This topic has been brought up here recently. How many sticks is your maximum when starting a PICC line? Does everyone stop at the 2 sticks and get another nurse or do they try for for more or a different vein?
I am curious to see what other are actually doing. I would direct your attention to the Infusion Nursing Standard of Practice, page S44, Standard 35 Vascular Access Site Preparation and Device Placement. Under the Practice Criteria General Section, #F states no more than 2 attempts and gives reasons for this. The reference is the INS textbook so it gets a ranking of V. There is no higher level of evidence available that I am aware of, however I would never allow any single person to make more than 2 attempts at placement of any type of VAD on me or a family member. I just know from actual practice, after 2 attempts the inserter is frustrated with the situation and the patient is not happy with the inserter either. So for clinical and personal reasons, it is always wise to bring in someone else. I would expect an experienced PICC inserter to be successful with 1 or 2 attempts in the majority of cases. So I would expect that the needs for more than 2 attempts happens rarely. This should also be a component of the competency assessment on an ongoing basis. If one inserter is having a problem with this, then more training would be required. Then if that does not improve the situation, it would be time for more assessment about whether this was a good role for that person to be in. Experience should bring an increased level of skill, but I agree that learners need some allowances for missing the vein. But then again, a learner should definitely not be allowed to make more than 2 attempts so we are back to where we started. Lynn
95% of the time we only do two sticks on a patient which we feel is best practice because we are both experienced inserters.
The exception is if we gained access on one side and unable to advance the catheter into position, we will go to the opposite side and "start over", meaning if we need two sticks on the other side we will.
We keep an Excel spreadsheet of patients who were difficult from one side or the other, or have vascular issues that prevent successful PICC insertions so we do not try in vain on these patients.
Unfortunately we mostly work alone so do not have the second nurse to do the other two sticks. (Let me hear a "booooo" from the crowd about working alone . . . )
Definitely a loud booooo! Do you mean working as the only PICC insertion nurse in the hospital on any given day or working alone on a single patient? If the first one, then there is no one else to call, right? If the latter, calling the other inserter would mean a delay for the patient's therapy, right? Lynn
In a perfect world there would be nothing but very experienced PICC nurses who would never need more than one or two sticks and there would be at least two PICC nurses working at one time. But in reality, there are new PICC nurses who have been well trained but are not yet "experienced". It will take them time to become experts in the field. Also, in this age of doing more with less, I suspect that there are probably thousands of small to medium sized hospitals across the United States that only have one PICC nurse on at a time. I recently spoke with a very experienced and competent Interventional Radiologist about the two stick suggestion and recommendation by INS. He chuckled at the suggestion and stated that if that were the case he would have to quit practicing. My thoughts are; are the INS practice standards written in stone or are they guidelines? As trained and experienced nurse professionals we need to be able to make judgement calls based on individual circumstances. Sometimes people just have a bad day or a bad moment. Have you ever gone to start an IV on a young healthy person with bulging veins big enough for a 14 ga. catheter, and missed? It has happened to us all and we say "what just happened" how did I miss that? Sometimes a person is a fairly easy PICC but we are all human. If we happened to miss twice do we send the patient to Radiology where they will be stuck again? Delay treatment? Incur more cost either to the patient, hospital, or both? Or, can we use our nursing judgement and say, okay, let me find another vein or switch arms and see what other options we have to work with. The majority of the time I will find another option and knowing that I now have about a 95% success rate of accessing a vein and inserting the guidewire on the first attempt, I'll go ahead and place the PICC. There have been other times when I chose to stop after two attempts because I didn't feel confident that I could place a PICC in a patient. IMHO we should be able to use our professional judgement and assess each situation. Guidelines are great but we also need to consider many other factors that I have mentioned and most importantly, what is best for the patient. Thank you and I would love to hear more comments on this subject.
Our guideline is 2 sticks and you are out. To me two sticks is two sticks. If you did not get it on the first two attempts, what makes you think that nubmer three will be magic? I have worked hard to change our working culture to adopt this standard. We used to poke & poke & poke (terrbily outdated ultrasound) and I started to wonder if we were doing these patients any favors. Turning their arm into swiss cheese sets them up for DVT, phlebitis, infection, scar tissue, etc etc. A new ultrasound has improved our "poke rate" significantly. Culture wise, this is a very difficult thing to change. No one likes to admit failure. Even more so, no one wants to be the person that has to say "Hey, is that your third stick? I think you are done". If you do not take this on yourself it puts your co-workers in a very difficult position.
