We have a new manager of our team who used to put in picc lines > 10 yrs age and with out u/s. she believes piccs are nothing more than fancy iv lines, it should not take two people to place a line,  and it should only take 3 successful picc insertions to become competent. HELP! what can i show her to tell her that it isn"s so. Is there anyplace i can get literature to show her the national standards, and how to manage a team the bestr way possible?

Yes, I lived through this bit

Yes, I lived through this bit of infusion nursing history. The first PICCs were placed in the mid 1970's. Baxter had the first PICC on the market as a silicone catheter, 20 inches long, with a 16 gauge slotted needle introducer, very difficult to use and painful. The catheter was coiled in a drum and the needle resulted in enormous blood exposure. Baxter gave a grant to MD Anderson in Houston to start a team to place these catheters. Millie Lawson the team manager published the first nursing article in AJN in 1979. She then went to a few cities to teach others. My experience along with several other IV teams in Atlanta started in 1981 through her efforts. Many years ago, Dr. Bob Hickman, the father of vascular access referred to Millie as the mother of vascular access at a NAVAN conference.

US was introduced in early 1990's but the picture was very crude and flickered a lot, making it hard on the eyes. MST use moved into PICCs in the mid 1990s. Bard Access acquired the US product and improved it. By this time, radiologist were wanting to gain a stronghold over vascular access so they began placing PICCs. Once they saw how much demand it made on their time and resources, PICCs moved back to the bedside where it all began.

It is hard to believe that we now have more than 35 years experience with PICCs. 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

General Info

Does anuone know or have a reference what years nurses started placing PICCs and what year nurses started using US and MST?

Tx,

Jen

Jennifer McCord, MSN, RN, CCRN, PCCN, CCNS, VA-BC

Bethesda North Hospital

Cincinnati, OH

Clinical Nurse Specialist

 I have been placing PICC's

 I have been placing PICC's for nine years. I have worked in facilities where a two people team was utilized...I have been practicing for > six years doing a one nurse procedure. I do utilize a staff member to position a pt when they are combative or extremly contracted. I feel that any nurse that is in the beginner leaning stage of the procedure should work in a team settting. Developing exceptional insertion sklills encompasses many aspects; maintaining sterilty, pt comfort being able to successfully place the catheter with minimal trauma to the pt. There are things that you can not possibly learn with a three pt minimum for competency. My three pt's were a bloody massacre. I have been practicing alone for so long i find that when I perform a procedure with another nurse that they get in my way.

I  placed PICC's before US availabilty became a neccesstiy. I certainly love the US. I am called to many facilities within a fifty mile radius and have probably placed > 7000 PICC's. I thought I was pretty good after I had practiced one year, but I learn new techniques all the time. I read the INS materials, CDC guidelines and Joint Commision updates. It is very important to be familar with current trends. 

Physicians expect the nurse to posess the capability to place a catheter in patients with medical issues that really challenge the nurse. 

The information you are seeking is in the AVA and INS criteria for PICC competency. I believe it is 30-60 successful insertions. Your facility should have a standard for competency in place that outlines the criteria. If three successful procedures is your faciility standard; I suggest you discuss the guidelines outlined in the governing bodies (INS) If they are not using these standards then they are practicing sub-standard care. It would not hurt to bring them up to date with guidelines related to reduction CRBSI that directly effect reimbursements. PICC negligence can be very costly to a healthcare facilty. It does not sound like your manager has kept up with medical advances related to central catheters.

Keep in mind when you are approaching her that you do not challenge her authority. If at all possible become her resource person. I'm sure she probably has plenty on her plate and could use some help. She won't be able to deny evidenced based research and global authorities.

 

Margie Hood RN

use of assistant when placing PICCs

 I place PICCs for sveral hospitals. One of the issues that i have been talking with my managers is care and maintenance of the PICCs that i place. Personally, i feel that nurses that places PICCs are always conscious of following the CVC bundle. There are very few if not a zero infections related to insertion that i experinece in the hospitals i service. Most of infections are related to care and maintenance. At the general hospitals that i do PICCs there is a checklist that the nurses and i are supposed to use. The nurses are supposed to observe and make sure that i follow all of them. In reality, these nurses never show up and so far in the two years that i have done PICCs for them, i have a zero infection rate related to insertion. Joint commission was recently at this hospital gave them a passing grade. What i am trying to drive at is that i think nurses that insert PICCs  do it with accuracy and precision as far as fear of infection is concerned. While we ask our nurses to observe us doing the PICCs we never ask our own nurses observe other nurses doing care and maintenance such as proper hub care, dressing changes, hand washing, proper use of biopatch, proper use of chloraprep etc. I believe the problem with infection in PICCs is related to care and maintenance versus insertion and therefore if we were to use our resources effectively, we should concentrate on educating our nurses on care and maintenance. I have always done PICC by myself except if patient needs to restrained or positioning issues. Also, covering the whole body including the face is something i have never done and my infection rate is zero. So therefore , maybe we need to reevaluate this issue of covering the whole body including the face. Is there a research on this that covering the face lowers infection rate? 

