A Return to IV Teams?

As with many things in nursing things change; the pendulum swings back. I am hopeful that we are witnessing the return to the use of IV teams. In speaking with nurses from all over the country, I am hearing that there is resurgence of the use of IV teams; with many teams transitioning to become vascular access teams.

A major goal in hospitals now is to “target zero” i.e.; achieve zero percent intravenous catheter-related infections. The CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections 2011 recommendations re: designation of competent staff for insertion and maintenance of IV catheters states: “Specialized “IV teams” have shown unequivocal effectiveness in reducing the incidence of CRBSI, associated complications, and costs.” It is well documented in the literature that IV teams improve vascular access outcomes and are a valuable resource to staff.

Although peripheral short IV catheters (PIVs) are less likely to cause a blood stream infection than a central line; CRBSIs due to PIVs can occur. CRBSIs are a major threat, but just one of the many problems poor insertion technique and multiple start attempts can cause. With CMS – Medicare/ Medicaid no longer paying for catheter-related infections; the impact of a dedicated IV/vascular access team can significantly decrease patient morbidity and costs.

Say it is so…

When to Pick a PICC: Top 5 Signs That Your Patient May Need a PICC

1.       The IV site does not last.

If you’ve had a patient on intermittent medications for a few days, and the IV site had to be changed daily or close to it, and you suspect that the patient will need a few more days of IV therapy.  Chances are that this patient may be a candidate for a PICC line.  A rule of thumb is 5 days or more of IV therapy.1

2.       The patient has poor access.

These signs can be cumulative.  If the patient is expected to need IV therapy for 5 days or more AND their veins are difficult to find, definitely ask for a PICC order.

3.       Frequent blood draws are needed.

Particularly if number 2 is true, save the patient from the discomfort of multiple venipunctures – ask for a PICC order.

4.       Diagnosis indicates IV therapy post hospital discharge

Certain diagnoses will require moderate to long term IV therapy.  Deep tissue and organ infections such as an infected diabetic foot ulcer, osteomyelitis, or endocarditis require 4 to 6 weeks of IV antibiotics, and gastric diagnoses such as a small bowel obstruction will require moderate to long term IV nutrition.

5.       Caustic IV Medication Ordered

If the medication to be infused is known to be an irritant or vesicant (irritates the vein/ causes phlebitis or worse, tissue damage or necrosis), a PICC may be indicated.  Does the medication have a high or low pH? The rule is less than 5 or greater than 9 = do not infuse through a peripheral vein.  Extreme examples are Vancomycin at 2.5 or Phenytoin at 12.  How about the osmolality of the infusion, is it greater than 600 mOsm (example 10% dextrose)?  If so, a PICC may be indicated. 1

Of course there are other types of central line choices, however PICCs are often preferred over other central lines due to the convenience of insertion and removal,  and avoidance of some of the more serious insertion related complications of chest or neck placed lines.

That’s my top five reasons.  If you can think of more- we can keep the list going.  Maybe we can get this to the top 10 reasons to pick a PICC?


Reference: 1The Infusion Nurses Society Standards of Practice, 2011.

Is an IV Insertion Class or IV Certification a Requirement for RNs?

Proper education in IV catheter insertions as part of becoming credentialed in IV insertion procedures is a standard of practice in infusion nursing. It is recommended by national infusion, vascular access, infectious disease, and regulatory organizations guiding our practice. I got fired up today over a discussion I saw posted on the web. My interest peaked as I read a discussion in which an experienced RN advised a new grad that education in insertion of an IV catheter was not necessary prior to being clinically supervised in a few insertion procedures. I found this to be a bit irresponsible especially since education is so readily accessible to most of us.

It may be true that it was common in the past, and unfortunately true still that some RNs do not take training classes to insert IV catheters. It is better to be trained, and here is why: Although insertion of a peripheral IV catheter is a routine nursing procedure that may be performed several times in one nursing shift (depending on the work setting); we should not forget that IV insertion procedures are invasive procedures with the potential to cause patient injury. Frankly, some nurses have poor venipuncture and IV catheter insertion skills. At best poor skills may result in being unable to insert a catheter in a patient with good venous access, and at worst poor skills can cause a patient complication.

