An old topics that comes up consistantly every other year in our hospital is the one about getting a chest x-ray in the ED prior to use (other than blood draws). It is currently in our PICC policy to obtain a chest x-ray pror to use of the line (with the exception to blood draws/flushing). Our ER Docs are bringing the issue up that they do not feel it is needed and would like the policy changed. Unfortunately, it seems to be nursings job to prove why it is currently in the policy, rather then them proving why it shouldn't be. I have polled area hospitals with more than half do do a chest x-ray prior to use. I have also referenced articles in the standards on malposition. I am going with the patient safetly aspect of this and feel, myself, that an x-ray should be obtained prior to use. The ER Docs feel it is an additional exposure to radiation ( we are currently trialing Sapiens, so this will cut down on the majority of first time x-rays at time of placement), and they do not want to be the ones to have to follow up on a "suspicious nodule" or something else that may show up on the x-ray when they are obtaining it only for PICC tip placement. They feel that if it gives a good blood return and flushes without difficulty that they should be able to use it without a problem. I have several concerns. First, we do not suture our PICC's in, we use a catheter securement device. In a rare case or two that we are aware of, the tip has migrated into the Right Atrium. We had one recent patient in the past several months who was readmitted with his PICC and it was flipped up into the jugular. We also had a port in our ICU that worked great, but upon xray, found that it was fractured. How many cases is too many to not do this, or is this not enough? There was no harm to the patients from these findingsI have read alot of literature and can see this going either way, but I am unsure at this point, which direction to go. Should I compromise with the ED Docs and say, lets obtain one once they are admitted (as not all patients that come to the ED with PICC's are admitted), or stand my ground and feel this is a standard of care locally and nationally, and for the safetly of the patient, and back up what our current policy states. As someone with more national exposure, can you give me your current take on this? Thank you for your time.
We could not write a standard of practice requiring that a chest xray be done upon admission for all patients simply because there is no evidence to support that position. But, I firmly beleive it is a necessary policy for a hospital to have. The standard states," The nurse should notiy the LIP immediately of any signs or symptoms related to CVAD malposition and obtain orders for diagnostic procedures."
I would ask how confident you are in the ability of your nurses in ER, ICU, med-surg, etc. to properly assess the functionality of each CVAD and request a chest xray when something is not right. The frequency of malposition is sporadic and unpredicatable and this is the basis for my position on knowing where the catheter is actually located prior to using it for infusion of any therapy. Even a thorough assessment without problems identified could be a malpositioned catheter. Think of those cases you have found such as the fractured implanted port. This could easily produce a severe extravasation injury due to many ICU drugs that are vesicants. This probably would have resulted in a very bad outcome and possibly a lawsuit against your hospital. There have been numerous lawsuits such as this. I would involve risk management in this decision. Get support from other physicians. You have done your homework on the evidence to support catheter malposition and your current policy. Take this up the chain of command to others who can insist that the physicians do the same homework to support their position and desired practice. 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