Good Morning Everyone,
Our day usually begins with several requests for U/S guided PIVs and midlines. Many of the requests are for patients that we've already seen for the same reason days earlier. When prudent, we encourage an early conversation with the responsible medical team and ask to consider a PICC because, as an experienced Vascular Access Team, we recognize the need for timely, appropriate access. Unfortunately, the response if very often, "No". "Not needed, too risky, not going to be here long enough, doesn't have anything that needs central access"....the list goes on.
Do you have these conversations ? Are you hearing the same "rationale"? Are YOUR patients being subject to repetitive IV starts, fails and restarts when a PICC, IJ, SC, Hohn or other device would be more appropriate ?
My theory is this: As a direct result of the recent legislation in which an institution does not get reimbursed for CLABSI costs, the FINANCIAL penalties (RISK) have outweighed the CLINCIAL NECESSITY (BENEFIT) for insertion of CVCs.
My proposal: Garner together a (much smarter than me) group of vascular access professionals to research and publish the NEGATIVE impact that this legislation has had on patient care.
Has the pendulum swung too far ?
Is there merit here ?
Dave B
I have no doubt that your theory would be proven in your facility and many others. But not all hospitals are taking this approach. There has been a trend over the past couple of years. The thought process seems to go something like this - no CVAD, means no CLABSI and no public reporting which will damage out reputation. The facilities that have worked hard to bring down their CLABSI rates by application of evidnece-based practices are using CVADs appropriately and not using this fear based approach. There is no doubt that we need more research on this issue. I have seen serious negative clinical outcomes through lawsuits over the past 20 years, but this trend of substituting an inappropriate midline for a CVAD with a serious complication has not reached a lawsuit yet. Or at least I have not been contacted for such a lawsuit --- yet. I am anticipating that they will be coming. 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
I agree, I'm not sure what's going on but I'm not a fan of this new approach. I understand no one wants a CLABSI. What's happen where I work is get the central line out as soon as possible and replace with a PICC. Don't quite get that. A central line for a central line. But I believe that the physicians do not want to be responsible if a CLBSI occurs. And in our institution it is prohibited to draw blood from a Midline. So we also see patients getting PICC lines, when a Midline is appropriate, just so serial labs can be done. Lynn, how do you see all of this playing out?
Jack
I think that another big problem, as Lynn has pointed out in the past, is that as hospitals are implementing VA Teams to facilitate INSERTION of CVADs for indications supported by practice standards, there is not the same impetus to implement VA Teams with staffing sufficient to care for and manage the CVADs once placed. So now you have all these patients who finally have CVADs, but it's often left to staff nurses to care for them. Heck it sounds like there a lot of VA Teams out there that are so minimally staffed that you can't even get a second inserter to validate IHI Bundle compliance! So now hospitals with small VA Teams that don't have the resources to manage established CVADs are choosing to skip CVAD placement altogether and prevent CLABSI in the first place by placing U/S-Guided PIVs. I hate to say it, but this conversation will only change once extravasation litigation starts flowing in and hospitals are held responsible for policies or practices that don't encourage the use of CVADs when truly indicated. VA Teams are so important, but they must be robust enough to support placement as well as maintenance.
Keith W. Gilchrist, MSN, RN, PHN, OCN, CRNI, VA-BC
Oncology Nurse Navigator, David Grant Medical Center
Travis AFB, CA
I wish I had a crystal ball to see the future. I don't have any faith in lawsuit changing this trend. I have not ever seen a lawsuit make any difference in the policy, procedures, or protocols/practices at any facility. That is really not the purpose of lawsuits. There purpose is to make the plaintiff whole financially. I am holding out hope that our shift to payment for performance will have an impact on infusion/VA practices. Of course, the ones trying to circumvent the practice recomendations for CLABSI prevention may drive more inappropriate use of midlines before the financial penalties for no payment extends to all types of infection in all types of VADs. Once facilities are paid based on outcomes and not procedures, I think things may change. 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
I'm so glad I read your post. Your comments regarding your experience mimic exactly my experience at my 900 bed hospital. PICC's and other CVL's are not being placed due to "fear" of CRBSI (or perhaps fear of costs associated with CRBSI). Patient's are having multiple IV attempts performed (sometimes over 20 times) to establish one peripehral IV that will be used to infuse multiple irritant medications including vesicants. My 20 year experience as a vascular access specialist is ignored. I make suggestions, try to educate, etc, only to be mocked and ignored. It's a very depressing time in the vascular access world at my instituition. It's a fight everyday....midline orders for dopamine, long term dobutamine, 6 weeks of gancyclovir. I could go on and on. Only consolation is that I'm not alone. Thank you for your post.
Thank you for all these great comments. I am in the process of writing a policy paper and you have given me a great topic to write on. If anyone has done a lit. search or similar research and willing to share would be greatly appreciated. I will share my paper once it is complete :)
Cindy Brown RN BSN CPN
IV Nurse Educator/Clinician
I couldn't agree more! Vasopressors in PIVs...at least two clots per month from PIVs ...femoral lines...feels like we are going backwards instead of forwards some days!!!!
I couldn't agree more with this conversation....I am wondering though, with docs skipping the central lines in lieu of a midline for vesicants and the patients do incure a DVT or extravasation-----does the VAS placing the line--even though she fought for the appropriate central line---become the target of blame since she "should have known better"? I have gone against the MD order to place these lines "just because they write the order" (is not a reason that would stand up in court is my guess) and place a PIV instead and wrote a lengthy note in the patients chart with all the perinent information as to why the midline was not placed and a central line is indicated. That way when the next VAS nurse comes along and they place the order again, she can see what happened prior. But if she did--my question is---is she the one blamed if a disasterous outcome happens and it does become a lawsuit???
Christin Dillon RN VA-BC
What really happens is everyone involved in care of that patient is named in the lawsuit to begin. As discovery progresses, some of those originally named may be excused from the lawsuit. I have seen cases (not involving a question about the appropriate VAD) where the physicians were excused from the lawsuit or their attorney reached a settlement agreement and they were dismissed from the litigation. You must be very careful about what you document in the medical record. It should only be facts and never opinion or pointing fingers at other professionals. I would definitely that the issue of documentation to the risk management director in your facility for guidance on what should and should not be documented in these cases. I have not yet had a case involving inappropriate choices of VADs that led to a serious complication and lawsuit. I do think they are coming but they have not made it into a case where I have been contacted yet. Others who do expert witness work may have seen such a case. The bottom line is an RN is held accountable for all decisions made. If you have evidence to support your conclusion that any LIP prescription will cause harm to a patient, you have a responsibility to pursue your questions up the chain of command in your facility. Be prepared with evidence to support your position. Several years ago, a case involving a midcalvicular tip location that produced vein thrombosis and CRPS along with complete loss of a career as an airline pilot due to pain management was brought to trial and the patient was awarded more than $7 million. The hospital would not allow nurses to place a PICC in the SVC and restricted their practice to midclavicular location only. Physicians were dismissed from this case and the nurses and hospital had the jury decision go against them. There is no way to predict the outcome of a specific lawsuit, especially a hypothetical one such as this. Each case is different and is based on all facts in that case. 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