Is there any literature supporting CXR on readmission for PICC lines that come from the community prior to use in the acute care setting? Does anyone do an alternative process on readmissions?
CVAD malposition is sporadic and unpredicatable. There is no guarentee that a chest xray on admission will catch all malpositions since they can happen after admission as well as before. Some have a policy about chest xrays to confirm the tip location because they know that others in their community may not be placing tips in the recommended tip location on insertion. So they are assessing tip location before infusing for many reasons, not just a malposition. There is lots of publications on primary and secondary malposition, both intravascular and extravascular. But I would tend to put my efforts into nursing education about a complete CVAD assessment before each use, which includes a blood return, and knowing the signs and symptoms of malposition and have a great policy and procedure or protocol about what should be done when a malposiiton is suspected. You will not find a study on chest xray on admission to check for any CVAD tip location. But there is a lot of evidence that CVADs do become malpositioned at any time. Lynn
We require a chest xray of central lines dwelling upon admission prior to use. There are plenty of picc inserters who are not interested in minimum standards of care. I've encountered their "piccs" with midclavicular tips among other things. It's the wild wild west out there sometimes.
We do not have a policy at our institution. I agree that some times an OSH PICCs or even PICCs that we placed end up in a location where it should not be when they are readmitted. Currently, our VAST no longer orders CXRs of our own discretion. We cannot justify the cost. But, we do talk to the physician and leave it up to them if they want to order one. One exception, any patient that is admitted with a PICC or CVC that is to receive Chemotherapy, must have a CXR to confirm tip location before using it. This is in a policy at our institutioin. The counter argument is what about those that receive Chemotherapy infusiions as an outpatient and thay also have a PICC. She they receive a CXR each time? That could be a tremendous cost to the institution. We should do a thouropugh assesment of the PICC and if a CXR is warranted, then OK. The problem is that we do not know all patient's that are admitted with a PICC and I feel that the floor nurses are not comfortabble with this responsibility.
The problem is that malpositioned CVADs may not present and clinical signs and symptoms. And my problem with limiting a repeat xray to chemo patients is that there are many other infusion therapies that are vesicants - parenteral nutrition is a big one, highly concentrated KCl, any calcium formulation, many vasopressors, etc. Your nurses must have great CVAD assessment skills which must include a blood return that is the color and consistency of whole blood. And NEVER let an LIP tell you that no blood return is not a problem! Lynn
CVAD malposition is sporadic and unpredicatable. There is no guarentee that a chest xray on admission will catch all malpositions since they can happen after admission as well as before. Some have a policy about chest xrays to confirm the tip location because they know that others in their community may not be placing tips in the recommended tip location on insertion. So they are assessing tip location before infusing for many reasons, not just a malposition. There is lots of publications on primary and secondary malposition, both intravascular and extravascular. But I would tend to put my efforts into nursing education about a complete CVAD assessment before each use, which includes a blood return, and knowing the signs and symptoms of malposition and have a great policy and procedure or protocol about what should be done when a malposiiton is suspected. You will not find a study on chest xray on admission to check for any CVAD tip location. But there is a lot of evidence that CVADs do become malpositioned at any time. 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 require a chest xray of central lines dwelling upon admission prior to use. There are plenty of picc inserters who are not interested in minimum standards of care. I've encountered their "piccs" with midclavicular tips among other things. It's the wild wild west out there sometimes.
We do not have a policy at our institution. I agree that some times an OSH PICCs or even PICCs that we placed end up in a location where it should not be when they are readmitted. Currently, our VAST no longer orders CXRs of our own discretion. We cannot justify the cost. But, we do talk to the physician and leave it up to them if they want to order one. One exception, any patient that is admitted with a PICC or CVC that is to receive Chemotherapy, must have a CXR to confirm tip location before using it. This is in a policy at our institutioin. The counter argument is what about those that receive Chemotherapy infusiions as an outpatient and thay also have a PICC. She they receive a CXR each time? That could be a tremendous cost to the institution. We should do a thouropugh assesment of the PICC and if a CXR is warranted, then OK. The problem is that we do not know all patient's that are admitted with a PICC and I feel that the floor nurses are not comfortabble with this responsibility.
David Dempsey MS, RN
The problem is that malpositioned CVADs may not present and clinical signs and symptoms. And my problem with limiting a repeat xray to chemo patients is that there are many other infusion therapies that are vesicants - parenteral nutrition is a big one, highly concentrated KCl, any calcium formulation, many vasopressors, etc. Your nurses must have great CVAD assessment skills which must include a blood return that is the color and consistency of whole blood. And NEVER let an LIP tell you that no blood return is not a problem! 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