I had posted this question earlier today and can't find it, So I will try again. I place midlines and PICC's in long term care facilities. The problem is, everybody seems to want midlines vs PICC's. It doesn't matter what drug will be infusing, they just want a midline. We see Vancomycin, Imipenem and Meropenem frequently and they still want a mid even after we discuss the potential complications. Either the staff or doctors don't want a PICC when we request one. Some homes always go with our recommendations but we have a few stubborn homes. We are told to place the line and document that we instructed the staff of potential complications etc. As long as we document this we are covered. I don't buy this. I feel that knowingly placing a line that is inappropriate for the therapy still puts us in a liable situation. I believe that we are responsible for what we do. I have refused in the past to place a midline for Vancomycin and told the staff that I would have someone else come to place the line. I was told that I could be brought before the board of nursing for abandoment. Is this true. I'm trying to do the right thing and to protect the patient. Whatever happened to "Do No Harm". Is this just a catch phrase or is it for real? So many people don't take INS as "credible" because they say, " shold be given centrally whenever possible". I hear things like, It's not mandated by INS, so that makes it OK? I wish that INS would be more definitive about this issue. They state in their standards that the inserter will obtain consent, but they are not so clear on drugs via approprite lines other than pH of 5-9 and below 600. My main concern is, are we liable if we place these lines after we document staff education etc.?
Warren Willard RN CRNI VA-BC
You are absolutely correct - you will be held accountable for the outcome of decisions you make. So don't insert the catheter that you know to be wrong for the therapy and/or patient. No one can assume this accountablity for you - no one!! Standards or guidelines documents do not use a prescriptive approach telling you absolute requirements. For instancce with Vancomycin, there could be a situation where you are waiting on culture results to know how long the vanco will be needed. You could use a very small PIV for this infusion until the culture results are know. The inserter would be accountable for site selection away from an area of joint flexion, using the smallest gauge possible, adequate catheter stabilization with an engineered device, correct dilution and infusion times. So in certain situations, the risk of using a PIV for 2-3 days of vanco may be less than the risk of inserting a PICC when the therapy will not be needed for weeks. As soon as the culture results are known, the appropriate device should be inserted. As the inserter you must choose the VAD with the greatest benefit and least risk to the patient. So those documents can never make strict requirements for all situations. If a midline is placed and the therapy has a pH and/or osmolarity outside the recommended parameters, the chance of thrombophlebitis is great. This could lead to such edema from the inflammation that nerve damage results, leaving the patient with complete or partial loss of function in that arm. I have seen lawsuits very similar to this hypothetical situation. If a lawsuit is filed, the inserter will be named in the case. You will be deposed and expected to explain why you did what you did. A statement that someone else told me to do it is not an adequate explanation for your actions. The final outcome will usually be settlement out of court to the patient's benefit. If it goes to trial, the jury will decide which expert witness is the most believable. Many documents are used to established the standard of care, but the Infusion Nursing Standards of Practice is a primary one used. Do you work for a VAD insertion company? If so, your company needs to have a written policy about VAD selection in situations such as this. I would refuse to insert any VAD that I know is not appropriate for the situation. As nurses we must act as patient advocates for their safety. 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
Thank you for your respons Lynn. What is your take on refusing to place a line once in the facility due to inappropriate use? Can I be charged with abandonment if I tell the staff that I will have someone else come to place the line. There are plenty of Vascular Access nurses out there that will place a midline for any drug. Yes, I work for a private vascular access company.
I am far from a lawyer and this is a question that should be addressed by a lawyer. Abandonment, according to my understanding, is accepting the care of a patient, then walking away and not providing that care. In my non-lawyer opinion, you have not accepted the responsibility to place a VAD until you have performed your assessment by first looking at the medical records or asking appropriate questions on the phone. Based on the information you learn, then you refuse to accept the responsibility - I do not think you could be charged with abandonment because your assessment lead you to reject the requested procedure for the patient. To me, this is acting as a patient advocate instead. Maybe Ann Zonderman, a nurse-attorney can provide additional insight on this issue. 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
Disclaimer.... the following information is offered as a personal - educated opinion and does not represent a full legal opinion. .... a lawyer should be consulted for your specific situation.... if needed
I agree with Lynn's statements noting you have not taken responsibility for the patient ....
To expand my thoughts...
1. You have been asked to provide a particular service for the patient... You are not assigned to care for the patient.. That would be the primary nurse assigned on the unit, for the date, time/shift...Even in the LTC... I\
I can not imagin, but if it is your employer saying you are abondoning the patient...Is it a financial thing... do they practice to your personal standards? I would be very leary of what situations you may be put in in the future...
2. IF you feel someone is trying force you into doing what you professionally feel is wrong, you alone must decide the road you take. Years ago I authored an article for INS on ethical dilemas... Still valid today... I recommend you and your fellow PICC'ers sit down, discuss the situation and identify options for managing such situations - Have a plan for when you are faced with this problem.
3. What is your employers policy? What do each of your co workers personally feel about the overall situation Can colleagues who are willing to do the task under the same circumstances, tell you how do they make that decision, Do you prescribe to their rational? or are you more firm on your position. What does your leadership say, will they support your decisions.
4. Can you be proactive = if you know a LTC ascribes to this practice, can you refuse assignments to the LTC.?
5. What discussions have been held with the doctors and facilities regarding the practice. Have they received education on the issue to understand your point... (may make some difference/ or not)
Who is imposing the pressure on you (your bosses or the LTC bosses/ doctors) do they have authority, or just wanting "get it done."Do they have reasonable background info to support their requests..
I have actually resigned from a job when I was asked to practice in a manner against my professional judgment .. That is always an option...
ANN the JD, CRNI...
Ann Zonderman, BSN, JD, CRNI