiple other departments with M-F 8-5 shifts. Our PICC Nurses have enough seniority that they'll have no problem picking up other M-F 8-5 shifts on other departments (booting less senior RN's out of those departments in the process), so they really have no incentive to agree to working off hours as PICC RN's or even to argue that the PICC team should remain RN's, since their best option (as they see it) is to allow the position of PICC "RN" to go extinct, thereby forcing a restructure. They could have just applied for openings on other units as they became available if they didn't want to part of PICC team once it went to off-hours coverage, but they would then have to accept the openings as they were posted, rather than a restructure where they have far more choices of FTE's and schedules.

In my area at least, CV tech salaries are very similar to that of RN. While I don't doubt that my hospital in mainly interested in who can do the same job for the least amount of money, they've been more than willing to keep the PICC team primarily RN's, in the end they just need somebody to do it and the PICC team and the union made it clear that it wasn't going to be Nurses, so I can't really blame the Hospital for looking elsewhere.

In the end, PICC placement is a task, one that hardly encompasses the wide breadth of skills and knowledge that defines Nursing, so I don't see it as a huge blow to Nursing to lose something that really best falls under the role of a "Tech". I do however think that the profession of Nursing needs to be more progressive; we need to be more assertive in filling demands, but unfortunately Nursing too often seems more interested in avoiding more complicated tasks and roles, rather than moving into areas where we could increase our value.

Asystole RN · May 17, 2012

I do agree that Nursing could have made more of an effort to hold on to this source of hours for Nurses. But I've long since learned that at least ANA unions will gladly sacrifice what's best for patients, what's best for all Nurses, and what's best for Nursing as a profession in order to make a relatively small group of Veteran Nurses happy.
We could have chosen to adapt to the changing needs of our patients, and in the process not only kept the FTE's we already have but actually add to them, although the way things are set up the best option for our PICC Nurses is to just surrender the role to another discipline. As it stands, when the PICC RN team is dissolved, this will require a restructure, which according to our union rules will have to include multiple other departments with M-F 8-5 shifts. Our PICC Nurses have enough seniority that they'll have no problem picking up other M-F 8-5 shifts on other departments (booting less senior RN's out of those departments in the process), so they really have no incentive to agree to working off hours as PICC RN's or even to argue that the PICC team should remain RN's, since their best option (as they see it) is to allow the position of PICC "RN" to go extinct, thereby forcing a restructure. They could have just applied for openings on other units as they became available if they didn't want to part of PICC team once it went to off-hours coverage, but they would then have to accept the openings as they were posted, rather than a restructure where they have far more choices of FTE's and schedules.
In my area at least, CV tech salaries are very similar to that of RN. While I don't doubt that my hospital in mainly interested in who can do the same job for the least amount of money, they've been more than willing to keep the PICC team primarily RN's, in the end they just need somebody to do it and the PICC team and the union made it clear that it wasn't going to be Nurses, so I can't really blame the Hospital for looking elsewhere.
In the end, PICC placement is a task, one that hardly encompasses the wide breadth of skills and knowledge that defines Nursing, so I don't see it as a huge blow to Nursing to lose something that really best falls under the role of a "Tech". I do however think that the profession of Nursing needs to be more progressive; we need to be more assertive in filling demands, but unfortunately Nursing too often seems more interested in avoiding more complicated tasks and roles, rather than moving into areas where we could increase our value.

You can blame the unions all you want but considering the fact that Arizona is a non union state your justification falls short. You have repeatedly speculated as to the nature of the trend, mostly blaming the nurses, but fail to adequately support your conclusions.

I do not understand why you seem to hold an overt hostility to PICC nurses, its strikes me as victim blaming. To state that PICC placement is simply a task, not deserving nor requiring a full nursing assessment demonstrates a gross misunderstanding of what a vascular access nurse actually does. To be honest, it is simply ignorant and insulting.

Were you refused by a PICC team or somehow denied

rpminfl · May 17, 2012

I am a Respiratory Therapist and have ben placing PICC lines in Az since 2000. I recently moved to Florida nd I can not find a hospital that uses Respiratory in that capacity.

MunoRN, RN · May 18, 2012

As I stated earlier I can only speak to why the PICC team at my facility will no longer include Nurses in the near future, although there are sources we can look to for some insight as to why this trend is occurring in more widespread terms; If you follow IV therapy issues then I'm sure you're familiar with Lynn Hadaway, here is her commentary on why there is a trend towards RT's placing PICC's;

"This is happening because respiratory therapists were willing and able to meet the business need and nurses were not. Simple matter of who stepped up and said I will accept this role. RTs did in these situations and nurses did not. I do not think this should mean a competition between RTs and nurses. The group that is able to meet the needs of patients 24/7/365 and produce a track record of good outcomes is the group that should be doing it. Many times nurses have not been willing to do this."

