Re: INS standard # 37

[Martha Pike]

Here's the long term facility (LTCF)care reality:
LTCF requests that referral sources send patients with appropriate  
line for therapy.
We provide them with specifics in writing.
Hospital does no discharge planning until day of discharge. (Hour of  
discharge?)
Hospital has no early VAD assessment process.
Neither radiology or the IV Team has staff available to place the  
PICC stat on Friday afternoon at 3 pm.
LTCF requests that patient remain in the hospital until the PICC is  
placed.
Hospital administration threatens the LTCF administration that they  
will receive no more referrals in the future unless they take this  
patient right now.
(OR in some cases they actually lie about the type of line the  
patient is coming with.)
An 83 year old patient with a long history of medical problems and  
multiple previous IV therapies arrives in LTCF with a peripheral IV  
for four weeks of vanco and no veins.
IV gets phlebitic - LTC nurse cannot restart it. They ask the on-call  
IV agency to place a peripheral because they think that will be less  
expensive. Of course that does not work either and the on-call IV  
nurse recommends a PICC.
Depending on coverage, the LTCF may have to absorb the entire cost of  
inserting the PICC and the cost of the xray, or they may have to  
absorb the total cost of transportation back and forth to the  
hospital with no reimbursement. The cost of inserting the PICC can  
deplete the entire reimbursement they receive from the third party  
payor for more than a week of the patient's stay in the facility. In  
some cases they facility will never  break even on this admission.
So.... LTCFs insist on contracts with the LTC pharmacy provider that  
includes PICC insertion at a rate that is one-third to one-half of  
what the pharmacy's subcontractor PICC insertion agency charges for a  
PICC insertion. Pharmacy has to absorb the extra cost.
Pharmacy does not want to / cannot afford to absorb the additional  
cost of ultrasound.
On-call IV agency would like to use it, but cannot figure out how to  
get reimbursed - or how to pay the initial costs of buying the machines.
Most agencies would need multiple machines due to geographic issues.  
The "central office" is most often an hour or two away from either  
the nurse's home or the patient.
So yes, it's certainly best practice, but there are still many  
obstacles and it's going to take us awhile to catch up in alternate  
sites...
/Martha

On Jan 31, 2006, at 7:38 AM, Chris Cavanaugh wrote:

Great Kathy, but LTC facilities in FL do not ask, some do, and some  
may get
a line, but I am very busy with those who don't. The company I work  
for
contracts with over 100 nurses to cover most of the nursing homes  
in the
state---if I have the US today to place 1 or 2 lines, how do I get  
it to
another nurse? Or do you suggest they buy 100 of them so we can  
each have
one? Nursing homes will not even pay an extra 10 cents for a  
quality diaper,
so I do not see them buying a $15000 US machine, or paying us more  
than the
$275 to place a line.  Option care is different, smaller territory,  
nurses
as employees, can go back and forth from the office. We all work  
from our
homes and our supplies are shipped to us. I am sure we are not the  
only
group who works this way.

Chris Cavanaugh, CRNI
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:owner- 
[EMAIL PROTECTED]
On Behalf Of Kokotis, Kathy
Sent: Monday, January 30, 2006 11:25 PM
To: Chris Cavanaugh; [EMAIL PROTECTED]
Subject: RE: INS standard # 37

Option Care in Sacramento only places PICC lines with portable  
ultrasound in
the home and nursing home as well as Roger in Las Vegas does the  
same.   I
can name you many others that have come to the plate.  I am sure  
some of you
are on this list.   What am I missing?  It is not an option.  I  
believe it
is all about the patient or am I so wrong. Please don't start my  
line.  I
personally choose to have all my VAD's done with US, and MST.  I  
guess this
time Kokotis is controversial.  Sleep on it.  How do you want your  
line
placed?  Do unto others as they do unto you.

As a sidenote those nursing homes should be insisting patients  
leave with an
appropriate device as they do not get paid for a line.

Kathy

________________________________

From: [EMAIL PROTECTED] on behalf of Chris Cavanaugh
Sent: Mon 1/30/2006 4:24 PM
To: [EMAIL PROTECTED]
Subject: FW: INS standard # 37






That is wonderful for your group of patients in CA, however, it is  
not a
reality for patients in FL. They get pushed out of hospitals every  
day with
a PIV, to both home and LTC. Many LTC facilities contract with  
independent
contractor nurses who work through pharmacies to place lines.  They  
LTC
facility pays the pharmacy, who pays us. They would never be able  
to handle
the cost increase for US, nor would US be an option, since we work  
from our
homes and have supplies shipped to us, there is no "central  
location" to go
get an US machine.

Chris Cavanaugh, CRNI
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:owner- 
[EMAIL PROTECTED]
On Behalf Of Cole, Darilyn - MET
Sent: Monday, January 30, 2006 3:43 PM
To: [EMAIL PROTECTED]
Subject: RE: INS standard # 37

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:owner- 
[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 nursing 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 nursing 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:owner- 
[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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