What is EBP or best practice for new admits with CVC and confurming tip location? Are you getting films or going with assessment? Any literature to support one method or another?
I have just been through a lit search on CVAD tip malposition. NONE of the literature mentions a chest xray upon admission to the hospital. This problem is intermittent, very sporadic, and caused by numerous things. An xray on admission will tell you the tip location, especially if you are concerned about the inserter not using the proper tip locaiton on the original insertion. But tip malposition is just as likely to occur while the patient is in your facility as it is while they are a patient in an alternative setting. Regardless of your policy all nurses must know the signs and symptoms of catheter malposition and what to do about it. Lynn
Having been an RN for 35 years, I remember a time when all admissions would have a UA, CBC, Chem 12-18, CXR and EKG. That day is gone and should be, so on occasion an admission will not have a CXR.
Nevertheless, if a patient arrives with a CVAD present there is an obligation to identify, assess, and care for the device. Not to do so would be below the standards of care. That being said, there is not a requirement to use the device, just to note its presents in the assessment and provide the standard of maintenance care required. I do believe the assess requires a confirmation of tip location.
Here are some references to consider:
American Society of Anesthesiologists Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology.2012;116(3):539-73.
Infusion nursing standards of practice. Standard 18:Infection Prevention. J Infus Nurs.2011;34;(1S).
35.8 Tip location of a CVAD shall be determined radiographically
or by other approved technologies prior to
initiation of infusion therapy.
53.3 The nurse shall know the anatomic location of the
CVAD tip prior to initial infusion through the catheter.
46. VASCULAR ACCESS DEVICE
SITE CARE AND DRESSING
CHANGES
This statements about initial infusion are meant to be about Cath insertion. That was the evidence when I wrote those sentences. My recent lit review was for the purpose of revising the INS SOP. New edition to be out Jan 2016. Lots and lots of new info but no direct evidence to require CXR on admission. But tip malposition can be a serious issue. Your facility will need to make a collaborative decision based on general studies on all tip malpositions. You also cannot eliminate concern even if tip is correctly placed on admission because this is a sporadic and unpredictable problem. Lynn
We just wrote the policy in our facility and yes we DO require chest xray on patients admitted with a dwelling PICC. Our reason for this is we have inserters in the region who place midclavicular tips and/or PICC devices cut to midline. We had a line this week on chest xray showed the tip deep and coiled in the atrium. Before our staff use the lines, we want documentation of a safe tip location.
Cutting a PICC short can be problematic and result in injury. Attemtps to label the alteration of the device may fail at some point during the dwell time. Locally a PICC cut short was infused with TPN, resulting in complications.
I have just been through a lit search on CVAD tip malposition. NONE of the literature mentions a chest xray upon admission to the hospital. This problem is intermittent, very sporadic, and caused by numerous things. An xray on admission will tell you the tip location, especially if you are concerned about the inserter not using the proper tip locaiton on the original insertion. But tip malposition is just as likely to occur while the patient is in your facility as it is while they are a patient in an alternative setting. Regardless of your policy all nurses must know the signs and symptoms of catheter malposition and what to do about it. 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
Having been an RN for 35 years, I remember a time when all admissions would have a UA, CBC, Chem 12-18, CXR and EKG. That day is gone and should be, so on occasion an admission will not have a CXR.
Nevertheless, if a patient arrives with a CVAD present there is an obligation to identify, assess, and care for the device. Not to do so would be below the standards of care. That being said, there is not a requirement to use the device, just to note its presents in the assessment and provide the standard of maintenance care required. I do believe the assess requires a confirmation of tip location.
Here are some references to consider:
American Society of Anesthesiologists Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology.2012;116(3):539-73.
Infusion nursing standards of practice. Standard 18:Infection Prevention. J Infus Nurs.2011;34;(1S).
35.8 Tip location of a CVAD shall be determined radiographically
or by other approved technologies prior to
initiation of infusion therapy.
53.3 The nurse shall know the anatomic location of the
CVAD tip prior to initial infusion through the catheter.
46. VASCULAR ACCESS DEVICE
SITE CARE AND DRESSING
CHANGES
R. Terry Jones, RN, CRNI, VA-BC
Memorial Hermann Northeast Hospital
Humble, Texas
This statements about initial infusion are meant to be about Cath insertion. That was the evidence when I wrote those sentences. My recent lit review was for the purpose of revising the INS SOP. New edition to be out Jan 2016. Lots and lots of new info but no direct evidence to require CXR on admission. But tip malposition can be a serious issue. Your facility will need to make a collaborative decision based on general studies on all tip malpositions. You also cannot eliminate concern even if tip is correctly placed on admission because this is a sporadic and unpredictable problem. 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
We just wrote the policy in our facility and yes we DO require chest xray on patients admitted with a dwelling PICC. Our reason for this is we have inserters in the region who place midclavicular tips and/or PICC devices cut to midline. We had a line this week on chest xray showed the tip deep and coiled in the atrium. Before our staff use the lines, we want documentation of a safe tip location.
Cutting a PICC short can be problematic and result in injury. Attemtps to label the alteration of the device may fail at some point during the dwell time. Locally a PICC cut short was infused with TPN, resulting in complications.
R. Terry Jones, RN, CRNI, VA-BC
Memorial Hermann Northeast Hospital
Humble, Texas