That said, we work alone (no other PICC nurse in-house) often and there are times where you have to go for a third attempt. In general this is only done when you easily accessed the vein but could not advance the guidewire or PICC in one limb and need to attempt on the other arm. I have to stress that this is very rare. For the most part, if we can not get the PICC placed we will use the ultrasound to start a fresh peripheral IV and leave the PICC for the next day (we do not have 24hr coverage or a call team).
Our guideline is 2 sticks and you are out. To me two sticks is two sticks. If you did not get it on the first two attempts, what makes you think that nubmer three will be magic? I have worked hard to change our working culture to adopt this standard. We used to poke & poke & poke (terrbily outdated ultrasound) and I started to wonder if we were doing these patients any favors. Turning their arm into swiss cheese sets them up for DVT, phlebitis, infection, scar tissue, etc etc. A new ultrasound has improved our "poke rate" significantly. Culture wise, this is a very difficult thing to change. No one likes to admit failure. Even more so, no one wants to be the person that has to say "Hey, is that your third stick? I think you are done". If you do not take this on yourself it puts your co-workers in a very difficult position.
That said, we work alone (no other PICC nurse in-house) often and there are times where you have to go for a third attempt. In general this is only done when you easily accessed the vein but could not advance the guidewire or PICC in one limb and need to attempt on the other arm. I have to stress that this is very rare. For the most part, if we can not get the PICC placed we will use the ultrasound to start a fresh peripheral IV and leave the PICC for the next day (we do not have 24hr coverage or a call team).
I absolutely agree with you, Dale. We must use our skills and experience to make sound decisions for each patient and that decision may deviate from rigid dictates on occasion. In my pediatric facility there is no IR. We have ex 22 and 23 weekers who are extremely challenging whose alternative would be a surgically placed cvl. Every patient is asessed and our actions and recommendations are customized to his needs. In a time when standardization is much touted, there is still no "one size fits all".
I am curious to see what other are actually doing. I would direct your attention to the Infusion Nursing Standard of Practice, page S44, Standard 35 Vascular Access Site Preparation and Device Placement. Under the Practice Criteria General Section, #F states no more than 2 attempts and gives reasons for this. The reference is the INS textbook so it gets a ranking of V. There is no higher level of evidence available that I am aware of, however I would never allow any single person to make more than 2 attempts at placement of any type of VAD on me or a family member. I just know from actual practice, after 2 attempts the inserter is frustrated with the situation and the patient is not happy with the inserter either. So for clinical and personal reasons, it is always wise to bring in someone else. I would expect an experienced PICC inserter to be successful with 1 or 2 attempts in the majority of cases. So I would expect that the needs for more than 2 attempts happens rarely. This should also be a component of the competency assessment on an ongoing basis. If one inserter is having a problem with this, then more training would be required. Then if that does not improve the situation, it would be time for more assessment about whether this was a good role for that person to be in. Experience should bring an increased level of skill, but I agree that learners need some allowances for missing the vein. But then again, a learner should definitely not be allowed to make more than 2 attempts so we are back to where we started. 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
95% of the time we only do two sticks on a patient which we feel is best practice because we are both experienced inserters.
The exception is if we gained access on one side and unable to advance the catheter into position, we will go to the opposite side and "start over", meaning if we need two sticks on the other side we will.
We keep an Excel spreadsheet of patients who were difficult from one side or the other, or have vascular issues that prevent successful PICC insertions so we do not try in vain on these patients.
