The following question was emailed to me from a colleague:
I have a question about the existing PICC (from home)...should we have a
CXR to verify placement when a patient is admitted with a PICC line
before we use it?
Having said that, should we verify tunneled catheters and ports prior to
use? (for patients that are admitted with these lines)
Our current policy has 2 statements Under "Policy"
--Confirm and document CVC tip placement in Superior Vena Cava
(SVC) by x-ray prior to initial use. (Exception: Life threatening
situations)
--For patients admitted with a CVC already in place: Obtain a
chest x-ray to verify tip placement if there is a problem suspected with
the line (i.e., unable to flush/ withdraw blood or patient complaint).
My response was:
The simply anwer is YES--PICCs have been shown to be very active within the vein.
The tip moves when flushed or the patient coughs or vomits and they frequently
malposition to the jugular or contralateral causing flushing and withdrawl issues.
It should be standard operating procedure that any patient presenting with an existing PICC should have a chest XRay to reconfirm the tip location.
In the case of a recent pt admitted to our ICU with an existing sutured BARD DL Power PICC placed by an MD at another facility turned out to be a ML and had to be repalced.
INS STATES "THE NURSE SHOULD NOTIFY THE LIP IMMEDIATELY OF ANY SIGNS OR
SYMPTOMS RELATED TO CVAD MALPOSITION AND OBTAIN ORDERS FOR DIAGNOSTIC
PROCEDURES INCLUDING BUT NOT LIMITED TO CHEST RADIOGRAPH"
Now my question is if it there is a more definitive standard/statement from either INS or other source
ie A statement that EVERY existing CVC [PICCs, Ports etc] presenting in the ED or for admission should have a chest Xray to reconfirm the tip location prior to use
NOT just in the presence of signs and symptoms [exception emergency] OR is that an individual facility decision based on the INS statement above?
I will take responsibility for writing the statement you quoted as this is a standard that I worked on. There is no other evidence upon which to base a more detailed statement. Please note this has a ranking of V, the lowest. There is nothing else. Secondary catheter malposition, aka tip migration, is extremely random and depends upon many factors. The only standard that can be written is the nurse must know the signs and symptoms and to notify the LIP to get the order for an xray. Of course, many hospitals write policies that all CVADs will be xrayed for tip location upon admission. That is certainly the policy that I would strive toward. This would be a case of the hospital going beyond the standard and that is great. But these changes in tip location can change at any time, so an xray on admission or at insertion does not mean it will always be in the same place. So this gets back to the nurse knowing the s&s for malposition. 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
Our facility has a protocol as Lynn mentioned however radiology questions are we exposing to much with multiple xrays. If for instance the line was placed in our facility and pt comes in for further treatment is it necessary to xray them each time. I agree we need baseline for those coming from other facilities as procedures and practices vary from facility to facility. Your thoughts please.
BJ Sherman, RN
Vascular Access Coordinator
Memorial Hospital