10/29/2012

1

Difficult Vascular AccessDifficult Vascular AccessSituations Situations

Nadine Nakazawa, RN, Nadine Nakazawa, RN,

BS, OCN, CRNI, VABS, OCN, CRNI, VA--BCBC

November 1November 1stst , 2012, 2012

DisclosuresDisclosures

•• Nadine Nakazawa is on the speakersNadine Nakazawa is on the speakers’’ bureaus bureaus for:for:–– CarefusionCarefusion–– Genentech Genentech –– Johnson & Johnson Wound ManagementJohnson & Johnson Wound Management–– Vasonova / TeleflexVasonova / Teleflex

•• There are no offThere are no off--label discussions of products in label discussions of products in this presentation.this presentation.

•• TodayToday’’s presentation is supported by an s presentation is supported by an independent educational grant from Teleflex. independent educational grant from Teleflex.

Case Study #1Case Study #1

•• Patient on the PICC schedule:Patient on the PICC schedule:

•• 46 y.o. woman in the ICU with a dx of 46 y.o. woman in the ICU with a dx of respiratory failurerespiratory failure

Review of medical record reveals:Review of medical record reveals:

•• Morbid obesity: > 450 lbs, 5Morbid obesity: > 450 lbs, 5’’66””

•• C. difficile colitisC. difficile colitis•• EndEnd--stage heart failurestage heart failure

•• On CVVH: Continous VenoOn CVVH: Continous Veno--Venous Venous Hemodialysis for acute renal failure & fluid Hemodialysis for acute renal failure & fluid

overloadoverload

What else do you want to know?What else do you want to know? Labs: WBCLabs: WBC

•• RisingRising? Falling?? Falling?

•• Does it matter?Does it matter?

•• Why?Why?

•• Evidence?Evidence?

•• 16K16K

10/29/2012

2

Acute Renal Failure: Acute Renal Failure:

What do you do?What do you do?

•• Nephrology Nephrology consultconsult

•• Which arm do you place the PICC? Or do Which arm do you place the PICC? Or do

you avoid a PICC at all?you avoid a PICC at all?

•• Prognosis vs accessPrognosis vs access

Fistula FirstFistula First

•• For pts with ESRD, a native arterioFor pts with ESRD, a native arterio--venous venous

(AV) fistula is the device of choice for long(AV) fistula is the device of choice for long--term access for hemodialysis.term access for hemodialysis.

•• AVF has lowest infection & thrombosis ratesAVF has lowest infection & thrombosis rates

•• Can last yearsCan last years

•• Potential pool for ESRD: CKD Potential pool for ESRD: CKD –– 26 million26 million•• Risk factors: HTN, diabetes, smokingRisk factors: HTN, diabetes, smoking•• Most are unawareMost are unaware

Chronic Kidney DiseaseChronic Kidney Disease

•• CKD is defined as either kidney damage or CKD is defined as either kidney damage or GFR <60 mL/min/1.73mGFR <60 mL/min/1.73m2 2 for ≥ 3 months (NKF for ≥ 3 months (NKF 2002)2002)

•• Stage 3: Stage 3: Moderate Moderate ��GFR 60GFR 60--89 89 ml/min/1.73mml/min/1.73m22

•• Stage 4:Stage 4: SevereSevere ��GFR 30GFR 30--59 59 ml/min/1.73mml/min/1.73m22

•• Stage 5:Stage 5: Kidney failureKidney failure; GFR < 15 ; GFR < 15 ml/min/1.73mml/min/1.73m2 2 or dialysisor dialysis

NKF / ASDIN / AVANKF / ASDIN / AVA

•• National Kidney Foundation: National Kidney Foundation: www.nkf.orgwww.nkf.org

•• American Society of Diagnostic and American Society of Diagnostic and Interventional Nephrology: Interventional Nephrology: www.asdin.orgwww.asdin.org

•• Association for Vascular Access: Association for Vascular Access:

www.avainfo.orgwww.avainfo.org

NKF: NKF: ““Fistula FirstFistula First””AVA / ASDIN Position PaperAVA / ASDIN Position Paper

•• When practitioners are faced with whether to use a When practitioners are faced with whether to use a

PICC in a pt with CKD, PICC in a pt with CKD,

–– Review each ptReview each pt’’s estimated glomerular s estimated glomerular filtration rate (eGRF) to identify CKD &/or filtration rate (eGRF) to identify CKD &/or

classify the stageclassify the stage–– Obtain nephrology consult if CKD is presentObtain nephrology consult if CKD is present

–– Hand veins if possibleHand veins if possible–– Use a smallUse a small--caliber IJ CVC rather than a PICCcaliber IJ CVC rather than a PICC

–– Consider alternatives to PICCs whenever Consider alternatives to PICCs whenever possible (Saad & Vesely, 2004)possible (Saad & Vesely, 2004)

Discussion with ICU TeamDiscussion with ICU Team

•• ARF is an independent predictor of morbidity ARF is an independent predictor of morbidity & mortality in critically ill pts& mortality in critically ill pts

•• Most have multiorgan failure, severe sepsis, Most have multiorgan failure, severe sepsis, DM, a hypercatabolic state, & a requirement DM, a hypercatabolic state, & a requirement for very large volumes of fluidfor very large volumes of fluid

•• ICU RN told me she had:ICU RN told me she had:–– Pulmonary hypertensionPulmonary hypertension–– EndEnd--state heart failurestate heart failure–– Liver failure, renal failureLiver failure, renal failure–– 450 + lbs450 + lbs

10/29/2012

3

Vascular AccessVascular Access

•• LIJ trialysis CVCLIJ trialysis CVC

•• L subclavian SwanL subclavian Swan--Ganz lineGanz line•• R subclavian implanted port (for frequent R subclavian implanted port (for frequent

transfusions for GI bleeding)transfusions for GI bleeding)

•• R brachial upper arm arterial lineR brachial upper arm arterial line•• History of thrombosisHistory of thrombosis

Damage to VasculatureDamage to Vasculature

•• An AV fistula is created by connecting an An AV fistula is created by connecting an

artery to a vein.artery to a vein.•• Any damage to the upper arm veins such as Any damage to the upper arm veins such as

with PICCs, or to the subclavian veins with with PICCs, or to the subclavian veins with

subclavian insertions of CVADs, may cause subclavian insertions of CVADs, may cause permanent thrombosis & stenosis precluding permanent thrombosis & stenosis precluding

the successful build of an AV fistula.the successful build of an AV fistula.

Complex Patient: Complex Patient:

What are your concerns?What are your concerns?

•• PICC or no PICC?PICC or no PICC?

•• Evaluation of available sites:Evaluation of available sites:•• Morbid obesity: Morbid obesity:

ResolutionResolution Case Study #2Case Study #2

•• 62 y.o. female w/ dx cellulits of L lower leg62 y.o. female w/ dx cellulits of L lower leg

•• Needs PICC for 4 weeks of IV antibxNeeds PICC for 4 weeks of IV antibx

10/29/2012

4

WWhat more do you want to know?hat more do you want to know?