IV access guidelines and standards change and are updated frequently, and we’ve come a long way from the days of “see one, do one” for our IV access nursing skills orientation. It may not be a necessity for RNs to take a privately run class when employer run programs are available. Hospitals in general have come a long way and are aware of the value of teaching new nurses good techniques in this area, and they will often employ a nurse IV specialist (or a vendor) that is involved in the development of policy and education in infusion therapy and IV access. An IV insertion class is often part of a new grad’s or other new nurse employee’s orientation education. This needs to occur before the new nurse performs clinically supervised initial insertions.

For those nurses out there considering whether to take a class or not; I’d advise that if your employer does not offer an education program- seek one out on your own. Doing what it takes to become more knowledgeable in nursing procedures is just good nursing practice. The majority of the attendees to our IV insertion courses are experienced RNs who seek out the education on their own. If you have considered taking an IV insertion course and decide not to take a class; I’d suggest reviewing policy and procedures at your employing facility prior to precepting in the procedure. If I were a new grad today; I would also obtain and review a copy of the Infusion Nurses Society (INS) Infusion Nursing Standards of Practice. Most U. S. health care facility IV therapy departments should have a copy. A copy can be purchased from the INS online.

How to Start IVs: 8 Tips to Improve Your IV Success

Although you may know how to insert a peripheral IV catheter; if you are having trouble starting IVs on patients with “difficult” veins- you are not alone. Getting an IV catheter started with one attempt and without any undo patient anxiety can be difficult to accomplish at all times. Not being able to find or choose a good vein site in my estimation is 60 to 70% of the problem most nurses have starting an IV. In this post, I have listed 8 tips to finding veins.

The first 2 tips are pretty basic – we sometimes need reminding that the basics are done for a reason.

1. Assess the patient’s veins with the tourniquet in place!

Although you may see the veins well without a tourniquet on; applying one will still make a difference and it may even show an alternative location better than the one you’ve found without it . Have the patient lower their hand below heart level and open and close the fist- flexing their muscle (strong like an weight lifter- not flaccid like, um my great grandmother). Next it is important to have the patient relax the fist and arm prior to the venipuncture. Ok, I am off my soapbox.

2. Check your tourniquet application.

If you have difficulty identifying a vein; it may simply be your tourniquet application. ALWAYS check this first. A too tight or too loose tourniquet can cause veins not to distend. If the tourniquet is too tight; you cut off their arterial circulation (always check their pulse and coloring). A too loose tourniquet = no blood pooling to distend the veins below it. Check and re-apply the tourniquet

3. Warm up the arm

Use instant warm packs applied to the IV area for 5 and even better: 10 minutes prior to prepping the skin. Always test the warm pack to avoid burns prior to application. Use of preset commercial devices like this are preferred to old methods of warming up towels and such in microwaves- there is too much of a risk of burns, and many employers forbid use of techniques like this in their policies.

If you’re working in home infusion- have the patient take a warm shower and cover their arms with long sleeves just before your visit, or if that is not possible run warm running warm water at a sink over their arm at the visit (not hot, test it carefully & again avoid burns!)

4. Hydrate the patient

Whenever possible, and not contraindicated- have the patient drink non-caffeinated fluids prior to the IV start. Even 3 cups can make a big difference in a dry patient. The old standby of encouraging 8 cups of fluid/water a day can be followed when time permits prior to the IV start.

5. Use palpation to find veins

In addition to visualizing veins, it is important to palpate using your index and third finger pad to evaluate the vein’s resilience, patency, valves, size. Is the vein straight, soft and bouncy (refills fast), and large enough to accommodate the catheter needed for the IV therapy? Or is the vein thin, flat (does not refill well), thready, hardened, irregular in shape, or have bumps (valves along the path chosen)? You’re looking for the latter of course.

6. Use visualization devices when available

Current Infusion Nurses Society (INS) Standards of Practice support use of visualization devices when performing IV insertion procedures. Devices like transilluminator lights and ultrasound machines decrease the number of venipuncture attempts made on patients with difficult venous access. However, the average non-PICC team nurse is not trained in using ultrasound for vascular access. Yes, old school nurses will tell you that a flashlight or other light works too, but they can cause burns. Devices made specially for visualizing veins are designed for that purpose and are much safer. There are a few on the market- the devices I favor lately for pricing, size, and ease of use are the Veinlite pocket devices.

