For those of you who are measuring arm circumference on Picc insertion, where are you measuring it...above or below the insertion site and how many cms.  We no longer measure because we don't feel it to be very accurate in most cases, but need information to justify this.  Is anyone aware of any references one way or the other about this?   Thanks

 I just searched the pdf of

 I just searched the pdf of the INS SOP using "circumference". In the 2011 edition, mid-arm circumference is defined in the glossary but there are no other statements about it in the document. There was no evidence to support any statements and this is an evidence based document. So we could not make any recommendations about this practice. This started as a means to identify venous thrombosis. I would direct you to SOP # 52 Catheter-Associated Venous Thrombosis however this section focuses more on treatment than prevention or assessment. Your facility will need to decide if this measurement should be a part of your plan of care. See SOP 13 Plan of Care. 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

arm circumference

where is it mentioned in the 2011 SOP?  I can't find it anywhere about a baseline measurement other than length of catheter

Cheryl E. Aldo, RN, BS VA-BC

arm circumference

where is it mentioned in the 2011 SOP?  I can't find it anywhere about a baseline measurement other than length of catheter

Cheryl E. Aldo, RN, BS VA-BC

The first draft of the

The first draft of the revised Infusion Nursing Standards of Practice will be sent out to those professionals who have volunteered to serve as reviewers. The job of reviewers is to read the document, provide your written comments and the references to support your comments to the INS office in the month of June. If you wish to serve in this capacity, you can contact the INS office and volunteer. Thanks, 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

arm circumference

I agree 100 % that the measurement was inaccurate and that nurses have skills of which to assess the increase in circumference before the measurment might. The revisions will assist with the changes. We are not doing intial measurements either because the team decided that this was not an accurate measurement either as everyone measures in a different area. 

I know that when we changed this over a year ago I had the information but unfortunately didn't think I would need it again and know I do.  

Thank you for your help Lynn.

Is there anyway that I could a copy of the first draft?

Carol Busch RN

cbusch@stez.org

PICC Team

Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse

The 2006 Infusion Nursing

The 2006 Infusion Nursing Standards of Practice changed this midarm circumference measurement to be a baseline before insertion and when clinically indicated. This change occurred because there was no evidence to support routine periodic measurement. I would consider this current standard to be evidence-based. This practice, like many other nursing practices, got started based on recommendations from a few speakers, or others recognized as experts. I could make a lengthy list of practices that fall into this category. As you may know, the INS standards are in the revision process now. The first draft has been finalized. They will go out for review to ~100 professionals in a few days. We will consider all comments and finalize the document so it will be released as a supplement to the Jan-Feb 2011 issue of the Journal of Infusion Nursing. 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

The evidence

There is no evidence on measuring or not however it is in protocols and hospitals are following them.  To have them changed from the policy, which in reality the measurement is not a conclusive measurement there needs to evidence of why it should be removed. However there is no evidence based practice that shows it is an important assessment of the picc line.  So where is all the evidence that started the arm circumference to begin with? I like your point Lynn but this won't remove it from our policy becasue Mosbys states it to be done.  I have to find the information why it is inaccurate. I will take this point of view forward. Carol

 

Thank you Lynn

Carol Busch RN

PICC team

St Elizabeth Medical Center

Lincoln, NE 68510

cbusch@stez.org

Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse

Show me the evidence

Show me the evidence supporting routine, repeated measurement of mid arm circumference. It is not in the literature. So why do we need evidence to support getting rid of a specific practice that was never evidence-based in the first place? 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

Arm Cirumference

Lynn,

We have stopped utilizing arm circumference r/t the reasons stated however I need to find EBP related to it. Not having success with finding it. Could you point me in the right direction

Thank you

Carol Busch

cbusch@stez.org

Carol Busch RN,VA-BC, CPUI
PICC/Vascular Access Nurse

I agree with Lynn and Leigh

I agree with Lynn and Leigh Ann.  We were doing weekly measurements after the baseline (because we always did it that way!), but now no longer feel that it is useful.  We measure baseline, and then only when we suspect a problem.  Even then, this information may or may not be indicative.  Usually, but not always, there are other symptoms when a problem has reached the clinical state - such as discomfort.  

Sometimes the patients forearm will be swollen and not the upper arm.  We will request doppler study then as well, and will find thrombi.

Mari Cordes, BS RN 

Nurse Educator IV Therapy
Fletcher Allen Health Care, Burlington VT
Educator, Bard Access Systems 

Mari Cordes, BS RN VA-BC
Nurse Educator IV Therapy/Vascular Access Fletcher Allen Health Care

INS does not require routine

INS does not require routine measurements.  This was changed in the 2006 standards. It is calling for baseline before insertion and then measurement only when a problem is suspected. The issue is with regular, scheduled measurement at established intervals. There is no evidence that this is beneficial. There are so many differences in measuring techniques, etc. and that was the reason we took it out. But you should do a baseline before insertion and then compare to what is measured when you suspect a problem.

 

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

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

Just curious...Why does INS

Just curious...Why does INS call for baseline measurements if there are no follow ups?  I agree with Leigh Ann.  When there was swelling due to a thrombus, it was never at an arbitrary point like 4 inches above the level of the a/c.

You need to publish your

You need to publish your results of this practice because there are no studies supporting a routine or regularly scheduled arm circumference measurement.  

Lynn Hadaway, M.Ed., RN, BC, CRNI

www.hadawayassociates.com

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 measure lower arm

We measure lower arm circumference 10cm below the insertion site.  We do a baseline measurement when the PICC is inserted and then the lower arm circumference is measured and documented daily.  If the measurement increases by 3cm or more, the MD is called and they will order a doppler study.  We document the measurements on the pt profile and if an increase is noted we can see trending. We have found this to be a very reliable way to monitor for clot formation but I always caution the nurses  to not rely on this alone.  Often times the first sign of clot formation is pain/achiness in the upper arm and shoulder area, and most often without swelling.     Vickie

Michael Drafz Vascular

Michael Drafz

Vascular Access Specialist

Sharp Memorial Hospital San Diego, CA

We do baseline on all PICC's and Midlines.

Then we do measurements every 3 days (3 inches above insertion site) on every PICC. Only IV team is taking care of the lines and are doing the measurements, which I believe is the key. If the floor nurses would do it I think it would become very unreliable data.

Our standard is, that if measurement is 2 cm above baseline we look at the other arm, measure and compare, as well as looking at the all over patient condition (fluid retention ect.) So if the problem seems to be isolated to the PICC arm we suggest a US study to the MD, it is then up to him/her to make the determination. In about 70 % of the times we get the study done, there is a thrombus, but not all of the time.

For us it is worth it, since the floor nurses often are not keyed in to look out for the complications with PICCs and nor do the MD's- unless it is infection.

Michael Drafz RN, CRNI, VA-BC

Clinical Lead Vascular Access Service

Sharp Metropolitan Medical Campus

San Diego, CA

 

I think a lot of nurses do

I think a lot of nurses do measure the AC.  But perphaps instead of asking how many measure the AC, let's ask, what do you do if the AC is 1cm greater than upon insertion or what if it is 5 cm greater? 

 My thought is that if it is 1 cm greater, most nurses would not do anything.

But if it is 5 cm larger and edema is present, I feel certain that the nruse woudl contact the MD for appropriate interventions.  Would not visualizing edema (as with a 5cm increase) be enough to warrant intervention?  Why do we need to measure.  My point, as I ramble, is that it's pretty easy to see if edema is present or not, thus use what we see to decide our approach.

 

Cheryl Kelley RN BSN, VA-BC
Independent Vascular Access Consultant

We discarded this a long

We discarded this a long time ago, as it was futile for us. We found no benefit to measuring circumference. The staff would not do measurements, and if there was swelling due to thrombus, it was often not at the point where we previously measured. It was often lower arm, if the thrombus was subclavian. Do you have any research that proves measuring arm circumference is predictably beneficial?

We do a baseline measurement

We do a baseline measurement of circumference at the insertion site.  The measuremet is at the insertion site, not at any other specified number of cms.from the AC.  We found that other measurements would be not comparable at a later date.

Gwen Irwin

Austin, Texas

I measure 4 inches above

I measure 4 inches above patient's elbow and measure arm circumference in inches. Do it only time of insertion.

Prior to PICC insertion we

Prior to PICC insertion we measure Mid-Shaft upper arm.

We take a baseline

We take a baseline circumference measurement at the level of the axilla and document it on the insertion note. 

The information has proved to be useful - a patient was transferred to another facility and the practitioners at that facility reported that the patient developed a peripheral thrombus and that they appreciated having the pre-procedure arm circumference measurement.

INS standards now call for

INS standards now call for only a baseline measurement before PICC insertion. There is no need to do routine measurements - they serve no purpose because of significant differences in techniques and locations. 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