Picc Line Occlusions

Mrs. Toren Dukes currently serves at MD Anderson Cancer Center as a supervisor of the Registered Nurse (RN) Infusion Therapy department. She places Intravenous Lines (IV’s), Central Lines, Peripherally Inserted Central Catheter (PICC) lines and Ports for the entire hospital, both inpatient and outpatient services.

Lewis et al. explain in Medical-Surgical Nursing, a central line is a catheter placed into a large blood vessel for a patient who requires frequent or long-term access to the vascular system. The authors explain that catheters are used for the administration of high volume fluids, medications that are irritating (such as chemotherapy), long term pain medication, blood products, parenteral nutrition, and hemodialysis. Kaiser policy states four different types of central line used for patients: Centrally inserted catheters, peripherally inserted catheters, injection implanted ports and hemodialysis catheters. Centrally inserted catheters

PICC line- thin, soft, long catheter that is inserted into a vein in a child 's arm, leg or neck

Central venous catheters (CVC) have become the most efficient means to administer long-term, vital medical treatments in hospitalized patients. These catheters are used in almost all types of medical settings for purposes related to, “hemodynamics monitoring, parenteral nutrition, chemotherapy, hemodialysis etc.” (Gorji, Rezaei, Jafari, Cherati, 2015, p.1). Its clinical relevance has become extremely significant in relation to treating patients with all sorts of medical diseases who necessitate the administration of extravasation drugs that can solely be administrated by a CVC. Therefore, CVC have “led to reduction in duration of hospitalization, increment of safety and reduction of hospital charges” (Gorji et al., 2015, p.1). Its benefits

What is the code for a tunneled centrally inserted central venous catheter, without pump or port, in a 72-year-old patient?

A nurse-driven protocol is the recommended tool to be used by the nurse to remove catheters without orders following set CDC guidelines and prevent CAUTI

Article by Clancy (2009) explained central lines were a result of an estimated 250,000 blood stream infections and accounted for 30,000 to 62,000 patient deaths, then adding that each infection cost upwards of $36,000 and cumulatively add up to at least $9 billion in preventable costs annually. The article also explains how the mindset has changed from the cost of having a central line in place and expecting complications to lowering infection rates by an intentional interventional process/s. The article speaks of 5 basic steps to reduce CLABSI, hand washing, insertion techniques, skin cleansing, avoidance of certain sites and earlier removal of the CVC. Studies showed that these guidelines were only followed 62% of the time. The system was changed to ascertain that all the clinicians were in compliance. This prompted 5 interventions, education, a CVC insertion cart with all necessary equipment, physicians having to validate central line necessity, a concise checklist for bedside clinicians and the empower of nurses to stop procedures if guidelines were not followed. These low cost interventions from 11.3/1000 in catheter days in 1998 to zero in the fourth quarter of 2002.

Conducted over a 108-day span at the Hospital Clinico ‘San Carlos,’ a university hospital in Madrid, Spain, this randomized controlled trial evaluated both open and closed safety PIVCs, replacing the PIVC only as clinically indicated. Qualifying patients were 18 years of age or older, had a clinically planned PIVC (non-emergent), no other peripheral or central lines, and a temperature less than 38C. The sample included 1200 catheters to eliminate possible effects of IV insertion learning curves. Random computer selection generated the sample group into closed-system (COS) PIVCs and those with open-system (MOS) PIVCs. (Lopez et al., 2014)

When hearing the term PICC line it maybe rather confusing; that is unless you’re in the medical profession or have a family member that has one. First, the name that groups all of them together is called; a central venous catheter. A PICC line is just one of many. It is described as a peripherally inserted central catheter; otherwise called PICC line. It is a long, thin, flexible tube that is inserted under the skin into a vein in the arm rather than a vein in the neck or chest. (“WebMD”). The purpose of the PICC is to give medicines, fluids and blood products over an extended period of time. Those with cancer, kidney disease, diabetes, Lyme disease and total parenteral nutrition or (TPN) are common reason that a PICC line could be used for. PICC lines are thought to be a safer and simpler way to distribute needed treatments. Fewer than 10% of patients have trouble or generate a venous injury. (“Peripherally Inserted Central Catheters and Other Intravascular Devices”, 2014).