7. Use a blood pressure cuff on a low setting

Instead of a tourniquet for patients with really poor access, try using a manual blood pressure cuff on a low setting around 60 mm Hg or less (below the patients diastolic BP, check it prior to application). Use a kelly clamp on the tubing used inflate the cuff to allow for easy deflation by opening the clamp once the catheter is in place.

Use good judgement, and caution as you may want to avoid using this technique in patients with delicate skin and/or fragile vessels (vessels with a potential to blow easily from the extra pressure). Examples of this are patients on anticoagulants who bruise &/or bleed easily, patients on steroid therapy, or patients who have paper thin skin that may tear easily.

Open the kelly clamp to deflate the cuff once you have visualized a blood return in the catheter flash back chamber and have partially advanced the catheter- ensuring the catheter is in good position. You can continue to advance the catheter after the BP cuff has deflated. Also with this technique as with use of a tourniquet; monitor the patients circulation to ensure they have a radial pulse and the arm/hand is not discolored and remove the BP cuff if indicated.

8. Prevent vein “rolling”

You thought you found a good vein, but then it wasn’t in the same spot after you performed the venipuncture. Often patients will tell you “my veins roll”, and they’ll tell you this because that is what nurses have told them. Hold traction on the skin below the IV venipuncture site, using the thumb side of your non dominant hand is best for most sites. Pull the skin downward to prevent the vein from moving above as you perform the venipuncture. Keep the hand and fingers holding traction lowered enough to keep out of the way of performing the venipuncture. I will post pictures to this area as a sample soon.

What is that you said? Did you say, but the vein disappears when I hold the skin taut? Yes that often happens; you simply release the skin long enough to re-visualize where the vein is for a second or two (or just keep a nifty transilluminator in place instead), and reapply traction again to perform the venipuncture. If you hold the skin appropriately 99% of the time; the vein will not roll. Again use good judgement and caution, do not hold the skin so tight that you hurt the patient or cause a skin tear!

PICC Certification: What Does It Mean?

I am starting off our blog with this topic because we often get the question- After I take a class, am I then PICC certified? or What is involved in becoming PICC certified? I have always tried to be careful to not loosely use the words “PICC certification” and instead used words to describe meeting competency criteria for independence in PICC insertion and care. The problem primarily is with the use of the word “certification”. On their website the American Board of Nursing Specialties (ABNS) defines certification as “the formal recognition of the specialized knowledge, skills, and experience demonstrated by the achievement of standards identified by a nursing specialty to promote optimal health outcomes”. Nurses that insert and care for PICC line catheters as a primary part of their job may opt to specialize in infusion nursing, but the performance of PICC insertion and care procedures does not qualify as a separate nursing specialty. In spite of this fact, establishing and obtaining competence in PICC insertions is commonly referred to within health care as obtaining “PICC Certification” or becoming “PICC certified”. Therefore many clinicians looking to obtain training in PICC insertion and care procedures often search for PICC certification programs. The words “PICC certification” do not have a standard definition; i.e. there is no non-profit third party organization that is dedicated to defining and establishing standards for PICC certification. In health care, there are other skills that have non-profit organizations that establish the criteria for certification. CPR certification overseen by either the American Heart Association or the Red Cross is an example of this. But since there is no organization like this in existence for PICC certification, the establishment of criteria for credentialing clinicians in PICC certification is done by organizations involved in training clinicians in PICC care and insertion procedures. This includes health-care facilities and continuing education companies. Program content and requirements can vary widely.

With such a wide variety of programs available, how do you choose a PICC education program to best suit your needs? Fortunately, state guidelines and organizations such as the Infusion Nurses Society (INS) exist. The INS is a non-profit organization established in 1973 to ensure high quality in infusion therapy for patients and to establish standards and guidelines to be followed by nurses involved in the specialty practice of infusion therapy care and procedures. The INS has published standards of practice position papers that require clinicians to possess and demonstrate specific and comprehensive knowledge related to PICC insertion and care. Another important organization is the Association of Vascular Access (AVA), AVA is a multidisciplinary organization composed of clinicians, educators, regulators and manufacturers from the medical field of Vascular Access. Part of AVA’s published mission is to improve patient safety, comfort and outcomes; and optimize professionals’ knowledge and skills in vascular access. The best programs will have their education and clinical assessment criteria founded on the basis of standards, guidelines, and recommendations set by government and leading industry organizations such as the INS and AVA and organizations like the Center for Disease Control (CDC), the Joint Commission (JCHAO), and the Institute for Healthcare Improvement (IHI).

