I have found over the last year this topic interesting

Some of the conversations discuss trading down catheter size to reduce other complications like DVT. 

As you can see I am not a firm believer in this theory.  The idea of trading down the number of lumens a patient needs for therapy or the size of the lumens fails to make sense to me.  I cannot tell you how many times I hear from staff RN's why did they place a single lumen PICC I need a dual or why did they place a dual and I need a triple. 

Time to talk to the staff RN's and discuss what the patient needs.  If the patient needs three lumens and the PICC is too big than call an MD to place an acute care line. 

The PICC RN is making a decison and is not the RN even giving the meds or doing the blood draws.  That is like saying to a chemo patient I think you need a Hickman and they need a port. 

I believe in multi-disciplinary decision making.  Is it not the choice of the PICC RN or MD exclusively.  There are other clinicians here and they should not have to take what you just give them because that is what the vein will accommadate or that is what the INS rules state.  Change lines than don't use the PICC line.  Don't trade down on what the patient needs.  All you need is the patient to have a dual lumen PICC and short peripherals both.  That works for me how about you????  Talk about low flow and higher complications.

Kathy Kokotis

Bard Access Systems

I believe our hosptial needs

I believe our hosptial needs to have a better assessment tool for deciding the number of lumens and size catherter to place.  What criteria ,( types of medication, assessment do you use to determine the number of lumens. What other type of assessments do you use?

We do look at the

We do look at the medications and their incompatibily in our assessment.  We also look at other complication potential factors.  The ICU nurses really want more lumens, but based on our medication assessment, we only place what it will take to adminster their tharapy and it ususually is only a dual lumen, instead of a triple.  Even on the patients that need a triple, the vien size is the ruler..  No triple unless the vein size actually accomodate it.  Some don't qualify for meds or for vein size and therefore, we don't do a triple.

If necessary, we will discuss with the ordering physician.  We fmd that they don't know as uch as we do about compatibilities and about vein size.

Gwen Irwin

Austin, Texas

kathy mohn-las vegas--Before

kathy mohn-las vegas--Before the days of triple  lumen PICCs-we used to put in 2 double lumens for the patients in ICU-usually.  I know I will get slammed for this but itdid work and we did not see adverse outcomes on these patients.  These were all upper arm placements.  We did find over time however that doubles on both arms wasn't always the best solution because of throbus formation occasionally.  We did try to get one of the PICCs out ASAP and had better outcomes. Our hospitals here are always the last to get new products and technologies demonstrated.  Just a thought!!!

kathy mohn-las vegas

Kevin We only have 2 picc

Kevin

We only have 2 picc insertions nurses at our facility and I feel your pain in trying to obtain more FTE's as we aren't able to do that either.

when I say teamwork, I am including all disciplines.  The nurses caring for the patients, the doctors, the pharmacists etc.  When we have an issue with placing a picc becasue of those that I mention, I did not mean that the picc team does all of the work involved in achieving the best for the patient - we all work together.  we discuss with the primary care nurse and physician our findings and often times they will collaborate with us to see what kind of meds are no longer needed or can be safely administered through the same tubing.  Although we are the ones with the picc insertion knowledge and risks and benefits of that, we pass as much information on to our staff so they feel involved in their patients care, not just an onlooker.

Karen

 

Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

Kevin:

I am a firm believer in collecting data to prove the following:

time and motion needs of current department

timeliness of PICC factors, ordering, insertion, dwell, number of PIV's prior, diagnosis, infusates etc

At that point write a business plan to get what you need or want

see Jamie bowen Santolucito article in JVAD on timeliness of PICC insertion and her retrospective study

This type of data collection proves to hospital administration you need early assessment and than see my article on Cost Containment in JIN to find out how to create a multi-disciplinary committee to implement it

kathy

Kathy Kokotis

Bard Access Systems

Ms Day,   What is your

Ms Day,

 

What is your staffing that your team can take on all this?  I am having a difficult time increasing my FTEs to get assessment tools, standing orders etc. in place.

Kevin

Kevin

in our facility, we get some

in our facility, we get some requests for triple lumen catheters and we look at what the patient is on and do discuss this with the caregiver and the physician.  Our staff know that we will only place a triple lumen in a patient's whose veins will accomodate this catheter.  If we feel that the patient's vessel size is not large enough to accomodate a triple lumen, then we discuss these findings with the MD.  Often times these patients already have a central line that is not currently causing any problems, but the physicians want to get them out as soon as possible and replace with a picc because of the need for long term IV access.  In these situations, we look to pharmacy to see what is compatible and place a dual lumen if it will benefit the patient or wait a day or two and hopefully the patient's meds may be reduced by one or two and dual lumen will work fine for them. 

 We also place single lumen catheters in all of our outpatient populations and those that are going home on antibiotics.

I agree with Lynn that we need to perform appropriate assessments on all of our patients and I also agree with Kathy that we need to involve all disciplines in this decision making - it shows TEAMWORK!!  Often times we are the experts at what we do and you will find that RN's and MD's will value your opinion, although there are times they don't either.

Kathy Kokotis Bard Access

Kathy Kokotis

Bard Access Systems

How many hospital patients are on two meds these days

that patient should be in homecare

kathy kokotis

Kathy Kokotis

Bard Access Systems

Kathy,  First, INS nor any

Kathy,

 First, INS nor any professional organization, does not "rules". There are standards of practice, guidelines, and recommendations, but none are rules that would imply they have the force of a law. 

I firmly believe that the person placing the line must do a thorough patient assessment of all factors which includes the types, numbers, and anticipated lengths of therapy along with numerous other factors. I have found that some PICC inserters focus on the task of insertion and neglect this assessment piece. In my opinion, this makes them nothing more than a technician. I would never rely exclusively upon what another professional told me to put in regardless of what catheter was ordered. I do my own assessment and make my professional decision.

I have seen times when a large size PICC was used or a double lumen PICC was used simply because that is all that was stocked in that facility. That is not correct in any stretch of the imagination. I also have no problem with choosing a smaller size PICC in many patients. There is no arguement that smaller is always better - less chance for mechanical irritation, more blood flowing around catheter to dilute medications, and less chance for blood flow distal to PICC insertion to be impeded. One must consider the type of therapy. I can not think of a single fluid or medication that can not be infused through a 4 Fr just as easily as through a larger catheter. This would exclude RBC transfusion and the need for huge volumes in ER, trauma and OR. That is it. So I do not agree with your idea of placing a subclavian or IJ line instead of a PICC. These lines have higher rates of insertion complications, are not recommended if bleeding is a problem, and these sites have greater density of skin organisms.

Let me give an example - a poorly controlled diabetic with 2 antibiotics only, one every 36 hours and 1 over 12 hours. That is all that is ordered and probably all that will be ordered. Placement of anything larger than a 3 or 4 Fr single lumen catheter is not appropriate. But I have seen 5 and 6 Fr double lumen PICCs placed just because that was what was handy or in stock.

I firmly believe that the person placing the line has the responsibility to ensure that their assessment produces the best choice of catheter type, size and number of lumens. But I have seen many PICC inserters totally skipping this step! That is the problem in my opinion.  

 

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