Unfortunately we mostly work alone so do not have the second nurse to do the other two sticks. (Let me hear a "booooo" from the crowd about working alone . . . )
Definitely a loud booooo! Do you mean working as the only PICC insertion nurse in the hospital on any given day or working alone on a single patient? If the first one, then there is no one else to call, right? If the latter, calling the other inserter would mean a delay for the patient's therapy, right? 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
In a perfect world there would be nothing but very experienced PICC nurses who would never need more than one or two sticks and there would be at least two PICC nurses working at one time. But in reality, there are new PICC nurses who have been well trained but are not yet "experienced". It will take them time to become experts in the field. Also, in this age of doing more with less, I suspect that there are probably thousands of small to medium sized hospitals across the United States that only have one PICC nurse on at a time. I recently spoke with a very experienced and competent Interventional Radiologist about the two stick suggestion and recommendation by INS. He chuckled at the suggestion and stated that if that were the case he would have to quit practicing. My thoughts are; are the INS practice standards written in stone or are they guidelines? As trained and experienced nurse professionals we need to be able to make judgement calls based on individual circumstances. Sometimes people just have a bad day or a bad moment. Have you ever gone to start an IV on a young healthy person with bulging veins big enough for a 14 ga. catheter, and missed? It has happened to us all and we say "what just happened" how did I miss that? Sometimes a person is a fairly easy PICC but we are all human. If we happened to miss twice do we send the patient to Radiology where they will be stuck again? Delay treatment? Incur more cost either to the patient, hospital, or both? Or, can we use our nursing judgement and say, okay, let me find another vein or switch arms and see what other options we have to work with. The majority of the time I will find another option and knowing that I now have about a 95% success rate of accessing a vein and inserting the guidewire on the first attempt, I'll go ahead and place the PICC. There have been other times when I chose to stop after two attempts because I didn't feel confident that I could place a PICC in a patient. IMHO we should be able to use our professional judgement and assess each situation. Guidelines are great but we also need to consider many other factors that I have mentioned and most importantly, what is best for the patient. Thank you and I would love to hear more comments on this subject.
Dale
I totally agree with you. To me this is "real world" picc nursing. Nothing in life is black and white. Judgement and common sense go a long way.
Our guideline is 2 sticks and you are out. To me two sticks is two sticks. If you did not get it on the first two attempts, what makes you think that nubmer three will be magic? I have worked hard to change our working culture to adopt this standard. We used to poke & poke & poke (terrbily outdated ultrasound) and I started to wonder if we were doing these patients any favors. Turning their arm into swiss cheese sets them up for DVT, phlebitis, infection, scar tissue, etc etc. A new ultrasound has improved our "poke rate" significantly. Culture wise, this is a very difficult thing to change. No one likes to admit failure. Even more so, no one wants to be the person that has to say "Hey, is that your third stick? I think you are done". If you do not take this on yourself it puts your co-workers in a very difficult position.
That said, we work alone (no other PICC nurse in-house) often and there are times where you have to go for a third attempt. In general this is only done when you easily accessed the vein but could not advance the guidewire or PICC in one limb and need to attempt on the other arm. I have to stress that this is very rare. For the most part, if we can not get the PICC placed we will use the ultrasound to start a fresh peripheral IV and leave the PICC for the next day (we do not have 24hr coverage or a call team).
Our guideline is 2 sticks and you are out. To me two sticks is two sticks. If you did not get it on the first two attempts, what makes you think that nubmer three will be magic? I have worked hard to change our working culture to adopt this standard. We used to poke & poke & poke (terrbily outdated ultrasound) and I started to wonder if we were doing these patients any favors. Turning their arm into swiss cheese sets them up for DVT, phlebitis, infection, scar tissue, etc etc. A new ultrasound has improved our "poke rate" significantly. Culture wise, this is a very difficult thing to change. No one likes to admit failure. Even more so, no one wants to be the person that has to say "Hey, is that your third stick? I think you are done". If you do not take this on yourself it puts your co-workers in a very difficult position.
That said, we work alone (no other PICC nurse in-house) often and there are times where you have to go for a third attempt. In general this is only done when you easily accessed the vein but could not advance the guidewire or PICC in one limb and need to attempt on the other arm. I have to stress that this is very rare. For the most part, if we can not get the PICC placed we will use the ultrasound to start a fresh peripheral IV and leave the PICC for the next day (we do not have 24hr coverage or a call team).
I absolutely agree with you, Dale. We must use our skills and experience to make sound decisions for each patient and that decision may deviate from rigid dictates on occasion. In my pediatric facility there is no IR. We have ex 22 and 23 weekers who are extremely challenging whose alternative would be a surgically placed cvl. Every patient is asessed and our actions and recommendations are customized to his needs. In a time when standardization is much touted, there is still no "one size fits all".