We used to have a completely written out and filed policy and procedure for PICC placement. In the last few years our organization has been reorganizing how things are done in each facility so that things are done uniformly across the area and by that I mean basically with the confines of our metropolitan area. That has made sense to me. The next thing I knew was that the organization decided that Mosby's Nursing skills was going to be their policy for most procedures and a policy has been written that defers to Mosby as policy and procedure. That might be fine for policy and procedure for Insertion of a foley catheter.
My problem is under the subject of PICC placement before it goes on to a very generic description of how a PICC is placed is the and I quote,
"ALERT
PICCs are contraindicated in patients with sclerotic veins or a history of chronic renal disease, and in extremities affected by a mastectomy, an arteriovenous graft, a fistula, or radial artery surgery.
This skill is performed by health care professionals with additional knowledge, skills, and demonstrated competence, and in accordance with the professional's regulatory scope of practice and the institution's standard." (Italics mine)
Our state is a decision tree state and says practices must be supported by hospital policy and procedure.
This has been under discussion for a year and supposedly under research. I expressed my concerns to the director of the Vascular Access Team from the metropolitan network a year ago and also wrote to the director of nursing of my own hospital who said she would look into it. I have kept silent, trusting that research was ongoing. Today at our monthly meeting a nurse from a hospital from our system from another state asked some questions about updating their PICC policy and procedure. I didn't get into that discussion as they are from another state. When the time opened up for anymore questions I enquired about the status of our PICC policy and procedure, my question was met with some vaguely masked hostility and was told that administration had said no to a specifically written PICC policy and procedure. We could always practice better than what was in Mosby's Nursing Skills. While that may be true, here comes my biggest concern. With Mosby's alert that this is performed in accordance with the professional's regularoty scope of practice and the institution's standards preclude their following discussion of PICC insertion as a default policy and procedure? I don't want to find myself in a lawsuit, my practice impeccible but possibly the issue become I shouldn't have been practicing at all because I wasn't following State Nursing Practice Rules.
I am getting ready to write to the State Board of Nursing and discuss the situation with my own malpractice insurance carrier.
Any thoughts?
Mary
I know our system is moving to a more generic policy that is set, then allowing for guidelines that are easy to update. Then as technology changes, the guidelines can be adapted and also allow for profession specific case changes.
Thanks for your comments. I don't have a problem with a generic set that can be updated. My problem is that they refuse to see our position that since Mosby's Nursing Skills starts our with an ALERT that this has to be in accordance with the institution's standard that we have problems. Mosby does not refer at all to the use of ECG guidance which we use, so other than to continue to chart each and every time that it has been approved by a clinical performance committee on a certain date we aren't covered for that.
I am concerned that a overall statement that the system has decided to use Mosby's Nursing Skills as Policy and Procedure as a Generic Policy is too vague for that specialized skill. Especially since Mosby refers to it as a skill needing additional knowlege. Doesn't that take it out of the scope of Mosby's?
Mary
I have not looked at all of these published procedure books, however the ones I have seen contain only the step by step psychomotor tasks required to perform the procedure. They do not contain policies. The policy should be established for each hospital based on patient populations, skills of the staff, etc. These are the nonnegiotiable, nonmodifiable rules under which each facility should operate. So each facility must establihsh their own policies even if they use the published books for the procedure itself. Those policies should include issues such as the required credentials for who can insert a PICC, the tip location and the method to confirm this location, hours of service, patient criteria for PICC insertion - just examples of what the policy should contain. I agree you have a significant issue that is being ignored. Are you personally practicing according to the decision tree used in your state? If so, you may be named in a lawsuit but so would your hospital and the issue would primarily fall to the employer who failed to establish the appropriate policies. You can show that you were practicing according to the decision tree, but your employer failed to do their part and write this as a policy. 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