Unfortunately, the expectation that one can be certified in PICC insertion simply by taking a one day class is encouraged by companies that advertise certification granted solely after taking their one day, 8 hour or so PICC training class. Is that true, and possible? Not likely. The more likely scenario is that the ad leaves out the clinical precepting requirement. Or it is possible that the ad is correct and all that is required for PICC “certification” by such a company is an 8 hour class room only experience with maybe a few insertions on class mates. I have to ask myself would I want a clinician finishing such a program inserting a PICC line in me or one of my family members? My answer?… Uhm, no.

A reputable company that provides continuing education in infusion related procedures stays current with industry practices and established guidelines and passes on applicable information to their trainees. The INS has published a position paper on PICCs in which the qualifications for insertion section states that the INS supports that a licensed physician or registered nurse that is educated and has demonstrated competency can insert a PICC. Regarding RNs, the position paper goes on to state: “The RN must have demonstrated competency and proficiency in intravenous therapy, including the insertion of short peripheral catheters, and a solid understanding of central venous catheters. Additionally, the RN should complete an educational program for PICC insertion. The education program must include both theoretical content and clinical instruction on an anatomical model. Once the nurse has validated initial competency, there must be an ongoing continuum of competency. An organization or facility must establish a program for maintaining clinical competency for device insertion within its chosen framework. Ongoing competency validation includes the knowledge and ability to perform the insertion safely and knowledge of appropriate care and maintenance strategies. All facilities involved with insertion of PICCs should have formal organizational policies and procedures in place that provide clear lines of responsibility for insertion, care, and maintenance. Finally, qualifications for inserting PICC lines must be consistent with state and federal laws.” Potential trainees should be aware of the PICC line procedure criteria that govern their practice in their state of residence. For example in Connecticut (our state of primary operations); the Board of Examiners for Nursing has published specific guidelines that spell out requirements for registered nurses inserting and removing specialty lines like PICC line catheters. These guidelines are very similar to the INS PICC position paper regarding qualifications for insertion and in addition the Connecticut guidelines include a requirement that a nurse must possess “substantial knowledge and experience in intravenous therapy” (click here to view a copy of these guidelines). To meet established industry criteria for PICC insertion and care the completion of a period of supervised clinical experience following a PICC insertion education class is a necessity. In addition to the technical skills, PICC insertion and care requires patient assessment and critical thinking skills that include the ability to judge when to change course in the procedure.

How do clinicians obtain PICC certification after completion of a PICC Resource class? There are two ways to complete training and become certified after a class, the traditional way through the clinician’s employing facility, or through a private PICC education company like ours. The traditional option is the way most clinicians have completed their training and become independent in PICC insertion and care procedures. This involves becoming credentialed by the employing facility after meeting their established policy and competency requirements that includes completion of a supervised clinical component. After our PICC insertion education programs; a client may use our tools to document meeting competency requirements. Whichever method is used; documentation and clinical supervision of the initial insertions and independence in the procedure is required. Does certifying either of these ways confer a national certification? Individual facility conferred certification is considered an “in-house” type certification that may not be recognized if a clinician leaves to practice at an outside facility. In actual practice if the PICC education program completed was administered by a national company and the clinician can produce proof of competency with an accepted number of supervised and independent clinical insertions; it is likely that the new facility will accept the certification. Regarding PICC Resource Associates, LLC programs– we are a national organization in that we offer continuing education programs that are accepted throughout the U.S. Our program contact hours are offered through an American Nurses Credentialing Center (ANCC) approver and they are valid nationally.

November 1st 2010: I have updated this post. The previously mentioned Asssociation for Vascular Access (AVA) has started the Vascular Access Credentialing Corporation (VACC), and they now offer a certification in Vascular Access. See my reply dated 10/31/2010 to a question on the original post for details.