At our facility we do not place PICC's after 6pm. There is only one IV nurse from 7p-7a, and they do not place PICC's. Although, they used to place them, they are no longer certified. When I am placing a PICC and it is not finished by the end of the shift, (confirmation by Radiologist and possible readjustment) I will stay and complete everything. But, there are some nurses who will not stay, they will leave it for the night shift nurse (no longer PICC certified) to complete everything. What do other hospitals do in this situation?
Also, if during the night shift a PICC becomes dislodged (for example, the catheter becomes repositioned in the jugular vein or gets pulled to a midline) and the patient is receiving TPN or other central medications, do other hospitals leave the catheter until the dayshift and place a peripheral site, or have night shift reposition it out of the jugular and obtain an order to use as is?
Bobbi Martin, RN
Archbold Medical Center
Thomasville, GA
Bobbi,
I feel your pain; there are only two of us on our team and we stay until confirmation and are able to place the "OK to use" order. We feel the person who places the PICC is responsible for making sure it is in proper position before walking away (leaving, that is). We are hoping for a tip locator approval some time soon to eliminate this wait time. There is no one in house once we leave, as is the same in your situation. I am wondering if your team needs to have a discussion or policy on expectations?
If a PICC becomes dislodged I would tell the staff to stop the TPN because the line is no longer in central circulation. Since no one is in-house I would not have any nurse readjust the line because they are not qualified, if I am reading your question correctly, about having someone else work with the PICC. If there is an emergent situation with vasoactive medications I would have the nurses call House or Residents to place a central line in the meantime.
We have asked our staff not to discontinue the line because unless there is a site problem we can do an OTW transfer. We do not like them to use the line for central infusions when it is not in central circulation and especially not if it has traveled up the IJ.
Others can probably offer more insight.
Carole
I strongly agree that the person inserting the PICC must be accountable for the final outcome of correct tip location. This can not be passed to another nurse, especially a primary care staff nurse. A hospital is required to provide the same level of care 24/7/365. So primary care staff nurses should never be expected to "take up the slack" when infusion/VA specialist are not present. There must be some way to provide the services of those specialists are all hours. Neither of your options for managing a dislocated PICC on the night shift would be acceptable. I can easily see either of these becoming a serious complication that would lead to a lawsuit. Lawyers would tear this apart as being below the standard of care!! 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
Hi Lynn, I just want to be clear, we are supposed to be getting an ultrasound machine and begin training to place PICCs at bedside using MST (still doing the "old-fashioned" way- the few that have decent enough access). We are only a 5-person team and peripheral vascular access and dressing changes are our major responsibilities now. We realize this will have to change when we do a LOT more PICCS ( IR can't wait for us to take over ). But- we will probably stop doing PICCs after 6pm also, our regular coverage is two shifts, 8am until 11:30pm. What is meant by same level of care 24/7 ? Even IR stops after about 6 or 7 normally. I recently talked to a nurse from MGH at a NEC-INS meeting and they also stop in the evening. A surgeon would be called in for an emergency central line in-house but there is no way we could have an IV nurse covering 11-7 to place lines,is this what you mean ?? Thank You
Inserting a new PICC is most often performed during designated business hours. I do believe that needs arise at all hours and the patient's needs must be met, but the initial insertion can be scheduled and prioritized according to the specific needs for insertion only during those established hours. But the original question was about problems that occur after those established hours. It is not acceptable and is below the standard of care for an inserter to turn over the job of establishing correct tip location to a staff nurse. The entire PICC insertion procedure must be finished including proper tip location confirmed before the inserter leaves the hospital. The job is not finished until the tip is documented to be in the correct location and the PICC is being used for infusion. So this will mean that those inserter nurses can not clock out and leave until the job is done. The other issue is complication management such as a dislodged PICC or one with tip migration or signs or symptoms of any other complication. The patient must have equal access to an infusion specialist at 3 am as at 3 pm. Nursing is a 24/7/365 responsibility. Staff nurses do not have the same level of knowledge and skill so this should not be delegated to that group. This means that someone from your team would need to be on call after your established hours. I do strongly believe that it is far better to have 24 hour coverage with a specialist in the hospital at all times. But that would depend upon the specific patient populations and their needs, the size of your facility and the volume of work you have. I have worked on numerous infusion teams and all have been a 24/7/365 team. The same level of care is required throughout the entire 24 hour day. 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