I am trying to gather info from peds picc nurses about your process in evaluating if picc is best line for the patient. Are your piccs put in under fluro, or by CVIR, peds surgeons, or by picc nurses. Do you use conscious sedation? Or general anesthesia? One or two person teams? And success rates in this population. Thanks you so much for any info you can offer. Sue
You should contact Darcy Doelman, CRNI at Cincinnati Childrens for details of their PICC insertion services. Also, Anne Marie Frey, CRNI at CHOP, Angela Lee, CRNI at Childrens in Birmingham, AL. Some of them are on this forum and I hope they will respond. Many use child life services during PICC insertion rather than conscious sedation and PICCs are inserted by specialty infusion nurses and it does not require radiology or a physician to do the procedure. 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
Thanks Lynn, I neglected to say this info needed was on children 2 years and under.
Sue G C.R.N.I
Sue, you may contact me at [email protected] and I will be glad to answer your specific questions. PICCs are placed by nurses (with few exceptions) and our success rate is very high..failure is not related to age but other factors.
Sue,
At Boston Childrens we have an OR PICC team that will accomodate patient population 2 and under if the patient cannot be done at the bedside or in sedation. (out ER docs run a sedation service for PICC placement).The algorithm is distinct as the patient is evaluated by the IV team and if they cannot accomodate the patient comes to us and if we fail the patient goes to IR. Our success rate is extremely high. We use ultrasound guidance and depending on the condition of the child they will either be intubated or have LMA. Our hospitalists have booking privileges if the patient is not surgical. If the physican has booking priviledges they simply place patient on our add on schedule or they call the booking office and book the procedure. We do not require them to be in the room but they must be on the premises. The physician also understands they must be able to come to the OR should anything happen that was unexpected or untoward. In the 4 years we have had this service we have not had any problems in this arena. The service has become quite popular, we have coverage 7 days a week. The in house IV team covers on the weekends. If we fail due to obstruction the patient is sent to IR. We have a collaborative PICC SME group that meets once/month and we are in frequent contact with in house IV team. They will utilize us for the units if they are busy and we do the same if we have 2 piccs happening at once. We also do a great deal of the IV starts for our day surgery patients and same day admit, as well as lab draws for the IR population and the girls that are unable to void for HCG. Essentially we have created an infusion service for the operating room and it has worked out nicely for all ages. I hope this helps, please feel free to email me if you have further questions. [email protected]
Sue,
At Cincinnati Childrens, Our VAT inserts around 150 PICCs/month and our overall success rate is around 97%. We routinely insert PICCs in pts < 2years of age. In my clnical practice, this age group is the most challenging.
Our PICC insertions are a two-person procedure although the 2nd person may be a VAT Patient Care Assistant specially trained in sterile technique and appropriate holding/supporting of the patient's extremity. We do use ultrasound guidance for PICC insertion. Many of our PICCs are inserted under floro, we do bedside insertions for critically-ill patients.
We do have a Child Life Specialist (CLS) on our team. They are a valuable member of our team and routinely prepare and support patients/parents throughout the PICC procedure. If the pt will be awake for the procedure, we do encourage parental presence. The parent(s) is with the CLS on the opposite side of the bed.
Based on each pt's developmental/cognitive assessment, we have many approaches for meeting the needs of the pt:
1. We do use a topical anesthetic for the planned insertion site on the majority of our pts. We also use 1% lidocaine intradermally prior to accessing the vein.
2. For infants, we may bundle and offer SweetEase.
3. If a pt has another planned procedure, we try to coordinate the PICC insertion before/after the procedure
4. We do have an anesthesia-assist team that offers varying degrees of anesthesia for the pt
There are many peds hospitals nationally that have developed successful models for PICC insertions. The Boston Children's model of including a VAT in the peri-operative setting that Pam described is an excellent way to meet the pt's needs beyond the bedside setting.
Darcy Doellman MSN, RN, CRNI, VA-BC
VAT Clinical Manager
Sue, we have an algorithm for line placement suggestions based on length of therapy, vein availability, etc. The prescribing clinicians don't always follow the algorithm and it is sometimes a work in progress and we attend rounds on kids identified as difficult access to recommend and advocate for appropriate access. The VAS team of nurses evaluates each patient for access, history, etc. and recommends either IV team placement or IR placement. We place our critical care PICCs at the bedside in NICU and PICU and CICU with ICU sedation. Depending on the age and demeanor of the patient, a sedatiion NP will evaluate and make a recommendation. For med-surg PICCs, the VAS team inserts these in IR using ultrasound and modified Seldinger technique. There are many IR fellows rotating through, so they will often do the PICCs in IR as well and we don't have the numbers of insertions that we used to have, unfortunately. If we place a PICC in NICU or a CICU infant, it usually one VAS team person and the NICU RN, and PICC tip location is verified by portable x-ray. For toddler and older critical care patients, two VAS team go to the bedside. Hope that is helpful...
Anne Marie
Anne Marie Frey RN, BSN, CRNI, VA-BC Clinical Expert Vascular Access Service: I.V. Team The Children's Hospital of Philadelphia [email protected]