Came across a right-sided PICC whose tip flipped jugular. Xrays for 2 days documented malposition & noted in radiology reports x 2 days. Vascular Team comes in Monday, line replaced, "unusual occurrence" entered. Unit manager claims it is not a nursing responibility to address malpositioned lines, and that the MDs should have addressed, a staff nurse doesn't need to review xray reports. My argument is that the legal standard to be held to is that a 'reasonably prudent' nurse would not use a malpositioned line. (FYI - step-down unit & this has happened many times in our critical care unit).
I find myself second guessing my instincts here. Shouldn't a staff nurse know where lines dwell? (This is an inpatient chemo floor also). I think back to my newbie days on a Tele floor, I always knew what patient's radiology reports said, and notified MDs accordingly. I have always been an ... overachiever, though. But doesn't a bedside nurse have a duty to review these reports? Can anyone give me opinions or data to support either side?
Thanks!
Kathleen Crowe BSN RN CRNI
Absolutely! This happens here as well and we have an agreement with Radiology that if they find a malpositioned PICC, they page the PICC nurse. We are 24/7/365 though. Do you have PICC nurses on call over the weekend? Could they be paged?
Yes, staff nurses should review all results on their patients, but the reality is that they have so much to keep track of, that this is something that often goes by the wayside. Does your radiologist notify anyone when they see a malpositioned line? The MD? Does the MD know what to do if this happens, or at least do they write an order to not use the line? Sounds like you need to do some education of the risks of a malpositioned line and set up some kind of mechanism so that it gets reported to someone! Good luck!
Wendy Erickson RN
Eau Claire WI
Do not second guess your first instinct. It is the responsibility of the primary care staff nurse to know where the tip is located by reading the xray reports. This catheter should never have been used until it was properly positioned and this means reading the report from radiology. For support, go to the INS Standards #1, applicalbe in all settings. This book and its contents applies to ALL nurses, not just IV nurses. Then go to INS SOP #35.8 about confirmation of tip location BEFORE therapy is started. Next, SOP #53 on CVAD Malpostion. 53.4 about the nurse knowing signs and symptoms of a malpostioned line. In this case the nurse did not have to rely on s & s only because she had a written rad report telling her it was not correctly positioned.
The INS Standards apply to all nurses regardless of where they work, just like ONS and ASPEN standards and guidelines apply to all nurses caring for oncology and nutrition patients. For all infusion related questions, there is not a standard for the staff nurse and a separate standard for the IV nurses. The difference is the scope of practice. The staff nurse is not responsible for manipulation of the catheter to get it into the correct position. But they are responsible for safe infusions into the correct tip location. When the tip is not correclty positioned, they must refuse to use the catheter until it is correctly positioned. So the knowledge of malpositioned lines IS within the scope of practice for the staff nurse and manipulation of the line to the correct location BEFORE it is used for infusion is the responsiblity of the inserter.
Why would a CVAD be any different than a NG or PEG tube or a chest tube that can all become malpositioned. Would that nurse claim it was not her responsiblity to know that the NG tube was in the lungs before she infused feeding solution? Same thing. At AVA this year, I addressed this issue (about another clinical problem though) from the podium after a presentation. On the podium with me was Russ Nassof, an attorney specializing in healthcare risk management, who agreed with my reply to the question. I gave a similar answer. When a nurse accepts the responsibllity for that patient, they are held accountable for the care they give. There are many situations like this. I have been asked about the staff nurses reponsibility to know if a certain drug is a vesicant before they give it, or to know the adverse reactions that can happen with a drug - other examples of the same issue.
My reply is coming from 18 years of work as an expert witness in over 500 lawsuits. I always give the same testimony about this issue and it is a frequent one. Go to my blog and read a message titled Custodian or Clinician http://www.hadawayassociates.com/1/post/2014/09/custodian-or-clinician.html
As you know the complications that can result from a malpositioned catheter could include thrombosis, vessel erosion, and neurological complications. An attorney would have lots of evidence to use against any nurse who knew or should have known (by reading the written xray report) that the catheter was malpositioned. If this patient had a serious complication that resulted in a lawsuit, it would be extremely difficult to defend their actions. I would also strongly advise that this be addressed in your written policies and procedures.
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
Thank you both!
Lynn, you reinforced eveything I've been saying to myself. When I picture the worst case scenario of an extravasation in the jugular, I imagine the expert witness likely to be called!
Wendy, unfortunately there is not 24/7 coverage yet. We are working towards this. No, our radiologist do not call & notify for a malpositioned line like they would for other issues. Working on bettering our nursing practice & raising the radiology standard bit by bit.
Kathleen