Stool around femoral line: How do I get the nurses to listen to a student?

[SNB1014, RN]

Hello, I'm a nurse intern in my last semester of RN school at a large community hospital on a neuro/ med-surg unit. As a tech/ intern I am doing a lot of diaper changes and peri care.

I've seen a disturbing trend: pts who are 5 days or so into their stay, or worse, about to be d/c with a femoral line in place with stool creeping into tjr iv insertion site!! Gross? Yeah. Unsanitary? Absolutely!

I do my very best to clean it. I alert the RN and show her the site( if possible) and hint / play dumb and ask that she might call the Dr and get an order for a new site location etc....after three months here, no one has listened to me. Doesn't ebp say to switch to a cleaner site as soon as a pt is stable? For peetes sake, there has been poop under the transparent dressing....aren't we begging for an infection? How do I be taken seriously?

Or am I being naive?

Thanks!

[Rob72, ASN, RN]

Lots of variables there, tho' on the surface, you are correct. However, if there is a femoral, no, it won't be changed readily, and one hopes there was a good reason for placing it (i.e., peripherals are inadequate to infusion demands). Radial lines are becoming more common, and I believe that's a good thing, overall.

The "best" answer is that if you have a marginally AAO patient, and/or an incontinent one, check the diaper frequently, and use a larger dressing, if this is a known problem. If there was poop under a dressing, its time to change the dressing, and hopefully do some positive site care.

[sauconyrunner]

You are correct that best practices do indeed state that the line should be moved. But they often are not, for a lot of reasons.

Like, in a recent situation we had, we had a guy with a Dialysis cath in his right chest, and it was discovered that he needed a pacemaker, but he also needed a central line to stay alive long enough to get the pacer. The MD put the line in the femoral area to save the upper area for the pacer.

Why are you DCing anyone with a femoral line? if they need to have a line outside of the hospital, it should be more like a PICC, not a TLC. Even if they are going to a SNF or somewhere else.

At our hospital, I keep track of all central lines placed (I miss some I am sure), how they were placed, and also if the line was changed appropriately. our physicians are evaluated based on this (and a number of other things), and if they get too many dings, they are gone...Ones that are placed incorrectly, I get to go and "educate the placer"

If you are curious, you can google National Health Safety Network- Central Line insertion Practice.

[wooh, BSN, RN]

It would be rare (and crazy) to go for a femoral line as a first choice. Chances are there's a reason it's there (couldn't get it elsewhere being the big reason.) They aren't ideal, but if things were ideal, there'd be no patients. Just keep them as clean in that area as possible.

[Anna Flaxis, BSN, RN]

I think you're right to be concerned, but knowing nothing about the culture at your workplace, it's hard for me to give meaningful advice. I think your approach of showing it to the nurse is reasonable. If there is fecal matter up under the dressing, the dressing needs to be changed. If there is a continuing problem with the dressing getting soiled with fecal matter, then definitely the physician needs to be made aware.

[iluvivt, BSN, RN]

Yes that is a disturbing trend. The Femoral vein is the least desirable of all central vein access points. Infection rates can be as high as 19 percent in this area for the obvious reasons such as high moisture area,proximity to perineal and perianal area,difficulty in keeping and maintaining a clean dry and intact dressing. It is used less than in the past though I still see it used quite a bit b/c its easy for the insertor to access that large vein and you get to avoid complications such as a pneumothorax. We see them mostly coming from the ED and then our MDS order a PICC line within 24 hrs. A lot of times the MD orders the PICC as soon as they admit the patient and we take the Fem line out ASAP. We never discharge to SNF or home with a fem line but we have transferred to another acute care hospital with one in place. So now your problem. There is not a guideline/professional standard anywhere that will tell you how long these can stay in place but keep this in mind...they are short term acute care CVCs and not intended for long term access. If a patient needs long term access they need a PICC placed or a tunneled CVC. Now the care of them in your situation. The site can be manged with a TSM dressing and a CHG or like product at the catheter skin junction and changed per the policy. A likely access point for bacteria to gain entry other than the insertion site is the caps. So make sure the caps are changed at least weekly and prn or per your policy. If there is fecal matter anywhere near that CVC..yes I would change the caps and before you add new caps..scrub each lumen hub with alcohol for at least 15 secs each. Better yet an isopropyl alcohol impregnated cover such as the curos cap would be great. Next he line should not stay in and used as a long term line. Watch the WBC..and if they go up unexpectedly with no other source..you need to get that line out. Honestly if fecal matter got anywhere near our fem insertion sites we would just take them out but I can see how a nurse can get stuck in the middle. Wow congrats to you for looking a the whole picture. A good many of the nurses I meet jut want to get through their shift and if there is a good line they just use it..often even if it is not good they still use it !

