Re: INS standard 37

[Halle Utter]

I am an independent contractor.  I bill the owner of the company who has the contracts with the various facilities.  I work in Colorado, in and around the Denver metropolitan area.  We do go north and south along I25 and sometimes up into the mountains.  There are 4 of us total. I began doing this 41/2 years ago, and at that time there was only myself and the gentleman who started the company.  We have since added two more people, and he mainly does the administrative end of the business now.  I also do IV related homecare, which is how I got started in this crazy business to begin with.  I did that for 20 years before moving into the independent contractor world and forming my own corporation.  We each have our own corporation.  We also provide education in the area of IV Therapy to the same facilities.  The need is huge in the LTC area.  I have huge respect for the nurses that work in LTC.  These nurses work so hard and often not in ideal circumstances.  I have placed PICCs in patients whose bed is on the floor due to seizure and fall risks.  So I have been down there on my knees, literally.  At times I have felt I was in a MASH unit!  I learned to be creative in homecare though.  I remember once arriving to give a home transfusion way out in the country with blood that would expire in 4 hours to find I had no IV Pole, so we jerryrigged an ironing board.  It worked, so what the hey!    In terms of what the facilities are billed, I honestly do not know.  I do know reimbursement rates vary widely across the country.  I know our rates vary some based on daytime versus weekend or evening hours.  Many of the facilities we service cannot justify the cost of a full time IV/PICC team as they just don't have the volume.  It is much more cost effective to use us on a case by case basis, plus they don't have to worry about turnover or vacation or illness coverage.  Some of the hospitals use us as a back up for IR.  If IR is too busy with cases then they will call us.  With the LTC facilities, I do know the billing is sort of round about.  We (the owner of the contracting company) bills the pharmacy who provides the IV drugs and supplies, which in turn bills it back to the facility.  I wish I knew more how that all worked.  Sometimes the patient does get transported into a hospital for placement due to billing issues, but in the long run that ends up costing much more because they always have to go by ambulance both ways.  It would be so much more cost effective for Medicare to pay for the line placement in the facility if there is no need for the patient to be admitted to a hospital.  They pay for the mobile portable Xray service to check the line.  Sort of reminds me of the homecare situation where Medicare won't pay for the IV antibiotics, but will pay for the nursing to teach and monitor the IV antibiotic administration, as long as the patient is homebound.  But that is a whole other can of worms.    The ultrasound is an invaluable tool for us though.  We were pretty darn good before we had them, but now our success rate is darn near 100%.  I would say it is probably above 95% for sure.  It is pretty unusual for us not to get the PICC, and we do bariatric patients too.  Some of those veins are really deep.  Without an ultrasound it would be difficult, if not impossible.   I wouldn't want to be without it.  I also think placing the line slightly higher in the arm keeps it from getting pulled out as much by the confused patient because it is easier to conceal.   Halle Utter, RN, BSN Intravenous Care, INC     ----- Original Message ----- From: Chris Cavanaugh To: 'Halle Utter' ; [EMAIL PROTECTED] Sent: Tuesday, January 31, 2006 5:42 AM Subject: RE: INS standard 37 Fantastic!—What state do you work in?  Do your nurses work for a company? Or are they independent contractors? Do you cover the whole state?  How many nurses do you have?  Your company must be doing well to afford an US machine for each nurse!  How much do you bill the LTC facility?    Chris Cavanaugh, CRNI From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]] On Behalf Of Halle Utter Sent: Monday, January 30, 2006 11:53 PM To: [EMAIL PROTECTED] Subject: INS standard 37       Our group places PICCs in all types of facilities mentioned, hospitals, SNFs, Rehab facilities.  We each carry our own Portable ultrasound and supplies with us and perform the procedure at the bedside.  Though I can't quote statistics, we have seen much less phlebitis since we got our ultrasounds and moved above the antecubital fossa.  I am sure there are multiple reasons for this.  The vein is bigger, there is less mechanical irritation, and the dressing adheres better on a smooth surface, (i.e not over a moving joint).  Also we are placing bigger lines with the increased demand for triple lumen PICCs.  The other thing I always do with my Tegaderm/Opsite is as I am applying it, I pull up on the "tail(s) of the PICC and pinch the biocclusive dressing together. This creates a much better seal, and avoids what I call "gaposis", (very official term I realize!)  By this, I mean the lifting of the TSM at the point where the tubing enters under the TSM, which over time leads right to the insertion site.  It also anchors the line more securely so if it is pulled on, the TSM acts as a "first resistance" before the tension is radiated up to the Statlok.  I've had very good success with this for years.      Halle Utter, RN, BSN Intravenous Care, INC