When a patient has a long term VAD, such as a PICC/implanted port, do you require a physicians order to use the port? For example a patient that is coming in for lab work request their port be used, do you get an order for thiis? How do you obtain orders to flush with heparin?
If a patient is a direct admit, or comes into the ER, do you require and physician to place an order to use the VAD?
What reference do you use for this, I do not find any information in the infusion standards.
Thank you for your assistance.
Rachel
I have always seen these question addressed in facility policy and procedure. And if a patient was requesting that I use an existing CVAD of any kind for infusion, there is no question that it would be done. I don't recall ever requiring a specific physician order to use a CVAD. The statement from the INS standards that would apply is found in Standasrd 10, Practice Criteria D." The nurse should advocate for organizational protocols and standard order sets for patient safety." I would consider this a matter of patient safety, comfort, vessel preservation, etc. Also it is a matter of healthcare worker safety. When a peripheral catheter insertion can be avoided because there is a CVAD in place, it should be avoided to reduce the risk of accidental needlestick injuries. I would speak with your risk manager and talke this to the appropriate committee. This is an issue that is decided by each facility rather than through a standard of 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
Lynn how do you address the physician who orders an implanted port absolutely not be accessed for any reason other than for the patient's scheduled chemotherapy. Seems to defeat the purpose of having the port. Yes?
Barbara
First I would talk to the physician to determine his/her reason for this position. Chances are he/she is thinking that more accesses and more infusion will increase the risk of CRBSI, but there might be other reasons. You should be prepared to show him/her the actual data on implanted ports and the fact that they have the lowest rates of CRBSI. I would make him/her aware of the patient's peripheral vein situation, if this is a problem. If we could not come to a "meeting of the minds" about the issue, I would educate the patient about the port and what it could actually be doing for the patient, especially if peripheral sites are a problem and frequent additional therapy for fluids, other meds, etc are required. The patient's desires about the use of the port should be the paramount facts. If the patient wishes for the port to be used for other reasons, the patient can then talk to the physician about this. You could say this is doing an end-run around the physician or enlisting the patient to demand something that the physician does not want. If the physician, the nurse, and the patient were all working as a team, and territorial turf battles were not an issue, then this strategy would not be necessary. If it is necessary, I would not hesitate to use it as I would consider this to be within the nurse's role of being a patient advocate. 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
Our Policies and Procedures state that CVAD's should be used for infusions and blood draws as appropriate and that no order is needed for the access of the device. As Lynn stated, it is what is best for the patient and the staff and it is best practice.
Kim Mills, W.Md Health System
We allow picc lines to be used without a physician order as long as a PCXR is done to confirm tip location. I think all nurse need to know where there line sits before infusing through it. When we have a line from the outside come into us staff get a PCXR for tip placement and then get an order from the doctor to use it since these nurses don't really know what is optimal placement for different therapies (not to say doctors always do either). Our picc team is limited in hours so once we return we review all lines in an audit. Making sure xrays were done, tip locations are ok with ordered meds, etc.