[wooh, BSN, RN]

iluvivt, the benefits over a femoral CVC are obvious, but what is the benefit of a PICC or tunnelled CVC over a regular (non-tunnelled) CVC?

[iluvivt, BSN, RN]

PICCs have a very low infection rate when inserted and cared for properly. The rates you will find vary by study but the ones I have look at are low .O5 to 1 percent. I believe with prudent nursing care that is evidenced based this can be brought down to a zero and in many institutions it has been. First, they are away from the mouth and nose,the arm also has a lower temperature than the chest and groin,there is a significantly lower number of resident bacteria on the arm than the other areas and there is a lower number of sweat glands on the arm than other areas. In theory ,the tunneled catheter also should have a lower infection rated b/c the catheter does not enter into the vein directly and the tunnel is supposed to decrease the infection rate.This type of catheter is a great choice when central access is needed for a dialysis patient in which the peripheral veins need to be preserved. I also find the fact the the cuff serves a great function and prevents pistoning in and out of the catheter..this helps to keep optimal tip position and limits bacteria migration along the catheter. The BARD power line is an example of a tunneled power line and in many hospitals the radiologist can place them. Both of these CVCs can be used for short term and long term use. Other types of tunneled CVCs such as the chest Groshong,Hickman,Broviac and Leonard catheters can be left in place for years and most are repairable. I took care of a home care patient recently that had been receiving TPN for 3 years through a PICC and we only had to replace it once for a suspected infection. My coworker and I prevented it from migrating at all with good care and patient teaching. The other benefit is that PICCs come in all sizes and types and configurations now and there are some available that have been coated with antimicrobials. I forgot to mention that another consideration if you must use femoral is to consider placing an antimicrobial coated CVC. I advocated for a CHG coated CVC with interior and exterior coated with CHG (30 day activity). We only leave those in for about a week but the regular ones were only 4 days so i bought us a few days. I hope that answered your question.

[wooh, BSN, RN]

Great info! Thanks!

[iluvivt, BSN, RN]

no problem

[Esme12, ASN, BSN, RN]

SNB1014 said:

Hello,

I'm a nurse intern in my last semester of RN school at a large community hospital on a neuro/ med-surg unit. As a tech/ intern I am doing a lot of diaper changes and peri care. I've seen a disturbing trend: pts who are 5 days or so into their stay, or worse, about to be d/c with a femoral line in place with stool creeping into the iv insertion site!! Gross? Yeah. Unsanitary? Absolutely! I do my very best to clean it. I alert the RN and show her the site( if possible) and hint / play dumb and ask that she might call the Dr and get an order for a new site location etc....after three months here, no one has listened to me. Doesn't ebp say to switch to a cleaner site as soon as a pt is stable? For pete's sake, there has been poop under the transparent dressing....aren't we begging for an infection? How do I be taken seriously?

Or am I being naive?

Thanks!

I am confused.....it this your new job that you got at the beginning of May in the Houston/Galveston area that you work 7-12 hour shifts per 2 weeks pay periods in your PRN position at a large community hospital for $12/hr? or the new job at HCA back in February.

I would find the placement of a fem line unusual even in the best circumstances.....let alone a confused neuro patient with flailing/moving limbs. Fem lines are really left for certain life saving equipment that MUST be placed there (like: Intra Aortic Balloon Pump). While somewhere along the last 34 years I have had a patient swimming in feces with a fem line and prayed that they didn't get gm neg sepsis.

If this is a common occurrence at this facility........they are EXTREMELY fortunate that they haven't been shut down for nosocomial infections and high mortality rates from gm neg sepsis (e coli/feces), closed by the health department or bankrupt from lack of reimbursement for nosocomial infections.

It is seldom, although it does occur, in my experience that a patient is discharged to rehab/home with a femoral line in place for it limits the PT/activity of the patient. Or that a rehab even takes a patient with an IV in place for that is not their level of care.

I can't speak to the practices of this facility for I don't know the whole story. I hope that maybe there is something you are not aware of, or is necessary that this is the practice....for what ever reason......and the drug is some super powered occlusive dressing.......that while you are learning you have misunderstood the situation. That the nurses haven't ignored you.....that there isn't an indication for intervention/removal/replacement of the IV line.

If however this is the practice......run as fast as you can from this facility for they will cost you your license shortly after your recieve it for negligence or you will quickly be unemployed for the facility will be shut down for unsafe practices.

I wish you the best on your nursing journey. Good Luck!

[threebrats46]

If the pt has a femoral line there has to be a good reason its there as its never the first choice. Where are they being discharged to with a femoral line? Right now with insurance companies refusing to pay for longer stays most rehabs and nursing homes are taking in pts. with the femorals. As for the feces,it should be cleaned well,with a good dressing.Are the caps being changed?