Yes all publications were considered, including
those with physician authors. Just look at the
reference lists and you can see that easily.
There are also statements about using
visualization technology for site selection on
all types of catheters. So I would suggest you
read the standards before making more off-handed
statements.
We were also careful about the age of a study so
it could be that the AHRQ report you are
referring to was too old for the established
criteria. Lynn
At 3:04 PM -0700 1/30/06, Kokotis, Kathy wrote:
You are right that there is no study that looks
at these two methods (traditional peel-away
versus MST & US) side by side in a prospective
randomized, blinded study. There is a large
article that does look side by side at the usage
of ultrasound versus no ultrasound to place PICC
lines in radiology that is prospective, and
radomized, and blinded (Dr. Howard Chrisman).
That article is one of several cited in the AHRQ
report.
The articles I do use are attached in summary:
Both hospitals have nursing teams using
traditional insertion and radiology with high
tech tools. The method of insertion is cited in
the body of the study for both groups. Both
studies report the nursing complications rate
separate from radiology complications rate post
insertion. The nursing complication rate was
way higher than the radiology rate. One study
written by RN and one by MD.
Thrombosis and phlebitis rate was higher for
the nursing insertions in both studies versus
the radiology insertions. That study would
prompt me to send all PICC line insertions to
radiology as there is a significat statistical
difference in thrombosis and phlebitis as
pointed out in Fong and Walshe studies.
However looking at medicine today why would it
not be mandatory to use US & MST to place all
Central lines regardless of setting. We
therefore are willing to accept bad patient
outcomes if we don't.
Success rate leading to patiend safety is well
proven and evidence based for the usage of
ultrasound
That alone is enough for me.
I think INS should have included the evidenced
based studies for the insertion of PICC lines
with ultrasound found in the AHRQ report. Were
those not considered in writing these standards
or were they insignificant as they were written
by physicians and not nurses. All the studies
cited in the AHRQ report were randomized,
blinded and prospective. You were on the INS
committee. Did these articles not get
considered or the the AHRQ report itself? I
know when the AVA guidelines are released these
articles will be definitely included. All
physician articles will be considered.
kokotis
________________________________
From: Lynn Hadaway [mailto:[EMAIL PROTECTED]
Sent: Mon 1/30/2006 1:23 PM
To: Kokotis, Kathy; Bev and Tim Royer; CAROLYN; [EMAIL PROTECTED]
Subject: RE: INS standard # 37
Well Kathy, I think that you are still comparing apples and oranges
when you compare IR inserted PICCs to a nurse-inserted service. I
think you are comparing data from multiple studies without going
through the strict analysis processes required for a meta-analysis.
When we were looking at the published data for the standards, I nor
anyone else on the INS standards committee found an article of any
kind comparing PICCs inserted with the standard through the
introducer to PICCs inserted using MST. You may claim that you can
compare data from multiple studies but until it has gone through a
true meta-analysis process and the peer-reviewed publications
process, it can not be used as a reference in a document such as the
standards.
I really do not think anyone is arguing that the AC inserted PICCs
are better than the ones placed above the AC, so I think we are
making a mountain out of a mole hill on this one! Lynn
At 11:54 AM -0700 1/30/06, Kokotis, Kathy wrote:
>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? Thanks
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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
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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
