And someday ultrasound will be obselete and we will move to the next way to do it that is better kathy
________________________________ From: [EMAIL PROTECTED] on behalf of Leigh Ann Bowe-geddes Sent: Fri 2/3/2006 4:09 PM To: [EMAIL PROTECTED]; [EMAIL PROTECTED]; Kokotis, Kathy; [EMAIL PROTECTED] Subject: RE: INS standard # 37 Kathy: Exactly. Yes, there are financial considerations and logistical considerations, but there is always someone who can "build a better mousetrap" and figure out a way to make it work. Home care and SNF care are a financial challenge, but the need does not change. There are those who are making it work with providing US and MST, and others will follow. Heather says, "Ditto." Leigh An Leigh Ann Bowe-Geddes, RN, CRNI IV Therapy Specialist Infusion Services Department University of Louisville Hospital Louisville, KY 502-562-3530n >>> "Kokotis, Kathy" <[EMAIL PROTECTED]> 02/03/06 5:42 PM >>> Had dinner Wednesday night with an independent contractor who does nursing home lines. She uses 100% MST and is starting to incorporate ultrasound on all her line insertions. She just got her portable ultrasound machine. She is taking business from the non MST and US contractors here. You do the math in life. If someone comes in and offers the same price but uses better toys and has a higher success who gets the business? It is not rocket science. Is not capitalism the most wonderful thing in life? The United States is based on entrepreneurs and the ones who provides the top of the line in quality, performance and service at a reasonable cost often finish first. I don't have to worry whether you all get it and come to the table with MST and US. The reason is simple, those who do not come to the bar will be extinct either by their own facilities or by the outside contractor who does it a little bit better and safer. Business in a capitalistic socieity works that way. Kathy ________________________________ From: [EMAIL PROTECTED] on behalf of Chris Cavanaugh Sent: Wed 2/1/2006 6:23 AM To: 'Martha Pike'; [EMAIL PROTECTED] Subject: RE: INS standard # 37 Martha, you explained it perfectly. I think US and MST is great, in a hospital where it will be used daily. However, we as a group must remember that we all do not work in hospitals, and line placement is different depending on point of care, LTC, Homecare, etc. So before we preach what should ALWAYS be done, we need to temper our thoughts and think globally. It is great to have the resources you need, but many of us do not, and do the best we can with what we have. Thanks for the great explanation, hopefully it will clarify things. Chris Cavanaugh, CRNI -----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Martha Pike Sent: Wednesday, February 01, 2006 4:24 AM To: [EMAIL PROTECTED] Subject: Re: INS standard # 37 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 > > Upgrade Your Email - Click here! > <? > RunPromo&El=&SG=&RAND=19301&pa > rtner=hbtools> > > > > > > > > > > > > > > > ----------------------------------------------------- Confidentiality Disclaimer This message, including any attachments, is confidential, intended only for the named recipient(s) and may contain information that is privileged or exempt from disclosure under applicable law, including PHI (Protected Health Information) covered under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. If you receive this message in error, or are not the named recipient(s), please notify the sender or contact the University of Louisville Health Care I.S. helpdesk at 502.562.3637 to report an inadvertently received message.
