Re: Need help with Dr who debates picc lines

[Lynn Hadaway]

Title: Re: Need help with Dr who debates picc lines

First, the article you are referring to is only one study of this issue. It is the first one to report this data. It is also data that was originally collected for other studies and the authors used it to extrapolate the PICC infection data.

CRBSIs occur primarily from 2 reasons - skin flora and hub manipulation. A PICC has a much lower risk of infection because the skin on the arm is dry skin with a smaller number and fewer types of organisms when compared to the oily skin of the neck. So that factor reduces the risk. Skin is considered the primary source of infection in short term catheters.

Hub manipulation would be the same risk factors for all central lines - no difference there. This is considered the primary source of infection for long-term catheters.

You may have to go back to using PICCs in only those patients that would have gotten a nontunneled central venous catheter anyway. A PICC offers far less risk on insertion than a subclavian or jugular inserted line.

You can also rely on the data about pH and osmolarity and the risk of permanent damage to peripheral veins.

Finally I would work on implementing the central line bundle from IHI - www.ihi.org - and their Save 100,000 lives campaign. This is designed to reduce CRBSI regardless of what type of catheter is being used. Collect your outcome data and document what you are producing. Zero rates of CRBSI should be the goal and some are now considering this to be a reachable goal. Good luck, Lynn

At 10:18 AM -0500 12/6/05, Ward Gina wrote:

 We have recently started a PICC program at our rural 101 bed hospital.  Originally our Pulmonologist was excited and really wanting us to get this process started.  It took us a while and now we have been up and running for 2-3 months and have done about 30 piccs total. 

Problem is,   recently he read an article in the "chest" magazine about how PICCs have no less infection rate than central lines, and to make a long story short he no longer encourages the use of PICC lines.  He feels they are just increasing the risk of getting a blood stream infection.  He turns down many requests for Physician inserted Central LInes for the same reason.  He openly says he would rather have the pt deal with poor peripheral access and multiple sticks than to increase the risk of a blood stream infection.    He feels they are only good for long term O.P. antibiotic therapy and then even when that happens and we ask;  he says if they have good veins just stick with the I.V. peripherally. 

I have discussed our outcomes, and our criteria for patients we put them in on, and how only myself and the other R.N. who insert them do the dressing changes etc.   He still feels very strongly about it.  He does rarely put in a request for us to put in a PICC when there is absolutely nothing else and all the "expert"  I.V. nurses have tried but thats it.

The Doctors as a whole dont want this to be a proactive approach now but a reactive approach after hearing his input. 

Any help or suggestions? 

Thanks,  Gina Ward

-----Original Message-----
From: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Cc: [EMAIL PROTECTED]
Sent: 11/29/2005 7:06 PM
Subject: RE: [vascular] SVC/IVC tip termination

Thanks a bunch Angie!

Tuality, OR?

I took my first PICC class there Dec 2001~~~!

Robin

        -----Original Message-----
        From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]]
        Sent: Tue 11/29/2005 12:19 PM
        To: [EMAIL PROTECTED]
        Cc: [EMAIL PROTECTED]; [EMAIL PROTECTED]
        Subject: Re: [vascular] SVC/IVC tip termination
       
       

        Here are several acticles that may be helpful:
        Lum, P. and M. Soski, Management of malpositioned central venous
catheters.
        Journal of Intravenous Nursing, 1989. 12(6): P 356-364

        This article includes mdeical references about neurological
problems
        associated with caudally directed catheters.
       
        Cohn, D., et al., Factors predicting subcutaneous implanted
central venous
        port  function:  Gynecologic Oncology, 2001. 83: p. 533-536
        Collier, P., et al., Cardiac Tamponade from Central venous
catheters.
        American Journal of Surgery, 1998.  176: p. 212-214
        Collin, G.R., A.S. Ahmadinejad, and E. Misse, Spontaneous
migration of
        subcutaneous central venous catheters. The American Surgeon,
1997. 63(4):
        p. 322-326
       
        We obtained this list from Lynn Hadaway when dealing with a
surgeon who
        said it was ok to use the port even thought the the catheter tip
had
        migrated up into the IJ.  After much ado the the tip was
repositioned by
        interventional radiology and the port was not used until this
was done.
        Angie Sims RN, CRNI, OCN
       
       
       

                              "Bell, Roberta

                              M."                      To:
<[EMAIL PROTECTED]>

                              <[EMAIL PROTECTED]         cc:
<[EMAIL PROTECTED]>

                              alth.org>                Subject:
[vascular] SVC/IVC tip termination

       

                              11/29/05 07:50

                              AM

                              Please respond

                              to vascular

       

       

       
       
       
       
        Hello all,
       
        I am in the process of implementing PICC policies as well as
rewriting
        central line policies and I am being questioned regarding tip
placement.
        This nurse has had a few occasions where a Subclavian line is
placed but
        the tip terminates in the IJ (goes up), and the physician has
ordered that
        it be used anyway. One occasion was actually fluid
resuscitation. My
        question to you all, is there anyone who knows of articles for
me to site
        that this is not best practice?
       
        Thanks Loads!
       
        Robin Bell RN
        Clinical Coordinator ICS/OPM
        Sutter Lakeside Hospital
        Lakeport, CA
       
       
       
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Lynn Hadaway, M.Ed., RNC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
http://www.hadawayassociates.com
office 770-358-7861