•• Labs: WNLLabs: WNL

•• Afebrile for 48 hoursAfebrile for 48 hours

•• Most recent BCs: NGTDMost recent BCs: NGTD

•• CoCo--morbidities: DM2, BMI 30morbidities: DM2, BMI 30

•• H&P reveals H&P reveals hxhx of breast CAof breast CA

DDiscussion w/ Patientiscussion w/ Patient

•• Ask patient: which breast? LND?Ask patient: which breast? LND?

•• 10 years ago: R mastectomy w/ LND10 years ago: R mastectomy w/ LND

•• L lumpectomy w/ sentinel node L lumpectomy w/ sentinel node bxbx

•• OK to place PICC in L arm?OK to place PICC in L arm?

Risk of BCRLRisk of BCRL

•• Kwan, M. et al. Kwan, M. et al. Kwan, M, et al: Arch Surg. 2010 Nov;145(11):1055-63.

•• Risk factors for lymphedema in a prospective breast Risk factors for lymphedema in a prospective breast cancer survivorship study: The Pathways Studycancer survivorship study: The Pathways Study

•• 997 997 ptspts followed for 20 monthsfollowed for 20 months

•• 13% risk of BCRL in early breast CA survivors13% risk of BCRL in early breast CA survivors

•• Even 1 LN removed increasedEven 1 LN removed increased risk of lymphedemarisk of lymphedema

•• Recommend small bore tunneled CVCRecommend small bore tunneled CVC

•• Discussion w/ MD & Discussion w/ MD & ptpt

•• Lymphedema is a serious, chronic conditionLymphedema is a serious, chronic condition

Case Study #3: Case Study #3:

EndEnd--stage Liver Failurestage Liver Failure

•• 46 y.o. male with ESLD due to alcoholic 46 y.o. male with ESLD due to alcoholic cirrhosis (hx of alcohol intake since age 12), & cirrhosis (hx of alcohol intake since age 12), & + Hepatitis B+ Hepatitis B

•• Admitting dx: hepatic encephalopathy Admitting dx: hepatic encephalopathy •• Had a TIPSS (transjugular intrahepatic Had a TIPSS (transjugular intrahepatic

portasystemic stentportasystemic stent--shunt) procedure 3 days shunt) procedure 3 days agoago

•• Now febrile & bacteremic by blood culturesNow febrile & bacteremic by blood cultures•• PICC has been orderedPICC has been ordered

Concerns?Concerns?

•• Labs: WBC trending downwardLabs: WBC trending downward

•• INR: 3INR: 3•• Platelet Platelet ctct: 20K: 20K

•• OK to place PICC? OK to place PICC?

•• Resolution:Resolution:

Case Study #4:Case Study #4:

•• 44 year old female44 year old female

•• Dx: bacteremiaDx: bacteremia

•• Other coOther co--morbidities: morbidities:

–– progressive encephalopathy of unknown originprogressive encephalopathy of unknown origin

–– kidney transplant 1 year agokidney transplant 1 year ago

–– now in renal failure and on peritoneal dialysisnow in renal failure and on peritoneal dialysis

•• Vascular access: Pt has a nonVascular access: Pt has a non--functioning AV fistula functioning AV fistula in L forearm, and a PIV in R forearmin L forearm, and a PIV in R forearm

10/29/2012

5

Complicated Renal FailureComplicated Renal Failure

•• A PICC line has been ordered for 6 weeks of IV A PICC line has been ordered for 6 weeks of IV

antibioticsantibiotics

•• What else do you want to know? What else do you want to know?

LabsLabs

•• WBC 14K, down from 18K yesterdayWBC 14K, down from 18K yesterday

•• Afebrile for 24 hoursAfebrile for 24 hours

•• CreatCreat 5, other labs WNL5, other labs WNL

ComplicationsComplications

•• Discussed with nephrologist and primary Discussed with nephrologist and primary

medicine team re: placing a PICC in R arm.medicine team re: placing a PICC in R arm.

•• Pt has had multiple PIVs in R arm.Pt has had multiple PIVs in R arm.

•• Attempted PICC placement, but unable to Attempted PICC placement, but unable to advance past shoulder area.advance past shoulder area.

•• Discussed small bore tunneled CVC with primary Discussed small bore tunneled CVC with primary

team.team.

ResolutionResolution

•• PtPt gets peritoneal dialysis, managed by familygets peritoneal dialysis, managed by family

•• Nephrologist ordered Nephrologist ordered antibxantibx to be delivered to be delivered

via dialysate QDvia dialysate QD

•• No PICC or CVC neededNo PICC or CVC needed

Case Study #5: Complex Congenital Case Study #5: Complex Congenital

Cardiac PatientCardiac Patient

•• 57 year old female admitted 2 days ago to CCU57 year old female admitted 2 days ago to CCU

•• Admitting diagnosis: fever, septicemiaAdmitting diagnosis: fever, septicemia

•• Medical history: Medical history: –– born with a single ventricleborn with a single ventricle

–– Had 1Had 1stst surgery at age 18 (1968) surgery at age 18 (1968)

–– Had 2 subsequent Had 2 subsequent surgeriessurgeries

–– Glen procedure: SVC connected to pulmonary arteryGlen procedure: SVC connected to pulmonary artery

•• Labs: WBC trending down & nearly normal, Labs: WBC trending down & nearly normal, other labs WNLother labs WNL

PICC PlacementPICC Placement

•• PICC placed but unable to get PICC tip into PICC placed but unable to get PICC tip into

distal SVC per tip navigation systemdistal SVC per tip navigation system

•• Why???Why???

•• Resolution:Resolution:

10/29/2012

6

Case Study #6: Case Study #6:

Lack of Blood ReturnLack of Blood Return

•• Pt is newly admitted for recurrent knee pain.Pt is newly admitted for recurrent knee pain.

•• Pt has had 8 knee surgeries, and has had a Pt has had 8 knee surgeries, and has had a PICC line in for past 6 months for longPICC line in for past 6 months for long--term term

antibioticsantibiotics

•• Staff nurse pages PICC nurse: Staff nurse pages PICC nurse: ““No blood No blood

return. Itreturn. It’’s hard to flush.s hard to flush.””How do you approach this situation?How do you approach this situation?

•• What is the infusion program?What is the infusion program?

•• IV rifampin very unstable & can precipitate IV rifampin very unstable & can precipitate out easilyout easily

•• Go over Declotting Procedure w/ staff RNGo over Declotting Procedure w/ staff RN

•• Look at PICC exit site: make sure there are no Look at PICC exit site: make sure there are no kinks in external portion of catheterkinks in external portion of catheter

How would you problem How would you problem

solve this?solve this?

•• CXR: to determine PICC tip locationCXR: to determine PICC tip location

•• MalpositionedMalpositioned PICC tips: outside of distal PICC tips: outside of distal SVC or SVC or cavocavo--atrial junctionatrial junction

•• Upper SVC or above increases risk of Upper SVC or above increases risk of

thrombosis by 60%thrombosis by 60%

Instill ThrombolyticInstill Thrombolytic

•• Instill alteplase 2 mg in 2 ml (Cathflo) slowlyInstill alteplase 2 mg in 2 ml (Cathflo) slowly

•• Leave for 30 min; check blood returnLeave for 30 min; check blood return

•• If NO brisk blood return, leave for additional If NO brisk blood return, leave for additional 90 min (2 90 min (2 hrshrs total)total)

•• If still no brisk blood return, instill 2If still no brisk blood return, instill 2ndnd dose of dose of alteplase 2 mg (Cathflo)alteplase 2 mg (Cathflo)

Case Study #7Case Study #7

•• Received phone messageReceived phone message

•• ““My PICC dressing was done yesterday at my My PICC dressing was done yesterday at my

doctordoctor’’s office. My skin is blistered & peeling s office. My skin is blistered & peeling

under the dressing. Can you call me & tell me under the dressing. Can you call me & tell me what to do?what to do?””

