My administration has asked my team if anyone out there has found a way to do a nursing order for PICC line insertion and if so..how have they set up the protocol to be initiated by a physician (because we obviously need a physician involved somehow). It seems pretty far out there but I was asked to ask the question...thanks for any thoughts as we may be missing something obvious.
Andrea Miller,RN, BSN, VA-BC
Many years ago (early 1990's) the hospital IV team where I worked sent a letter to all physicians asking them to sign and return the letter giving the IV Team permission to make the initial decision about PICC and midline catheter insertion on their patients. If the physician agreed with this plan, they signed and returned it to the IV team. We kept a list of those who had signed this document and would do our assessment and place the catheter if we thought the patient meet that criteria. If there was no signed letter on file, we still had to call and get an order for each patient. It worked then, but I am not sure if they are still doing this or not. Every day, I get something across my email discussing standardization in all of healthcare. There is no greater need for standardization than which patients receive a PICC or midline or other CVAD and when the line is placed in the course of their therapy. This would save lots of money, I think, Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Andrea I don't think this is out there at all!! I am presenting at AVA this year and part of my presentation relates directly to your question. I have often wondered why the clinicians who know the most about vascular access often don't get to even see a patient until after a difficult IV or PICC is ordered. Doesn't this take away the benefit of our expertise from the patient? We all know the typical scenario, a pt. is stuck multiple times by multiple practitioners until finally an IV is established in the ER. Then the pt. is admitted, the IV infiltrates, and the pattern repeats itself until a physician orders a PICC and we then place it. At this point we are really not able to share our expertise, just our valued skill sets. Unless if course the PICC is ordered in a renal patient by hospitalist, then we can explain KDOQI guidelines! We really need a better way, and the answer can be so simple! Get the admissions orders at your hospital to have a check off box that says. "Vascular Access per vascular access team". That box checked by the physician would then be your order to place the most appropriate device, or to suggest the most appropriate device more appropriately placed by a physician, i.e a port. We already see standing orders for "wound care per wound/ ostomy nurse" and "TPN per TPN RN". I think we are long overdue for "Vascular Access per VAT"!
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness
Steve, one thing that many facilities consider is what is known as the "legend" statement on these VADs. This is required by the FDA and I know you have seen it - This device is to be sold or use only upon the order of a physician - or something to that effect. Many are fearful of the legal implications for nurses making decisions with this statement in place. But we all know that PA and NP have prescriptive authority now. Another case of a federal agency not keeping up with practice changes. The whole 510(K) process for devices coming to market is in the process of change right now but I don't know if this statement will be changed in any way. This same statement is on lots of other things that we commonly use such as prefilled sryinges, etc. Not saying this is right, just offering it as a possible excuse for why nursing practice has not evolved. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
We are working to develop a protocol much like consulting the wound team or when the dietitian makes a recommendation. Our working plan is to have a scoring system that the RN's can use (Like a Braden Scale) that would trigger a consult. Our team would then assess the patient and make a recommendation. The goal is not to have it be a nursing order per se. More like an ICU protocol that includes emergency drugs, foley catheters, etc. I am not sure about placing lines without physican involvement. Even if I could, I am not sure I want to. My chart review may not give me the whole story & something could get missed. The physician may know something about the treatment plan or history that is not in the actual chart yet. Central Lines (peripheral or not) are a big deal and should get a team approach.
Martha
We are working to develop a protocol much like consulting the wound team or when the dietitian makes a recommendation. Our working plan is to have a scoring system that the RN's can use (Like a Braden Scale) that would trigger a consult. Our team would then assess the patient and make a recommendation. The goal is not to have it be a nursing order per se. More like an ICU protocol that includes emergency drugs, foley catheters, etc. I am not sure about placing lines without physican involvement. Even if I could, I am not sure I want to. My chart review may not give me the whole story & something could get missed. The physician may know something about the treatment plan or history that is not in the actual chart yet. Central Lines (peripheral or not) are a big deal and should get a team approach.
Martha
The physician does have involvement in my suggested scenario. Just like the ED doc had involvement back in my ED days when I started an IV, gave ASA, got an EKG, put nitropaste on and drew labs....all before the MD even saw the patient! The real question should not be lost in concerns about device statements or the FDA(with due respect) but in are we expert enough to fulfill the physicians expectations(and the patients) when the physician checks off a vascular access consult? I know many nurses who are and many who are not. Martha I would respectfully suggest your plan is destined for failure before it starts, another admission documentation for the nurse to fill out? When it is finally completed a consult will be generated? And then the doc has to be called to give an order....sounds like at least 4 days of peripheral Vanco to me.
Stephen Harris RN, CRNI, VA-BC
Chief Clinical Officer
Carolina Vascular Wellness