I don't hold any "overt hostility" towards PICC Nurses, particularly since I doubt true "PICC Nurses" would not have traded the existence of Nurses on PICC teams for a potentially better pick of a shift on another unit. I don't hold the union fully responsible either, although they did close the door on the possibility of any other options for staffing the PICC team with RN's by refusing a process that could have opened the door for Nurses who were more willing to work off hours to join the PICC team.

No I am not a spurned PICC team hopeful, although I have had many a patient who needed a PICC after hours or on weekends and had to wait, resulting in delayed or sub-optimal care, so my issue is with any Nurse who intentionally obstructs attempts to meet the needs of our patient population in order to obtain what in comparison is a trivial benefit to themselves.

I don't argue that there are definitely Nursing skills that accompany PICC placement, although these assessments and interventions typically fall under the primary RN, not the PICC RN. With proper collaboration with the primary RN, there's nothing about placing a PICC that is absolutely limited to the scope of an RN and is actually very well suited to being a delegated task, particularly when you consider how well suited other disciplines are to including PICC placement in their scope, such as CV techs.

Personally, I'm all for PICC Nurses holding on to their piece of the healthcare delivery pie, if only PICC Nurses themselves felt the same way.

mandomania · Aug 8, 2012

great transcript of your discussion. i'm glad i ran across it. both of you bring up some very good points.

i have had the opportunity to work with some very good techs in an i.r. setting. they were/are very strong professionally, however, techs are not trained to deal with a lot of the intricacies that surround really sick people getting piccs.

to be fair, nurses that are placing piccs have usually worked in the trenches so to speak and are intimately familiar with seeing patients as a whole. what i mean by that is you can see a patient's info (age, diagnosis, medical history, medications, labs, current overall condition, body habitus, etc.) and you immediately know how all of these things are going to interplay with a line placement.

on one occasion, i was going to help with staffing in an i.r. and with placing piccs in a hospital that was affiliated with the hospital i work at. the tech placed the piccs at this hospital.

we grabbed the cart and ultrasound, etc and went to the icu to place a picc. i was just helping out opening things on the sterile field, etc. and tech placed the picc. super nice guy, but after watching that picc placement, i was like, no way.

the short story is that it's more than just a procedure or act. i walked away from that assignment.

i understand that hospitals need coverage etc. all things being equal, i'll take the nurse.

"in the end, picc placement is a task, one that hardly encompasses the wide breadth of skills and knowledge that defines nursing, so i don't see it as a huge blow to nursing to lose something that really best falls under the role of a "tech"."

like i said, great discussion, but this particular point made by munrorn above is completely contrary to my experience assessing for and placing piccs.

i have noticed similar trends in working in/around unionized hospitals and could not agree with you more.

SusanneS RN · Sep 28, 2012

Here in Arizona several of the hospitals have started an experiment, they are actively replacing PICC nurses with RTs and calling them "Vascular Access Specialists." These RTs will place PICC lines, midlines, and US guided PIVs. My local INS chapter has not issued an official statement about this and my local AVA chapter is fully supporting this with about half of the members being RTs.
Any thoughts on this? Has anyone seen this in any other State?

I am reading what is being said about RN's and RT's placing PICCs. I actually own an IV Team in the state of Washington and have about 20 RN's servicing facilities needing IV lines placed 24/7 throughout a major part of Washington. Although we are a busy team, our turn around time for services are normally able to be provided within 2 to 4 hours of receiving the call. Our services expand beyond the placing of lines to include troubleshooting lines over the phone as concerns come up and providing educational programs for placement, care and maintenance. Although I know RT's can be trained to place PICC lines, to me it doesn't necessarily mean they should be placing them. RT's have a real expertise in their field but it doesn't necessarily mean they have the educational background that an RN has. If I was going to be getting a PICC placed in me or a family member my choice would not be to have an RT place it, just like it would not be my choice to have an RN feel they know everything they need to know about providing RT services. I know RT's are being brought into the field of placing PICC lines in the state of Washington and other states. I know, administrators are using the excuses of not being able to get coverage provided by RN's because they don't want to work after hours, but this is primarily a cope out. Nurses go into the health care field knowing they will be working nights and week-ends and holidays. It is cost related and I know this because I have spoken to administrators about the reasons for the changes and that is the main reason I have been given. Our team is always open for expanding and I have nurses willing to take those calls 24/7.