What are your concerns or ??sWhat are your concerns or ??s

10/29/2012

7

My concerns or ??sMy concerns or ??s

•• Name & DOB or MR#Name & DOB or MR#

•• Look up ptLook up pt’’s hx & info re: PICCs hx & info re: PICC

•• Date PICC laced 2Date PICC laced 2--1/2 months ago for TPN1/2 months ago for TPN

•• Dx: persistent gastroparesisDx: persistent gastroparesis

•• Called pt:Called pt:

–– Does she anticipate longDoes she anticipate long--term TPN?term TPN?

–– What has been her discussion with MD?What has been her discussion with MD?

–– Has food via GI tract been r/oHas food via GI tract been r/o’’d?d?

DDiscussion w/ Patientiscussion w/ Patient

•• Has she had a discussion re: long term plans?Has she had a discussion re: long term plans?

•• Anticipate long term TPN?Anticipate long term TPN?

•• Alternative access? E.g., tunneled CVCAlternative access? E.g., tunneled CVC

•• PtPt said she was happy w/ PICC except for skin said she was happy w/ PICC except for skin

blisteringblistering

•• PtPt never heard of a tunneled CVCnever heard of a tunneled CVC

•• MD never discussed tunneled CVCMD never discussed tunneled CVC

RecommendationsRecommendations

•• PtPt stated her gastroenterologist seemed very stated her gastroenterologist seemed very UNUN--interested in her medical problemsinterested in her medical problems

•• Recommended:Recommended:–– Change dressing: IV Advanced by 3MChange dressing: IV Advanced by 3M

–– She switch to MD who takes care of She switch to MD who takes care of ptspts w/ long term w/ long term TPNTPN

–– Oley Foundation: talk w/ someone w/ a tunneled CVC Oley Foundation: talk w/ someone w/ a tunneled CVC & long& long--term TPNterm TPN

–– Told Told ptpt to make decision in 1to make decision in 1--2 weeks; time helps2 weeks; time helps

–– Sent letter to MD for referral to IR Vascular Access Sent letter to MD for referral to IR Vascular Access Service for tunneled CVCService for tunneled CVC

CCase Study #8ase Study #8

•• H6 H6 yoyo female w/ recurrent female w/ recurrent thrymicthrymic CA (has CA (has

already had chemo & XRT over past 1.5 already had chemo & XRT over past 1.5 yrsyrs))

•• Needs PICC for adjuvant chemo in Needs PICC for adjuvant chemo in

conjunction w/ XRTconjunction w/ XRT

AAny concerns or ??sny concerns or ??s IImportant to read H&Pmportant to read H&P

•• Originally dxOriginally dx’’d in 2009: presented w/ night d in 2009: presented w/ night

sweats, worsening R sided chest pain, & sweats, worsening R sided chest pain, & engorgement of superficial chest painsengorgement of superficial chest pains

•• 2010: CT showed a large mediastinal mass2010: CT showed a large mediastinal mass--> CT > CT

bx showed thymic CAbx showed thymic CA--> neoadjuvant chemo> neoadjuvant chemo

•• O7/2010: resection of thymic mass, R O7/2010: resection of thymic mass, R innominate vein & pericardium; tumor extended innominate vein & pericardium; tumor extended

into mediastinal pleural & adventitia of into mediastinal pleural & adventitia of innominate veininnominate vein

10/29/2012

8

•• 20102010--2011: 2011: cchemo /XRThemo /XRT

•• 6/2012: Chest CT: known SVC occlusion w/ 6/2012: Chest CT: known SVC occlusion w/

innumerable chest wall collaterals & innumerable chest wall collaterals &

reconstitution of the distal SVC via the reconstitution of the distal SVC via the azygousazygous veinvein

•• 7/2012: PE: engorgement of superficial chest 7/2012: PE: engorgement of superficial chest veins as well as over proximal arms bilaterallyveins as well as over proximal arms bilaterally

WWhat are your concerns? hat are your concerns?

What do you do?What do you do?

•• MDs have access to the same infoMDs have access to the same info•• BBut may not understand venous access issuesut may not understand venous access issues

•• Vascular access clinician may need to explain Vascular access clinician may need to explain these issues, and make recommendations for these issues, and make recommendations for alternative accessalternative access

•• Referred to IR Vascular Access Service for Referred to IR Vascular Access Service for tunneled CVC transhepatic or transthoracic tunneled CVC transhepatic or transthoracic approachapproach

•• Extensive discussions, clear note, referral to IR Extensive discussions, clear note, referral to IR VAS & phone discussionVAS & phone discussion

The right line for the right The right line for the right patient at the right time!patient at the right time!

Thank you!Thank you!

ReferencesReferences

•• Fistula First Breakthrough Initiative CoalitionFistula First Breakthrough Initiative Coalition•• AVA / ASDIN Position PaperAVA / ASDIN Position Paper•• www.nkf.orgwww.nkf.org•• www.asdin.orgwww.asdin.org•• www.avainfo.orgwww.avainfo.org•• Kwan, M, et al. Risk factors for lymphedema in a Kwan, M, et al. Risk factors for lymphedema in a

prospective breast cancer survivorship study: the prospective breast cancer survivorship study: the Pathways Study: Arch Surg. 2010 Nov; 145(11): 1055Pathways Study: Arch Surg. 2010 Nov; 145(11): 1055--63.63.

•• Nakazawa, N. Challenges in the Accurate Nakazawa, N. Challenges in the Accurate IdentificatoinIdentificatoin of the Ideal Catheter Tip Location. of the Ideal Catheter Tip Location. J. of the Association for Vascular Access (JAVA), J. of the Association for Vascular Access (JAVA), 2010, Vol 15, No. 1, 1962010, Vol 15, No. 1, 196--201.201.

8/1/2012

1

Nancy Moureau, BSN, CRNI, CPUI, VA-BCPICC Excellence, Inc.

Special thanks to 3M for sponsorship

A vascular access specialist with 30 years of experience

PICC Trainer and expert for 21 years

Per Diem employee with Greenville Memorial IV/PICC

Speaker/Consultant with:

Access Scientific

Angiodynamics

Arrow/Teleflex

BaxterTeam

Legal expert reviewer and witness since 1987

Educator Owner of PICC Excellence –

an educational company

CareFusion

Cook

Excelsior

Hospira/ProCE

R-4

Sonosite

3m

Discuss healthcare changes that made CLABSI occurrence un-reimbursable with greater liability implications

Define steps that hospitals are taking to reduce infection risk with legal implications associated

ith f il t l t ti tiwith failure to apply preventative practices

Identify Federal and State government efforts to reduce incidence of CLABSI

Provide examples of legal cases involving vascular access device infections with practical application for healthcare facilities

Healthcare-associated infections (HAIs) are among the top causes of unnecessary illnesses and deaths in the United States

HAIs are infections patients get while in a hospital or other healthcare facility – infections the patients did not have before being admitted accounting forhave before being admitted, accounting for approximately 1.7 million infections and almost 100,000 deaths annually.

HAIs result in extra days of hospitalization and higher health care costs

Estimated financial impact of HAIs between $28 billion and $33 billion a year

Any infection is now a liability to the healthcare facility

Central Line Associated Bloodstream Infections or CLABSIs are primary bloodstream infections associated with the presence of a central vascular catheter, PICC, CVC, Port, Triple Lumen, or other CVAD

A bloodstream infection occurs when microorganismsA bloodstream infection occurs when microorganisms such as bacteria or fungi attach and multiply on a catheter, tubing or in the infusate with access or in the vessel with resultant symptoms of infection

According to the Centers for Medicare and Medicaid (CMS) ruling- CLABSIs are preventable complications

CMS Changes in 2008 that eliminated payment for CVC infections acquired in the hospital

Result is increased awareness of cost and impact of CLABSI with reporting

I ith id tifi ti f P t Issues with identification of Present on Admission (POA) and CLABSI occurrence

Emphasis on prevention and education

8/1/2012

2

Failure to perform at an acceptable level based on the Standard of Care What is the hospital’s responsibility to patients

related to infection?

Is there a requirement to perform at a certain level as reflected by the outcomes?

Are application of recommendations mandatory?

CMS statement that CLABSIs are preventable changes the entire landscape for litigation

Any infection that a patient contracts in a hospital is now considered a breech in care

Performance Related Duty to perform in a manner

considered the Standard of Care

D h it l h Does a hospital have a responsibility to prevent injury and improve the patient’s condition?

When complications occur, is this always a breech?

• Performance within the Standard of Care is reflected in:– Up-to-date policies

Reporting requirements

Public reporting

General quality of theand procedures

– Quality control measures to ensure standards and policies are upheld

– Safety report card

General quality of the hospital/facility based on morbidity and mortality statistics

• Federal Mandates that allow reimbursement for Medicare/Medicaid services include:

• State Mandates

• 28 States have enacted legislation services include:

– Denial of payment for treatment of hospital acquired infections

– Shift to pay for performance

– Reduction of payment for bad outcomes

requiring hospitals to report incidents of hospital acquired infections

8/1/2012

3

• CDC 2011 Guidelines for Prevention of Infection

• AHRQ Agency for Healthcare Research and Quality Recommendations

• NHSN National Health and Safety Network - CVC Checklist and Infection Criteria

• Other Association Standards and RecommendationsOther Association Standards and Recommendations

• Accreditation requirements - Joint Commission National Patient Safety Goals

– Healthcare Facilities Accreditation Program (HFAP)

– Joint Commission (JC)

– Community Health Accreditation Program (CHAP)

– Accreditation Commission for Health Care Inc (ACHC)

– The Compliance Team: "Exemplary Provider Programs"

– Healthcare Quality Association on Accreditation (HQAA)

– DNV Healthcare Inc. DNVHC

Good Results - Positive outcomes Increased client satisfaction

Positive image to attract qualified practitioners

Improved image in the community

Increased revenue with cost savings associated with avoidance of HAI

• Poor results - Negative impact – Continued patient morbidity/mortality from infections

– Damage to reputation and census reduction

– Increase length of stay with unreimbursed costs and l floss of revenue

– Poor response in attracting qualified specialists

– Impact on staff, retention, respect, performance

– Increased litigation and revenue losses due to failure to implement recognized measures of prevention

Every patient has a right to understand risks and benefits associated with a procedure

Do hospitals include the risk of infection in the general hospital consent?

Does the patient know there is a risk of Does the patient know there is a risk of acquiring and infection that could kill them and do they consent to treatment despite the risk?

Will hospitals be required to inform patients in the future statistics on what their risk really is for treatment in that hospital?

Negligence Failure to perform at the established

Standard when there is a duty. Negligence is a violated duty causing unintentional harm.

Stated more formally negligence is Stated more formally, negligence is “conduct which falls below the standard established by law for the protection of others against unreasonable risk of harm.”

Is an infection always NEGLIGENCE??

Standard of Care The Standard is that level of care

expected of the reasonably competent clinician, rather than the reasonably prudent person. Alabama, for example, has held that a clinician must “exercise

h bl dili dsuch reasonable care, diligence, andskill as reasonably competent physicians” would exercise in the same or similar circumstances.

In other words “what a similar nurse would do in the same situation”.

8/1/2012

4

Standard of Practice Standard of Practice is defined by an expert As a rule, expert testimony is required to establish

the custom of the profession. Both the complaining patient and the defendant clinician are required to produce experts to legally establish what

tit t th t d d f d tconstitutes the standard of care as opposed to substandard care. Experts, by virtue of their skills, knowledge, experience or education — supported by authoritative texts, articles and research as necessary — then articulate the standard as it applies to the particular case. In reaching their verdict, the jurors listen to all the evidence and decide which expert, and therefore which of the parties, is the more credible

• Joint Commission now requires compliance with National Patient Safety Goals (NPSG)

• This is considered a duty to perform

• NPSG can now be considered a Standard ofNPSG can now be considered a Standard of Practice and a requirement including– Insertion checklists measuring compliance with

Central Line Bundle

– Monitoring, surveillance, reporting

– Education

– Disinfecting protocols, carts for CVC insertion

Follow the BUNDLE (hand hygiene, max barriers, CHG/alcohol prepping, optimal site selection and removal when IV meds completed)

For all CVC/PICC insertions use CLIP – checklist with independent observer

Educate insertion and maintenance staff Consider antimicrobial

dressings/catheters/caps/devices when zero not met

Establish surveillance and accountability for compliance

Daily assessment and device removal

In a courtroom there are certain questions put to the witness: What could you have done differently

to avoid the infection to this patient? When antimicrobial products were

available why weren’t they used?available, why weren’t they used? What practices do you have that

safeguard patients?

Think about this: Are we currently doing everything we can to avoid complications?

Acute care patient died from infection – case review with settlement

H I f i ti t Home Infusion patient receiving TPN – nurse did not wash hands

Acute care PICC infected

Educate staff for all areas of Vascular Access recommendations

Evaluate new products and provide the best antimicrobial protection

Ch ll f ilit t i Challenge your facility to improve practices and incorporate those products that safeguard patients

Read Research and Journals monthly

Benchmark acceptable levels of complications

Forever strive for Best Practice!

8/1/2012

5

1. CMS Reports Rates of Hospital Acquired Conditions in America’s Hospitals. www.cms.gov/apps/media/press/factsheet Accessed August 30, 2011.

2. Healthcare-Associated Infections Program. California Department of Public Health www.cdph.ca.gov Accessed August 30, 2011.

3. Hospital Acquired Infections: The Unseen Health Risks of Hospital Stays. Philadelphia, PA Medical Malpractice Lawyer, Silvers, Langsam & Weitzman, PA

4. State Plans to Address Healthcare-Associated Infections. www.cdc.gov.HAI/stateplansAccessed August 30, 2011.

5. State Legislation and Initiatives on Healthcare-Associated Infections.5. State Legislation and Initiatives on Healthcare Associated Infections. www.hospitalinfection.org/legislation Accessed August 30, 2011.

6. O’Reilly, Kevin. Central-line infections declining, CDC reports. Amed News staff. www.ama-assc.org/amednews Accessed August 30, 2011.

7. 15 Steps you can take to reduce your risk of a hospital infection.www.hospitalinfection.org Accessed August 30, 2011.

8. Bailey, Tracey and Nola Ries. (2005) Legal Issues in Patient Safety: The Example of Nosocomial Infection. Healthcare Quality, Vol 8.

9. Hseih, Sylvia. (2009) Hospitals fight off infections and lawsuits. 10. www.lawyerssusaonline.com Accessed August 30, 2011.

Thank you!Questions?Nancy Moureaunancy@piccexcellence.com

www.piccexcellence.com

10/30/2012

1

Author and Presenter Disclosures

• This presentation is graciously sponsored by Medcomp

• Consultant, National Speaker Bureau –Genentech

• Cathflo Nurse Trainer -Genentech

▪ 7 million CVADs are implanted each year in patients in the United States (Galloway)

▪ CVADs are a necessary tool for the administration CVADs are a necessary tool for the administration CVADs are a necessary tool for the administration CVADs are a necessary tool for the administration ofofofof:

— Parenteral nutrition— Blood and blood products

— Fluids for hydration— Lab testinginginging

— Chemotherapy— Antibiotic therapy

— Frequent blood tests

(McNight)(McNight)(McNight)(McNight)

▪A Central Venous Access Device provides lifelifelifelife----sustaining therapysustaining therapysustaining therapysustaining therapy to patients

▪ Indicated when the duration of IV therapy will likely exceed six days (CDC 2011)(CDC 2011)(CDC 2011)(CDC 2011)

▪Placed in a variety of clinical settings

Factors Influencing the Selection & Factors Influencing the Selection & Factors Influencing the Selection & Factors Influencing the Selection & Placement of CVADs: Four CategoriesPlacement of CVADs: Four CategoriesPlacement of CVADs: Four CategoriesPlacement of CVADs: Four Categories

1)1)1)1) Patient characteristics and preferencePatient characteristics and preferencePatient characteristics and preferencePatient characteristics and preference

2)2)2)2) History and CoHistory and CoHistory and CoHistory and Co----morbiditiesmorbiditiesmorbiditiesmorbidities

3)3)3)3) Infusion needsInfusion needsInfusion needsInfusion needs

4)4)4)4) Device options Device options Device options Device options (Egan(Egan(Egan(Egan----SansiveroSansiveroSansiveroSansivero))))

Their accurate use requires a comprehensive approach to assessment, device placement planning and use, potential complication-management, and removal (Egan(Egan(Egan(Egan----SansiveroSansiveroSansiveroSansivero))))

A catheter inserted via a peripheral vein

Catheter tip resides in a central location (Egan(Egan(Egan(Egan----SansiveroSansiveroSansiveroSansivero))))

Entry and exit sites are one in the same (Egan(Egan(Egan(Egan----SansiveroSansiveroSansiveroSansivero))))

Commonly performed at the patient’s bedside ((((NakazawaNakazawaNakazawaNakazawa))))

Can remain in the patient for several years if needed ((((EganEganEganEgan----SansiveroSansiveroSansiveroSansivero))))

Commonly placed in the veins of the upper extremity ((((EganEganEganEgan----SansiveroSansiveroSansiveroSansivero))))

10/30/2012

2

PICCs Placed in the Upper Extremity Venous SystemPICCs Placed in the Upper Extremity Venous SystemPICCs Placed in the Upper Extremity Venous SystemPICCs Placed in the Upper Extremity Venous System

▪ Basilic, brachial or cephalic veins may be used for PICC placement.

▪ Basilic vein is the preferred choice: Typically the largest upper extremity vein, follows a fairly straightforward pathway to the subclavian vein, and is NOT in close proximity to neighboring arteries.

▪ Brachial veins accompany the brachial artery in pairs known as vena comitans or “companions of arteries.”

▪ When placing PICCs near the brachial vein, clinicians must carefully avoid inadvertent puncture of the brachial artery, or irritation of the brachial nerve, which resides in the same bundle.

▪ Cephalic vein is smallest of the upper extremity veins

Sources: Egan-Sansivero; http://education.yahoo.com/reference/gray/subjects/subject/172.

� The chest radiograph has been the The chest radiograph has been the The chest radiograph has been the The chest radiograph has been the primary toolprimary toolprimary toolprimary tool to identify the catheter tip location after bedside placement of PICCs

� The distal SVC & cavoatrial junction are only estimated on chest x-ray because they are NOT specifically visualized using this modality.

� The typical means by which to identify the location of the catheter tip immediately after catheter placement and before

“releasing” the catheter for use is to obtain a postobtain a postobtain a postobtain a post----placement chest radiographplacement chest radiographplacement chest radiographplacement chest radiograph

� The location of the catheter tip is critical to avoid bad outcomesThe location of the catheter tip is critical to avoid bad outcomesThe location of the catheter tip is critical to avoid bad outcomesThe location of the catheter tip is critical to avoid bad outcomes

� Must factor in Must factor in Must factor in Must factor in the radiation exposure to the patient the radiation exposure to the patient the radiation exposure to the patient the radiation exposure to the patient when obtaining chest xwhen obtaining chest xwhen obtaining chest xwhen obtaining chest x----rays for tip location.rays for tip location.rays for tip location.rays for tip location.

((((NakazawaNakazawaNakazawaNakazawa; Egan; Egan; Egan; Egan----SansiveroSansiveroSansiveroSansivero.).).).)

�The most severe adverse event is cardiac most severe adverse event is cardiac most severe adverse event is cardiac most severe adverse event is cardiac tamponadetamponadetamponadetamponade with a mortality rate of 70%

�Catheters placed too deep can result in cardiac arrhythmias

�Catheter tips placed too high in the SVC or in feeder vessels=high rate of venous high rate of venous high rate of venous high rate of venous thrombosisthrombosisthrombosisthrombosis���� Caused by repeated mechanical trauma to the endothelium from catheter tip

�Catheter-related thrombosis can cause pulmonary embolism, major vessel thrombosis and has has has has a clear relationship with cathetera clear relationship with cathetera clear relationship with cathetera clear relationship with catheter----related sepsis!!!!related sepsis!!!!related sepsis!!!!related sepsis!!!!

((((NakazawaNakazawaNakazawaNakazawa))))

Overwhelming clinical evidence that improper tip location negatively impacts Overwhelming clinical evidence that improper tip location negatively impacts Overwhelming clinical evidence that improper tip location negatively impacts Overwhelming clinical evidence that improper tip location negatively impacts clinical outcomes:clinical outcomes:clinical outcomes:clinical outcomes:

�Chemical vessel erosionChemical vessel erosionChemical vessel erosionChemical vessel erosion

�Mechanical vessel erosionMechanical vessel erosionMechanical vessel erosionMechanical vessel erosion

�Fibrin sleevesFibrin sleevesFibrin sleevesFibrin sleeves

�Spontaneous Spontaneous Spontaneous Spontaneous malpositionsmalpositionsmalpositionsmalpositions

�Catheter dysfunction including persistent withdraw occlusionsCatheter dysfunction including persistent withdraw occlusionsCatheter dysfunction including persistent withdraw occlusionsCatheter dysfunction including persistent withdraw occlusions

((((MedcompMedcompMedcompMedcomp ECG education)ECG education)ECG education)ECG education)

�Essential to understand that CVAD tip positions are NOT fixedNOT fixedNOT fixedNOT fixed

�Devices move with inspiration and expiration, changes in patient position, and upper extremity movement

�The tip of a CVAD is typically positioned in the distal third of the SVC

((((NakazawaNakazawaNakazawaNakazawa & Egan& Egan& Egan& Egan----SansiveroSansiveroSansiveroSansivero))))

�Chest radiograph is often further complicated by patient factors such as morbid obesity or “wet lungs”

�There is more “scatter” as the radiation beams have further to travel and a greater density of tissue or consolidations to encounter

�Other structures in the chest can obscure the catheter tip if they lie in the same view: Examples include other CVADs, spinal rods, pacemaker or intracardiac defibrillator wires

((((NakazawaNakazawaNakazawaNakazawa & Egan& Egan& Egan& Egan----SansiveroSansiveroSansiveroSansivero))))

10/30/2012

3

◉ In 1998 NAVAN (now AVA)In 1998 NAVAN (now AVA)In 1998 NAVAN (now AVA)In 1998 NAVAN (now AVA) issued a position statement recommending that issued a position statement recommending that issued a position statement recommending that issued a position statement recommending that the optimal location for the tip of a PICC is the lower onethe optimal location for the tip of a PICC is the lower onethe optimal location for the tip of a PICC is the lower onethe optimal location for the tip of a PICC is the lower one----third of the SVC, third of the SVC, third of the SVC, third of the SVC, close to the junction of the SVC & right atrium.close to the junction of the SVC & right atrium.close to the junction of the SVC & right atrium.close to the junction of the SVC & right atrium.◉ INS shares this recommendation in their INS Standards of Practice 2011 INS shares this recommendation in their INS Standards of Practice 2011 INS shares this recommendation in their INS Standards of Practice 2011 INS shares this recommendation in their INS Standards of Practice 2011 stating: “CVADs shall have the tip dwelling within the SVC near it’s junction stating: “CVADs shall have the tip dwelling within the SVC near it’s junction stating: “CVADs shall have the tip dwelling within the SVC near it’s junction stating: “CVADs shall have the tip dwelling within the SVC near it’s junction with the right atrium.”with the right atrium.”with the right atrium.”with the right atrium.”◉US FDA, ONS, ASPENUS FDA, ONS, ASPENUS FDA, ONS, ASPENUS FDA, ONS, ASPEN----> Catheter tips should NOT reside in the right atrium.> Catheter tips should NOT reside in the right atrium.> Catheter tips should NOT reside in the right atrium.> Catheter tips should NOT reside in the right atrium.◉ SIRSIRSIRSIR----Quality Improvement Guidelines 2003: Quality Improvement Guidelines 2003: Quality Improvement Guidelines 2003: Quality Improvement Guidelines 2003: cavocavocavocavo atrial junction.atrial junction.atrial junction.atrial junction.◉NKF: Dialysis Quality Initiative Guidelines 2001: SVC/right atrium junction.NKF: Dialysis Quality Initiative Guidelines 2001: SVC/right atrium junction.NKF: Dialysis Quality Initiative Guidelines 2001: SVC/right atrium junction.NKF: Dialysis Quality Initiative Guidelines 2001: SVC/right atrium junction.

(AVA website; INS Standards of Practice 2011; Egan(AVA website; INS Standards of Practice 2011; Egan(AVA website; INS Standards of Practice 2011; Egan(AVA website; INS Standards of Practice 2011; Egan----SansiveroSansiveroSansiveroSansivero; ; ; ; MedcompMedcompMedcompMedcomp).).).).

Current Practice &

Practice Outcomes

Standards of Practice

Position Statements

Standards of Practice / Professional Positions

Surface (anthropometric) measurement. AP Chest X-Ray post procedure. Estimated 5 – 10% reposition rate.

“The nurse should not advance any external portion of the CVAD that has been

in contact with the skin into the insertion site. Skin cannot be rendered sterile, and no studies have established an acceptable length of time after insertion for

such catheter manipulation.”

“CVAD’s shall have the tip dwelling within the superior vena cava (SVC) near it’s junction with the right atrium…”

“NAVAN recommends that the most appropriate location for the tip of

peripherally inserted central catheters (PICCs) is the lower one-third of the superior vena cava (SVC), close to the junction of the SVC and the right

atrium.”

�Reduce time to therapy.

�Achieve consistent & accurate catheter placements.

�Reduce catheter malpositions� Rates documented to be as high as 10Rates documented to be as high as 10Rates documented to be as high as 10Rates documented to be as high as 10----13%!!!13%!!!13%!!!13%!!!

�Reduce patient radiation exposure.

� Improve patient satisfaction

� Improve clinician workflow & efficiency

The INS Standards of Practice 2011; The INS Standards of Practice 2011; The INS Standards of Practice 2011; The INS Standards of Practice 2011; 35.835.835.835.8---- “Tip location of CVAD shall be “Tip location of CVAD shall be “Tip location of CVAD shall be “Tip location of CVAD shall be

determined determined determined determined radiographicallyradiographicallyradiographicallyradiographically or by other or by other or by other or by other approved technologiesapproved technologiesapproved technologiesapproved technologies prior to initiation prior to initiation prior to initiation prior to initiation

of infusion therapy.”of infusion therapy.”of infusion therapy.”of infusion therapy.”

�The traditional practices to ensure proper tip location for The traditional practices to ensure proper tip location for The traditional practices to ensure proper tip location for The traditional practices to ensure proper tip location for PICC placement has included prePICC placement has included prePICC placement has included prePICC placement has included pre----procedure landmark & procedure landmark & procedure landmark & procedure landmark & surface measurements followed by postsurface measurements followed by postsurface measurements followed by postsurface measurements followed by post----procedural procedural procedural procedural chest chest chest chest xxxx----ray.ray.ray.ray.

�The challenge has been in the inherent inefficiency of The challenge has been in the inherent inefficiency of The challenge has been in the inherent inefficiency of The challenge has been in the inherent inefficiency of radiography & known inconsistency of the interpretation of radiography & known inconsistency of the interpretation of radiography & known inconsistency of the interpretation of radiography & known inconsistency of the interpretation of PICC tip position via a radiographic image.PICC tip position via a radiographic image.PICC tip position via a radiographic image.PICC tip position via a radiographic image.

�Considering the clinical significance & the position of peer Considering the clinical significance & the position of peer Considering the clinical significance & the position of peer Considering the clinical significance & the position of peer groups (AVA & INS) regarding proper central tip placement, it is groups (AVA & INS) regarding proper central tip placement, it is groups (AVA & INS) regarding proper central tip placement, it is groups (AVA & INS) regarding proper central tip placement, it is not only best practice, but also should be the professional not only best practice, but also should be the professional not only best practice, but also should be the professional not only best practice, but also should be the professional standard of practice to ensure proper central tip placement is standard of practice to ensure proper central tip placement is standard of practice to ensure proper central tip placement is standard of practice to ensure proper central tip placement is achievedachievedachievedachieved!!!!

�Consequently, clinicians should consider more accurate & Consequently, clinicians should consider more accurate & Consequently, clinicians should consider more accurate & Consequently, clinicians should consider more accurate & efficient technologies to reach this goal!!!!efficient technologies to reach this goal!!!!efficient technologies to reach this goal!!!!efficient technologies to reach this goal!!!!

10/30/2012

4

▪NavigationNavigationNavigationNavigation refers to a technology that ascertains information regarding general directionality of a vascular access device.

▪ Tip Tip Tip Tip Location Location Location Location refers to a technology that ascertains a precise location of the distal tip of a vascular access device within the superior vena cava (SVC).

Technologies that Technologies that Technologies that Technologies that utilize electroutilize electroutilize electroutilize electro----magnetic field detection magnetic field detection magnetic field detection magnetic field detection to illustrate audibly or visually catheter direction and general position. These systems measure the relationship between the catheter stylet and its external sensor (chest plate or hand held wand). These devices require a custom stylet wire inserted within the catheter. These devices are effective in reducing catheter malpositions, however they do not provide detailed information regarding the catheter’s tip location with respect to the heart.

Examples includeExamples includeExamples includeExamples include: Bard Sherlock, Viasys Navigator.

� Utilizes a catheter stylet that incorporates both intravascular ECG & intravascular doppler.

�IV doppler senses the direction of blood flow taking advantage of the fact that venous blood flow is always returning back to the right side of the heart.

�Computer algorithm calculates ECG signature & height of the P wave as well as doppler signals to give an icon indicating the catheter tip is navigating in the right direction or against blood flow meaning it is going in the wrong direction.

�When the tip is in the lower 1/3rd of the SVC, the computer algorithm calculates the “sweet spot” & gives a blue bulls eye on the height of the P wave and the unique blood flow pattern in the CAJ.

Methods & Available Products

Tip Location VS. Navigation

Sapiens - ECG based device.

Claims: 97% at the cavoatrial junction or within +/- 1 cm 3% in middle or lower

SVC greater than 1 cm and up to 3 cm away from the cavoatrial junction

Vasonova VPS – ECG / Doppler device.

Claims: 98% 1st time accurate placement rate.

Both FDA indicated as an “alternative” to xray and fluoroscopy.

Navigator / Sherlock

magnetic field detection systems - Displays the relationship between the

stylet and the Navigator Wand or Sherlock chest pad.

No indication as an alternative to xray or fluoroscopy.

ECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location Terminology

▪▪ Tip Location, Tip confirmationTip Location, Tip confirmationTip Location, Tip confirmationTip Location, Tip confirmationTip Location, Tip confirmationTip Location, Tip confirmationTip Location, Tip confirmationTip Location, Tip confirmation: Refers to a technology that ascertains a precise location of the distal tip of a vascular access device within the SVC.

▪▪ NavigationNavigationNavigationNavigationNavigationNavigationNavigationNavigation: Refers to a technology that ascertains information re: general directionality of a vascular access device.

▪▪ CavalCavalCavalCavalCavalCavalCavalCaval--------atrial junctionatrial junctionatrial junctionatrial junctionatrial junctionatrial junctionatrial junctionatrial junction: Anatomic location where SVC terminates into the right atrium.

▪▪ Intravascular Doppler UltrasoundIntravascular Doppler UltrasoundIntravascular Doppler UltrasoundIntravascular Doppler UltrasoundIntravascular Doppler UltrasoundIntravascular Doppler UltrasoundIntravascular Doppler UltrasoundIntravascular Doppler Ultrasound: IV doppler senses the direction of blood flow taking advantage of the fact that venous blood flow is always returning back to the right side of the heart.

▪▪ ECGECGECGECGECGECGECGECG: A graphical recording of the cardiac cycle produced by an electrocardiograph.

�� Intravascular ECGIntravascular ECGIntravascular ECGIntravascular ECGIntravascular ECGIntravascular ECGIntravascular ECGIntravascular ECG: Technologies that employ a saline column or stylet as an intracavitary electrode to monitor ECG waveform changes as the vascular access device approaches final tip position.

10/30/2012

5

ECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location TerminologyECG Tip Location Terminology

▪▪ Waveform/tracingWaveform/tracingWaveform/tracingWaveform/tracingWaveform/tracingWaveform/tracingWaveform/tracingWaveform/tracing: A typical ECG tracingECG tracingECG tracingECG tracing of the cardiac cycle (heartbeat) consists of a P wavewavewavewave, a QRS complex, a T wavewavewavewave, and a U wavewavewavewave.

▪▪ Sinus Node (SA Node)Sinus Node (SA Node)Sinus Node (SA Node)Sinus Node (SA Node)Sinus Node (SA Node)Sinus Node (SA Node)Sinus Node (SA Node)Sinus Node (SA Node): Known as the heart’s primary pacemaker & consists of a bundle of cells known as the SA Node located in the upper posterior wall of the right atrium.

▪▪ PPPPPPPP--------wavewavewavewavewavewavewavewave: Electrical signals from the brain arrive at the SA Node to stimulate a heartbeat. The depolarization spreads from the SA Node across the atrium causing the atrial muscle to contract while generating the P Wave.

▪▪ Negative DeflectionNegative DeflectionNegative DeflectionNegative DeflectionNegative DeflectionNegative DeflectionNegative DeflectionNegative Deflection: Deflections that are downward on an ECG.

▪▪ AmplitudeAmplitudeAmplitudeAmplitudeAmplitudeAmplitudeAmplitudeAmplitude: Defined as the height of the deflection & is a measure of voltage.

▪▪ BiphasicBiphasicBiphasicBiphasicBiphasicBiphasicBiphasicBiphasic: Defined as having two phases, parts, aspects, or stages.

� Technologies that employ a saline column or stylet as an

intracavitary electrode to monitor ECG waveform changes as

the vascular access device approaches final tip position.

�IV ECG takes advantage of the fact that the sino-atrial (S-A)

node lies in the upper right atrium right below the SVC/CAJ

juncture.

� As the S-A node initiates the cardiac cycle, the atrial

contraction can be recorded as the P wave on the ECG

recording.

Over 60 years of ECG accuracy

� Von Hellerstein, HK et al. Recording of Intracavity Potentials Through a Single Lumen Saline Filled Cardiac Catheter Proc Soc Exp Biol Med 1949; 71:58-60.

� Hoffman MA, Langer JC, Pearl RH, et al. Central Venous Catheters – No X-Rays Needed: A Prospective Study in 50 Consecutive Infants and Children. J Pediatric Surgery 1988; 23:1201-3

� Madias, J., Intracardiac (Superior Vena Cava/Right Atrial) ECGs Using Saline Solution as the Conductive Medium for the Proper Positioning of the Shiley Hemodialysis Catheter - Is it not

time to forgo the post insertion radiograph? (2003) Chest, 124, 2363-2367

� Pittiruti, M et al. The intracavitary ECG method for positioning the tip of central venous catheters: results of an Italian multicenter study. J Vasc Access (): 0 (2012) PMID 22328361

� Raviraj, R et al. A Simple Method of Electrocardiogram: Controlled Central Venous Catheterization. Annals of Cardiac Anethesia, Vol. 14 No.2 May-August, 2011, pp154-155.

