On the issue of PICC placement, can we agree that there are many skilled and compassionate practitioners who work in nursing, angio suites and alternate care settings who do a good job? I think we can. And we can probably agree that one approach does not necessarily fit all clinical situations, no matter what the issue.
Let's also be careful to differentiate between opinion and fact in all our discussions...be this PICC placement or errors. One of our responsibilities as professionals is to carefully read anecdotal reports, research studies and othe professional publications with an eye to statistical rigor, adequate study design and potential bias. Please note that the report mentioned included many areas outside of radiology departments (such as cardiac cath labs). Let's agree to healthy intellectual discussion on strategy, outcomes and program development with an eye to critically evaluate reports which may not be exactly what they seem. Thanks >>> "Lynn Hadaway" <[EMAIL PROTECTED]> 01/30/06 6:43 PM >>> I would rethink that position in light of the recent article in the Washington Post reporting that medication errors that harm patients are seven times more frequent in the radiological service than in other hospital settings. This comes from an analysis by the USP. The issue appears to be many communication failures when patients move to this dept. So in my opinion, a PICC can and should be done at the bedside to reduce the workload and burden on radiology depts while they get control of this problem. I learned of this article through MedScape but can not get back to that article to give an address. Mike Cohen from ISMP is quoted in this article, so there could be more information about this from other sources. Lynn At 3:06 PM -0700 1/30/06, Kokotis, Kathy wrote: >I am beginning to believe all PICC lines should be placed in >radiology where there are: > >PICC, Stick and Run teams > >PICC lines placed with traditional peel-aways > >PICC lines placed without Ultrasound > >Radiology does it safer in those instances > >If I were the patient in any of the above I opt for the radiology >placed PICC line > >Kathy > >________________________________ > >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 >> >>Upgrade Your Email - Click here! >><> >> > > >-- >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 -- 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 ----------------------------------------- CONFIDENTIALITY NOTICE: This email and any attachments may contain confidential information that is protected by law and is for the sole use of the individuals or entities to which it is addressed. If you are not the intended recipient, please notify the sender by replying to this email and destroying all copies of the communication and attachments. Further use, disclosure, copying, distribution of, or reliance upon the contents of this email and attachments is strictly prohibited. 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