Our skilled nursing facility and home care companies will not accept a patient with an order like that until the hospital places a PICC, hospital absorbs the cost. If a SNF patient needs a PICC after the admission they call us and we go there to place it, dragging along our US device, SNF absorbs the cost. We place many PICCs for home care patients in our Out Patient Infusion Center. Doctors are doing more home referrals from the office these days but they know that the PICC must be placed in the hospital setting so patient comes here first. I have a rule though, no line is placed until home care is arranged. Learned that one the hard way. We are reimbursed for this service.
Darilyn Cole, RN CRNI IV Therapy Dept. Methodist Hospital 7500 Timberlake Way Sacramento, CA 95823 -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] Behalf Of Chris Cavanaugh Sent: Monday, January 30, 2006 12:08 PM To: 'Kokotis, Kathy'; 'Bev and Tim Royer'; 'CAROLYN'; [EMAIL PROTECTED] Subject: RE: INS standard # 37 In a perfect world, or in a controlled setting like an outpatient center or hospital, sure all PICC lines could and should be placed with US and MST. However---what should we do with our LTC and homecare patients who are discharged from the hospital for 5-6 weeks of Vancomycin or other antibiotic with a peripheral IV? Send them back to the hospital for a line to be placed? And who will pay for that? The nursing home? Insurance? The hospital or home care agency? The reality is none of the above. Not every patient who needs a PICC line is in a hospital, or has been in one. We need to stop forgetting about alternate infusion sites such as LTC and homecare when we get on our MST/US soapbox. Chris Cavanaugh, CRNI -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Kokotis, Kathy Sent: Monday, January 30, 2006 1:55 PM To: Bev and Tim Royer; CAROLYN; [EMAIL PROTECTED] Subject: RE: INS standard # 37 I do not know if anyone read my last paper in the LITE spectrum but I did address the two papers with looking at complications rates of MST & US and upper arm placement vs nursing traditional insertions. How did I do this. IR used upper arm and MST and ultrasound and nursing used traditional tools. Phlebitis rates, thrombosis rates were higher for nurisng group significantly. If INS does not understand to this day that upper arm basilic placement has a lower rate of complications and that usage of portable ultrasound is highly recommended and evidence based in the AHRQ government safety report than how can I defend practice that is so out of date. I can defend what we do not easily as INS is not reading the literature My soap box is over. Get with the times. By the way from my figures 45% of PICC lines are placed in nursing with MST and 100% in radiology with MST. You do the math. The doctors are right and more patient focused. Ultrasound is used 15% in nurisng insertions and doctors use fluoro or ultrasound in 100% of cases. I don't know about INS but standard of care dictates the usage of US or MST or all PICC lines should be send to radiology to be placed. What do you think of that one? kathy ________________________________ From: [EMAIL PROTECTED] on behalf of Bev and Tim Royer Sent: Sun 1/29/2006 10:02 AM To: 'CAROLYN'; [EMAIL PROTECTED] Subject: RE: INS standard # 37 When looking at this standard it is important to note that Paragraphs II & III A and B which come before paragraph C state: A "Site selection criteria should be established in organizational policies and procedures and practice guidelines." B "Site selection should be determined per manufacturer's labeled uses(s) and directions for device insertions." To me, as a clinician, I am covered under paragraphs A & B if placing in the upper arm using ultrasound imaging. Currently there is very little scientific evidence based practice published on the topic of comparing antecubital and upper placement of PICCs. Most manuscripts, address increase in successful PICC line placement rates in the upper arm using micro-introducer and ultrasound imaging technology. Only antedotally is it mentioned that there is a decrease in mechanical phlebitis and an increase in patient and nursing satisfaction not having the PICC placed in the region around the antecubital fossa. The use of micro-introducers and ultrasound imaging with nursing is still only a small percent of the total number of PICCs placed by nursing. There are many facilities and agencies that place PICCs using the traditional approach of sight and feel and place in the antecubital fossa regional and report that they have good outcomes. Nurses are good at what they do. Antedotal evidence is OK and is considered but it is not considered rigorous scientific study. Outcome data analysis carries a little more weight and should be published more than it is in this area. However, like everybody else in our field, our time is so involved in patient care and management that publishing is low on our priority list. Best would be research in this area involving a more rigorous scientific study comparing both areas of placement (antecubital fossa vs upper arm). Again our time is limited at work and the time involved in getting an approved study through the IRB at the facilities we work at and the time necessary to carry out the study is very involved and time consuming. Nursing Research is not a high priority for many institutions. We all need to be tracking our data on PICCs and complications and have the data published. Bottom line here - "The Infusion Nursing Standards of Practice", revised 2006 edition, cannot put a standard in that is not backed up by rigorous scientific study even though antedotally we see better outcomes. It has been published over and over again that nurses can place PICC lines safely in the antecubital fossa region. Timothy Royer, BSN, CRNI Nurse Manager / Vascular Access / Diagnostic Service VA Puget Sound Health Care System Seattle / Tacoma, WA Disclaimer - This are my personal beliefs and do not represent the institution I work at. ________________________________ From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of CAROLYN Sent: Sunday, January 29, 2006 7:40 AM To: [EMAIL PROTECTED] Subject: INS standard # 37 # 37 Site Selection - Practice Criteria: II Peripheral-Midline and III PICC it states: Site selection should be routinely initiated in the region of the antecubital fossa; veins that should be considered for cannulation are the basilic, median cubital, cephalic, and the brachial. When we use ultrasound we are hardly ever placed in the antecubital fossa because of the larger catheters being required, increase in antecubital complications because of movement and of course patient comfort. What are the legal implications of this in court by not using the antecubital for placement? 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