This may be a local problem only as our PICC program has only been up for 1 year, but here goes. I have been placing PICC's for 1 year at a rural hospital and am currently the only person on the team full time (I do have a relief nurse for when I take a day off etc), my problem is when I place a line for a Nursing Home patient then within days or weeks they bounce back into the ER for occluded PICC or other PICC problem, these patients come in with dirty dressings and in some cases the same needleless connector that I placed at insertion which in the case of today's patient was 3 weeks ago. We were told by the nursing home "nurse" when asked if they had tried to use cathlfo for the occlusion, "we are just a nursing home sweetie", upon arrival to the ER the site looked good but the line was completely occluded. After calling back to the nursing home the line was not being used to deliver meds it was "just flushed with saline when we are suppose to". I feel very responsible for these lines and would like to refuse to place them but am afraid of what would happen to the patient then. I have been to nursing home forum meetings to give information and offer question and answer services.....Help!! any advice? (just FYI I pulled the patient's line as I did not feel comfortable using cathflo on it, and I did send tip for culture, pt had other issues going on as well, very ill)
There are all levels of care in nursing homes - the great, the good, the bad, and the real ugly. Fortunately for the past 7 years of my mother's life she was in a great nursing home with a geriatric NP in there every day. It definitely sounds like there are problems at this nursing home. But you also must realize that the nursing home is staffed by LPNs. I don't know what state you are in and the rules and regulations for LPNs and IV therapy vary greatly between states. So you first need to determine what is the legal scope of practice for LPNs in your state. Just doing forum meetings, Q&A sessions is just not suffiicent for any NH regardless of how good they are. The better ones will recognize the need for education and provide it. Additionally, if infusion therapy is no longer needed, then why in the world was this paitent sent to the NH with the PICC still in place. This should be monitored by you or someone in your facility. Technically, you would carry the legal liability for any decisions you made at the time of insertion. If you are responsible for other activities of discharge planning or patient teaching, then your liability would extend to that aspect as well. Any legal case would be decided by the facts in each case and each would be very different. But I do belileve there are things your facility can and should do with patient assessment, discharge planning, collaboration with these other facilities. 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 know that in New hampshire some nursing homes are able to take patients with vascular access devises and others aren't. Those that aren't won't even take a patient with a port. those that do are responsible to keep their staff educated. If there is a nursing home with problems with bed sores or other signs of neglect one would notify the state ombudsman. check with your case management department - it might be an appropriate step to take. When our local nursing homes started doing IVs the hospital education department was part of the educational process for the nurses. There is also a system that patients living in one nursing home may go to a different home - the one with IV trained nurses - as a skilled patient during the time they are needing infusions. That way the nurses get more experience, and there are less people to keep trained. We also had a problem with clotted lines from one home. I spoke to the director of nurses there and we decided that when a patient came in for catheter declotting or assessing the site the RN would call, set up an appointment usually within a couple of hours and then come in with the patient so I could do some one to one teaching. It cost them money to send a patient in for something that could be prevented. I hope some of these thoughts are helpful.
Gail McCarter, BSN,CRNI
Franklin, NH
This is a topic / issue very near and dear to my very being. As an IV nurse since the mid 80's I have spend years educating bedside nures ( nursing home ones included) to care and maintain iv lines.
My favorite job, an IV educator for a long term care pharmacy got cut /infact the entire role of an IV educator got cut from the company model. Sad. Many other pharmacies cut their programs also or run very minimal support classes. In that job I taught LVN (LPN) IV certification classes that met the California BVN 30 hour requirements, which was a really good course. In CA all LVN's must pass such a class to do any IV care. The scope of practice is very clear.
On the other side, RNs rarely get the same depth of training., they learn on the job and hopefully have enought interest and integrity to get more training.
So fast forward to my current role. I am a state surveyor of nursing homes and home health agencies in CA. Many facilities take residents with infusion needs. I see RN and LVN workers. Many lack true training/skills for providing quality IV care. Sad again. I see policy books that are provided by the parmacies, but many times the staff forgets to utilize them.
Communication between acute care and nursing homes should be very extensive for directing the care. Many patients arrive at a nursing home with no info re the PICC., Port or other device they have. Some times the nursing home has no idea a port exists and monthly maintenance is lost. (I can personally attest to identifying such an issue).
I urge you to send all related documentation for care and maintenance. send the cath info, the brand, the measurements, the # lumens, arm measurements and PLEASE .. a contact name and number as a resource or person to answer follow up questions.
If anyone wants more info than all that please contact me privately. [email protected], [email protected]
Ann
Ann Zonderman, BSN, JD, CRNI
Thank You all for your input, I know teaching and training is key, however when offered I can't get these nurses to accept for whatever reason. I send all the information along with the patient such as ID card, informational booklet on specific picc as well as home care instructions. I have called facilities before and asked if they have these items and they don't have any idea, however they tell me they have policies in place that they are to abide by (some I believe others I have a hard time believing). In any event I will be evaluating those patients referred to me for picc placement much more closely and unless placed in appropriate facilty for duration of therapy I will have to refuse. I believe the doctors have a bit of a learning curve as well and this may force them to look at the situations more closely.
My director and ultilzation reveiw nurse have worked together to help us offer education to these facilities. We sent our offers to the directors of nursing not the staff nurses. If you have specific issues you could also share them with the DON at the nursing home. Many have accepted and been very grateful for what we have taught them. Others we are still trying to reach out to. I also educate patient and/or family when possible. Proper care of central lines is just as important as proper placement. Keep offering the education and you will make changes eventually.
Rose Galyan RN, BSN, CRNI
Speciality Practice Nurse
Vascular Access Team
Indiana University Hospital Bloomington
[email protected]
FYI - if you have any problem (even clinical = such as not being able to care for PICCs) with a facility that is licensed by a state and receive federal or state funding, you can report your conderns to the the Department of Health that licensed the facility. In California you can do it anonomously if you wish and you can even leave a voice message - after business hours.
An invesatigation follows, and if the facility is found to have deficient practice, they must implement a plan of correction = EDUCATION opportunity !!!
Ann
Ann Zonderman, BSN, JD, CRNI