ditto Victoria Sallese VAT Johns Hopkins Hospital
----- Original Message ----- From: Raye Dillon <[EMAIL PROTECTED]> Date: Saturday, February 4, 2006 11:04 am Subject: RE: INS standard # 37 > i > i learned that discharge planning starts at the time of admission. > sounds like a lot of the problems are caused by poor planning and > thatssomething that is a case management issue. why would someone > startdischarge planning on the day of discharge on a friday > afternoon. dont > blame the LTCF or the payer for that. perhaps more time and money > shouldbe spent at the front end with good case management. > > >>> "Chris Cavanaugh" <[EMAIL PROTECTED]> 02/03/06 11:19 PM >>> > Wonderful, I would love to be that nurse---where do I get the > $15000 to > buy > an US machine, and do you know which nursing homes will pay more than > $275 > for a PICC line placement? That is the going rate in Florida, and no > LTC > facility will pay more than that when they know they can get it > for that > price. > > Chris Cavanaugh, CRNI > -----Original Message----- > From: [EMAIL PROTECTED] > [EMAIL PROTECTED] > On Behalf Of Kokotis, Kathy > Sent: Friday, February 03, 2006 5:57 PM > To: Martha Pike; [EMAIL PROTECTED] > Subject: RE: INS standard # 37 > > You all want to know what is going to happen in alternate care sites > like > nursing homes > > You are not going to like it > > This is how American business works or capitalism. The LTC is > forced by > the > hospital to take a patient with no line therefore they eat the > cost of > the > line or they force their pharmacy to eat the cost. The pharmacy > sends a > nurse to do the line with no high tech tools. The patient veins get > worse > and worse each year. Soon the pharmacy will make a decision based on > cost > loss ratio's. The final answer as each company cannot buy a > machine is > the > independent contractor who comes equipped and charges by the job. > > Life will be full of high-tech independent contractors in the > future who > do > nursing homes, hospitals, skilled care, home care, etc. Hospitals > willalso > be full of new infusion nurses but they will not be low tech. > They will > not > do peripheral IV's and dressing changes. I see it everyday. My > visionwill > be 75% complete in five years. The high tech VAD nurse is my ultimate > goal. > I started this in 1996 and I will not stop until it is done. I > believein > the last seven days I will have created another 15 new high tech PICC > nurses. These are hospitals that don't even do PICC lines or do lines > in > radiology. It is all about the money savings. My vision of the > futureis a > high tech PICC nurse that services every facility in the United States > that > is an employee or outside contractor. High tech does mean US and MST > > Kathy > > ________________________________ > > From: [EMAIL PROTECTED] on behalf of Martha Pike > Sent: Wed 2/1/2006 2:24 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] [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] [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] > > [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] [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] [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> > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > >
