Where PICC lands!

IVRUS, BSN, RN · Nov 16, 2015

We are a small hospital that has about 100-120 PICCs a year. We are trying to get updated equipment that uses ECG guidance but at this time we can't afford it or it is being decided somewhere in the financial planning for next year. We use US and Sherlock but our sherlock is old and can't be replaced now because it is obsolete. It works some of the time but is not totally reliable. So my question is
If one is pulling back or advancing a catheter to be at the CAJ is there a protocol somewhere that states when a second X-ray has to be taken. I have heard that if it is advanced 3cm or pulled back more than 5cm it must be re X-rayed. I would like to see this somewhere in writing.
I have been doing PICCs for 8 yrs now and I had to pull back 6cm and the tip was easily viewed. It was a pt where getting the x-ray was difficult due to his pain and positioning, not to mention his agitation. I did have them get another x-ray and it was perfect but I really didn't want to put the pt through another x-ray. Please advice me. Is this a suggestion or more than that. Would love to see article or INS standards on this. I tried to find it but couldn't.

Well the problem as I see it is this: If you do NOT do a repeat CXR, and the patient is harmed somehow, all you have to show in a court of law is a malpositioned PICC. You absolutely want confirmation of where it is after you retracted it.

Asystole RN · Nov 17, 2015

This is the relevant INS standard

35.8 Tip location of a CVAD shall be determined radiographically

or by other approved technologies prior to

initiation of infusion therapy

Note that it does not mention repositioning xx amount and not needing verification.

If you do not know the exact final location you need verification.

Asystole RN · Nov 17, 2015

There are a couple of options for your hospital in getting new ultrasound. The companies are usually more than willing to work a deal to run the cost of the US into the cost of the PICCs or put it on a payment plan. Contact your Bard rep or even contact your Arrow rep to see what can be done.

Also contact which department is in control of capital expenses or see if other departments can purchase the equipment, one hospital I know of had environmental services purchase 2 fully loaded ultrasounds with ECG. Environmental services simply had a large excess of funds that year and all it took was one nurse asking.

Personally though, if you hospital has digital radiographs I prefer to place my PICCs that way. Using other means of tip verification such as 3CG or VPS seems to take much longer (around 60-70 minutes) compared to just using digital radiographs (30-45 minutes) from door to door.

This highly depends if your hospital has gone digital or not though.

MikeyT-c-IV · Sep 12, 2016

I agree. Always CYA. I'm sorry it sucks for your patient to get another xray but the fact is we need to verify placement and we need to CYA.