I would like to emphasize that i am not trying to contradict the opinion stated by Darilyn, i am trying to expose the issue of effectively using resources. There is a a lot of nice things to do but if these things are not fiscallly justifiable, i would rather use my resources on something that will have tangible effects such as educating nurses on care and maintenance because this is where the evidence points to as problematic. Insertion procedure to me is not where the problem is.True, there are things we need to follow however if we can prove from results that some of these issues can be changed effectively, safely and with evidence, then why not. case in point, covering the the face of the patient while doing PICCSs. I have a lot more trouble encountered if i were to cover the face than not and i have no infection related to my insertion. 

Jcaho, was at the hospital where i do PICCs. They were given a passing grade. In reality, have i seen a JCAHO person inspect/observe a nurse properly access a central line? All of the nurses there barely know the 15 second scrub the hub way of accessing the PICC ports. Some biopatches are applied upside down. Blood, debris at hub junction sites, looping of IV tubings, nurses barely washing hands or using alsohol gel, laying down IV flushes on dirty, soiled bedside tables on isolation patinets, ect. ( I am not involved in this area of care) how about JCAHO check the insertion sites of there central lines? When JCAHO emphasized the use of two persons to do PICCs all the time, was it really necessary? Lets go back to where the problems of infection in central line arise from. We can agree most of them are related to care and maintenance!!  Where is JCAHO and what is JCAHO doing about this when they do there inspections? Where is JCAHO and what is JCAHO doing with nursing homes who literally does not care about infection of central lines in nursing homes!! In other words, i am afraid our concetration of resources is improperly applied  based on evidence. 

Thank you.

Oh boy, that is a tough one. 

Oh boy, that is a tough one.  I think you must insist that she spend some time watching you to understand the complexities of picc insertions these days.  My team members were just talking aboiut how difficult insertions are now vs 10 years ago.  Our patient population is degrading exponentially and I could not imaging trying to insert a picc on my own without a skilled assistant and I've been doing piccs for 20+ years.  So many of our patients are critically and chronically ill.  I am aware of one hospital in our area that got dinged by Joint Commission for placing a picc alone with no one to spot them on steriliity.  They are now required to work in pairs.   It is so much more efficient and safer to have a skilled person assisting.   I often need my assistant to do arm manuevers to get lines to drop that want to go into the IJ especially on vented patients.  I have yet to figure out how a single inserter covers a patient "head to toe" all by themselves. 

Write down all the justifications you use to have a paired team for picc insertions focusing on the what is essential that the second person know and be able to do without prompting.  Focus on the infection control aspects of this team model. 

Above all let your manager know that you respect and understand her motive from a  budgetary standpoint (that is always their driving force because that is how they are evaluated) but stand firm on not compromising patient safety by lowering your standards.     If you have a relationship with your infection prevention department get their opiniion.  I'm assuming you are filling our clip form for all your picc insertions.  As a last resort if you have a union, give them a heads-up that there is a proprosal for a change in your practice that could compomise patient safety.

 

Good luck

 

Darilyn Cole, RN CRNI VA-BC

Darilyn Cole, RN, CRNI, VA-BC
PICC Team Mercy General Hospital Sacramento, CA

 

I feel your pain, I have an

I feel your pain, I have an idiot for a manager too. The INS Standards might be helpful if your manager can READ AND UNDERSTAND THE LANGAUGE OF IV THERAPY, STANDARDS OF PRACTICE!!!!

The national standards to

The national standards to which you, your manager, and your organization are held accountable is the Infusion Nursing Standards of Practice from the Infusion Nursing Society, 2011. This is available for purchase on www.ins1.org. There are numerous other documents such as the CDC guidelines, new one due out any day, the Compendium from SHEA and Joint Commission National Patient Safety Goals, plus numerous research studies and other published position papers, etc. You will need to do lots of homework if you do not already have these documents. 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