A percutaneous central line is entered into the patient’s subclavian vein. Because TPN solution is concentrated it is better to have CVC access in the subclavian vein so the solution has less distance to travel to its destination. This reduces the risk of the line clotting or damaging the vein.

The hospital’s current practice for CAUTI prevention includes the use of the HOUDINI protocol. This protocol features the acronym for the strict indications required for the insertion and the continued use of the urinary catheter (hematuria, obstruction, urologic surgery, decubitus ulcer, intake and output, no code/comfort care, and immobilization). The physician places the original order for the catheter with HOUDINI protocol and chooses the indication that applies. The order empowers the nurse to assess the patient daily for the continued indications and to remove any urinary catheter that no longer meets the indications. Hospital wide the protocol has been successful at decreasing CAUTI rates, however the target for CAUTI rates is 0 and our current rate is 1.37 per 1000 catheter days. Intensive care units have higher urinary catheter usage than in medical surgical or telemetry units (Halm, O’Conner, 2014). In MICU the most common indication for a urinary catheter is the need for accurate intake and output on patients with hemodynamic instability. Staff nurses are required to assess the patient daily and readdress the continued indications. In the past month no urinary catheters were removed

Central line bundle is a group of evidence-based practice strategy for patient with central catheters, when implemented together, produce better outcomes than implemented individually (Institute of health care improvement, 2010.). The main elements of central line bundle are hand hygiene, maximal barrier precaution upon insertion, Chlorhexidine skin antisepsis, optimal catheter selection, and daily review of line necessity with prompt removal of unnecessary lines Aseptic technique when using and caring for a central line catheter can decrease the chance of contamination in this critically ill infants. Staff education on adherence to aseptic technique and strict central line care guidelines are essential to decreasing bloodstream infections.

Only when it is absolutely necessary should a catheter be inserted into a patient. Every patient is assessed for the need for a Foley catheter. If the Foley is inserted, assessments are also then done daily to see if the need is still valid. If the reason is not justifiable the catheter must be removed from the patient (Joint Commission releases new NPSG for CAUTI, 2011). Nurses must follow guidelines while inserting indwelling catheters as well. Aseptic technique is critical to maintain during this process. The use of sterile equipment and a sterile procedure helps to reduce the risk of CAUTI. If in any way the catheter becomes contaminated during the process of insertion, the nurse should discard of the entire catheter and start with a new, sterile kit. Proper hand hygiene is very important before and after contact with indwelling catheters to decrease risk of infection. Maintenance of a close drainage is system is also important that way bacteria are not able to get in and cause infection (Revello & Gallo, 2013). Decreasing the number of times Foleys are inserted and how long they stay in for can help reduce the risk of CAUTI since the longer a Foley stays in, the higher the risk of infection becomes. Nurses must keep the catheter line patent, with no kinks to allow urine to flow freely through into the collection bag. When a urine sample must be obtained it must be done in a sterile

Central lines are often used or put in place in patients to prevent multiple IV access, administer fluids, medications, parenteral nutrition, blood products, and also for long term therapy treatments. Although, central lines are very useful for long term therapies, it can also result in infection if not properly cared for by healthcare providers and patients. According to the Centers for Disease Control and Prevention [(CDC)] (2012), central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and lead to increase costs to the U.S. healthcare system. Some of these bloodstream infections occur because central line catheters are not flushed properly, cleanse correctly, or dressed appropriately. The

4) Significance: This research shows that there is a gap in the evidence, but that the primary concern for nursing staff is to ensure that catheters are removed as soon as it is possible to do so.