What would you do?

[Putter]

The facility I am currently working normally does not except patients with IV because the nurses are not trained. There had never been any policy or procedure book at out facility in re: to IV infusion. Well two days ago I came to work and to my surprise we have a patient with a PICC in place. There is no Dr. Orders as to when the PICC dressing should be changed. We are a psych facility that recently moved from the hospital, and relied on the IV team. Now we are not part of the hospital and can not rely on this team. Our census is down and I am almost positive that is why we have this patient. I am not sure if I did the right thing and may loose my job, but I like the many other nurses have still not recieved IV training, nor PICC training. I find it very unsafe for the patient and staff so I wrote a letter to the my boss, my bosses boss, and the man that is in charge of the facility. We have to demonstrate that we are competent in taking blood sugars, but yet they through a PICC with vanco at us. We don't even have sterile gloves that is how non medical the facility I work for is. I have worked the last two nights and still do not have orders for PICC cares. The facility I work for has 0 standing orders. I am debating if I should continue to work there because you ask a person if they no anything and they don't. In the letter I mentioned that the facility should educate there staff and have policy and procedures in place before accepting patients that have PICCs. It is a huge unsafe mess, did I cross the line by writing the letter to upper management? What would you do in my situation>

[Flare, ASN, BSN]

i understand where you're coming from - if you are not trained to handle something and so not have the supplies then that patient should not be admitted.

Perhaps if you came to them with a solution - such as contacting a local visiting nurse service that handles piccs to come for dressing changes - maybe everyone would get through this. Keep us posted

[Kittyfeet]

Yeah I think it's very unsafe to have a picc line when there is nobody to care for it... if it hasn't been touched in two days it's going to clot off! I don't know how the chain of command works in your hospital but if I were in that situation I would def. be trying to get this resolved. Good for you for being the patient's advocate!

[GitanoRN, BSN, MSN, RN]

Unquestionably, the issue on hand is disturbing, first of all, the PICC pt. has no medical orders, there's no nursing staff certified to work with this type of IV line, and there are no supplies to deal with this matter, to be honest if I was the personnel in charge of this facility I would be praying that JACHO would not pay a non-schedule visit to this facility. Moreover, regarding your concern I commend you for being a compassionate nurse, however, it would have been easier to contact the IV team and state the urgency for them to provide their services and maybe the outcome would be to certified the rest of the staff. Please keep us posted on the outcome of this situation:rolleyes:

[imintrouble, BSN, RN]

I don't wing anything. If I have never done a procedure, somebody goes with me or shows me first. The bad thing here is this pt can't win. If his line is not flushed it will clot off. He's at risk for an infection if the drsng is not changed. If you're responsible for the pt, you're responsible for any adverse outcome. I would contact my boss everyday I cared for this pt and request some guidance on what to do with the situation, and I would chart it.

[GitanoRN, BSN, MSN, RN]

As I stated previously, I commend you for trying to do the right thing in this situation, a critical information from me to you would be, keep charting everything that has occur with this pt. & besides that, keep a journal with dates & time,of your own regarding the responses you get from your superiors, its always good to keep your back covered. Mind you this is coming from a case manager point of view. Lastly, I would like to reinforce how grateful this pt. should be to have you as his nurse . Once again keep us inform regarding the outcome of this issue.

[everthesame, LPN, LVN]

Are you still affiliated with the hospital? Maybe someone from the IV team could come out and give some in-services to get the staff familiar with PICC line care. IMO, PICC care really isn't that hard.

In this economy, I wouldn't be surprised if your psych hospital accepts more of these patients. It is better to learn and get comfortable with it now and your facility would be smart to train the staff now before there is a negative outcome because the nurses don't have the training or the right supplies to appropriately care for a PICC.

I also wonder if the current patient is going to have to endure another PICC placement if this one goes bad because it isn't being properly cared for.

[Putter]

Hi thanks everyone for your feedback. Unfortunately we do not have an IV team at our facility and we are not affiliated with the hospital. I took it upon myself to contact a friend who does home health care and she had a patient with a PICC and is currently on Vanco like the patient at our facility. She just happened to have to go to this clients house to do a PICC dressing change, flush the line, and drew labs. I am so thankful because I would not of known to tell the patient to turn there head or what to document or that you have to measure the arm and line. But she advised me with out any orders not to change the dressing, because that is when patients end up getting infections and I should just send the patient to the ER or urgent care. So still with out orders my hands were tied. That is why I spoke up because I am aware of the risks a patient can have with a PICC. We finally do have supplies now but we still do not have Dr. orders in re: to PICC cares, or policies in place. The facility I work for printed off info as to how to change a PICC dressing. That info is fine but if you have someone who has never done this procedure what do expect the nurse to sit and read through the procedure as she is changing the dressing. Even after watching her do all of this on a patient I would like more training. The only orders we have in place right now is to flush the PICC before and after hanging the bag of Vanco. My friend told me she knew of a situation where a nurse ended up in court because she was not properly trained in PICC cares and the patients PICC became infected. The nurse did not have good documentation as to the care she provided. So that in itself was good to know. A staff member wrote a note to change the dressing Monday, but like I said before no Dr. orders. Not sure where the note came from because there was no signature or date and it was just shoved in her chart. I get so frustrated because I feel like patient safety and quality care is becoming a thing of the past. I work nights and just told the staff watch that site and document everything. If the dressing becomes soiled or starts to fall off I guess to protect our nursing license we will just have to send her to the ER and they will have to provide PICC cares. With out orders and proper training that is what I was advised. I am not willing to take the risk because I don't want to take want the risk of worse case losing my license or harming a patient. So once agian I sent a friendly e-mail saying we need orders. So hopefully when I come to work tonight there will be orders if not, I am going to report this to the state. I just find it troubling when we have to demonstrate we can do blood sugars, and upt test, and checked off on our skills list. But they admit a patient with a PICC and staff is not trained or signed off for skills. Thanks everyone for your advice and I will continue to keep you posted. Thanks for listening to my soap box moment.

[iluvivt, BSN, RN]

Keep working on it b/c the facility and its nursing staff will be held to what the standard of care is. In this case, the dressing needs to be changed at a determined interval or whenever it is NOT clean dry and intact. The caps should also be changed at no more frequently then every 72 hrs. Most dressing change frequencies do not extend past one week in place. For example, we change ours every 7 days and prn if compromised..we also change our caps every 7 days. SO...you either need to provide the care or make certain that it is provided. Your nursing administration should hire a home infusion company to come in and change the dressing and caps and perform an assessment for any complications..AND if the nursing staff is using it they also need to be monitoring for complications and documenting that assessment. Granted, you need to have a policy in place but you are still responsible so get a solution and get one fast...the concern here is to prevent a catheter associated blood stream infection...that is the risk here if this line is not cared for properly. Make sure you are all performing a standardized cap care...scrub the cap really well with good friction prior to any access..did you look at the records and make certain you have a SVC tip placement...yep that is your responsibility as well as the accepting facility

[Putter]

So I have been reading up on materials in Re: to PICC care because many of us still do not have training. I have heard and read two different things when it comes to the PICC dressing change with a stat lock. Do you remove the stat lock when removing the dressing and biopatch with clean gloves. Or do you remove the old dressing with clean gloves and then put the sterile gloves to remove the stat lock. Does anyone have any visual educational materials that demonstrate changing a PICC dressing change with a stat lock? I am on the night shift and have yet to receive training along with the rest of the night crew. I am off for the next few days and have time to research topic more. I could use all the help I can get because I'm not getting it from work. Thank you everyone. I watched my friend do a dressing change but it all went so fast, I need to replay it over and over again. Maybe I could share it with my fellow co-workers on the night shift.

[AggieNurse99, BSN, RN]

At my facility, PICC dressing changes are Q7days or prn soiling if using a biopatch, and q48H if using gauze under the tegaderm. The statlock needs to be changed with every dressing change; search there's also an 800# that comes with the statlocks on an orange sticker. I personally wouldn't do a procedure that I wasn't trained or checked off to do, because as a prudent nurse you shouldn't. Also my facility requires annual competency check offs for procedures like PICC dressing changes.

I have another issue with this case, you work at a psych facility? And central venous access is considered safe for a pt on your unit?