� Lucey, B Routine Chest Radiographs after Central Line Insertion: Mandatory Postprocedural Evaluation or Unnecessary Waste of Resources. Cardiovasc Intervent Radiol 1999; 22:381-4.

� Frances KR et al Avoiding Complications and Decreasing Cost of Central Venous Catheter Placement Utilizing Electrocardiographic Guidance. Srg Gynecol Obstet 1992; 175:208-11

� Pittiruti, M., Scoppettuolo, G., LaGreca, A., Emoli, A., Brutti, A., Migliorini, I., et al. (2008). The EKG Method for Positioning the Tip of PICCs: Results From Two Preliminary Studies, JAVA. Pp. 179-

186. JAVA, 13(4), 179-186.

� Gebhard, R MD, et al . The Accuracy of Electrocardiogram-Controlled Central Line Placement A & A January 2007 vol. 104 no. 1 65-70

� Moureau, N, RN et al . Electrocardiogram (EKG) Guided Peripherally Inserted Central Catheter Placement and Tip Position: Results of a trial to Replace Radiological Confirmation. JAVA 15(1)

2010 pp8-14

ECG applied

Figure Figure Figure Figure 5555

An inverted P wave An inverted P wave An inverted P wave An inverted P wave indicatesa catheter is approaching

the right ventricle.

Figure 1Figure 1Figure 1Figure 1

No evident P wave changesNo evident P wave changesNo evident P wave changesNo evident P wave changesindicates a catheter is

not in acceptable position.

Figure 2Figure 2Figure 2Figure 2

A P wave at its maximumA P wave at its maximumA P wave at its maximumA P wave at its maximumheight height height height will indicate the

catheter is in the lower 1/3

of superior vena cava/rightatrial junction.

Figure 3Figure 3Figure 3Figure 3

A downward deflectionA downward deflectionA downward deflectionA downward deflectionon the leading edge ofon the leading edge ofon the leading edge ofon the leading edge of

the P wave the P wave the P wave the P wave indicates the

catheter entering the rightatrium.

Figure 4Figure 4Figure 4Figure 4

A biphasic P wave A biphasic P wave A biphasic P wave A biphasic P wave indicates

the catheter is within

the right atrium.

� IV ECG has been widely used in Europe for over a decade to place CVADs in the SVC. Devices include acute CVADs, implanted ports, and most recently PICCs. (Pittirutti).

�Heart: Composed of 4 chambers.

�Chambers are electrically stimulated to contract in a specific timed and paced fashion.

�The heart’s primary PM is a bundle of cells know as the sinoatrial node (S-A node).

�S-A node is located upper posterior wall of the right atrium.

▪ Electrical signals from the brain arrive at the S-A node to stimulate a heartbeat.

▪ Depolarization spreads from the S-A node across the atrium causing the atrial muscle to contract while generating the P wave.

▪ This stimulation reaches the A-V node & passes through a set of fibers out to the ventricles.

▪ This depolarization then spreads across the ventricles causing the ventricles to contract while generating the QRS wave.

▪ The repolarization of the ventricles generates the T wave as the ventricular muscles relax.

▪ The height or amplitude of the deflection is a measure of voltage.

▪ Positive deflections are upward on an ECG, negative deflections are downward.

▪ ECG analysis examines the shape, consistency, & the time between waveforms elements (deflections) to assess the functionality of the heart’s conduction system.

10/30/2012

6

▪ Sinus rhythms are a class of rhythms which originate in the S-A node.

▪ Sinus rhythms generally travel through the heart’s entire conduction system without inhibition.

▪ NSR is required for reliable ECG tip location.

▪ Atrial fibrillation is most common sustained arrhythmia.

▪ It affects as many as 10% of patients over 75 years of age.

▪ A-Fib is characterized by small, rapid, erratic spikes that may appear like a wavy baseline.

▪ A-Fib is caused by an unorganized depolarization of the atrial foci.

▪ AAAA----Fib will NOT allow Fib will NOT allow Fib will NOT allow Fib will NOT allow accurate interpretation of accurate interpretation of accurate interpretation of accurate interpretation of the P wave response for the P wave response for the P wave response for the P wave response for ECG tip location.ECG tip location.ECG tip location.ECG tip location.

▪ A-Flutter is recognized by the distinct “saw tooth” pattern of P-waves.

▪ It is characterized by a series of identical “flutter” waves in back to back succession.

▪ AAAA----Flutter will NOT allow Flutter will NOT allow Flutter will NOT allow Flutter will NOT allow accurate interpretation of the accurate interpretation of the accurate interpretation of the accurate interpretation of the P wave response for ECG tip P wave response for ECG tip P wave response for ECG tip P wave response for ECG tip location.location.location.location.

▪ With S-A node pace failure, and artificial pacemaker may be implanted as a permanent pace making source.

▪ The demand feature engages when the inherent rate of S-A node is insufficient.

▪ An artificially atrial paced An artificially atrial paced An artificially atrial paced An artificially atrial paced heart will not allow heart will not allow heart will not allow heart will not allow accurate interpretation of accurate interpretation of accurate interpretation of accurate interpretation of the P wave response for the P wave response for the P wave response for the P wave response for ECG tip location.ECG tip location.ECG tip location.ECG tip location.

Assessing P waves:

1) Are they present?

2) Do they look alike?

3) Do they occur at a regular rate?

4) Is there one P wave for each QRS?

5) Are they upright?

10/30/2012

7

ECG Tip Location Explained

• Sino Atrial node is located at

the opening of the right

atrium. These cells emit

electrical impulses.

• These impulses serve as our

reference point or

anatomical landmark for

ECG guided tip location.

The “Ideal” method for checking the position of the catheter tip

medcompnet.com

� Provide a way to check the position of the tip both during and after the procedure.

� Easily and autonomously performed.

� Accurate enough to ascertain that the catheter has gone in the right direction.

� Inexpensive, noninvasive, easy to repeat, have reproducible results

� Easy to learn and teach.

� Able to print and record results.

Pittirutti, M et al. The EKG Method for Positioning the Tip of PICCs : Results from Two Preliminary Studies. JAVA, Vol 13; no 4 2008

FDA Clearance

FOR ADULT USE

▪ Romedex: Sapiens – July 2010 (Device later purchased by Bard)

▪ Teleflex: Vasonova VPS – February 2011

▪ MedComp: Celerity (pending)

FOR PEDIATRIC USE

None.

Medcomp CelerityECG Based Location Technology

Touch Screen

Medcomp Tip Location

USB Ports

VESA Mounts

Patient ECG Cable Connector

Remote Box ConnectorPower Switch

Battery Compartment

Medcomp Tip Location

10/30/2012

8

� Simple software upgrade to add navigation technology

� No calibration required

�Wide, deep viewing.

ECG Tip Location: Summary

▪ In the current economic health care climate, ECG tip location for PICC placement can be used in the inpatient, outpatient, or home care arena.

▪ Avoidance in long wait times for chest x-ray to be read for PICC tip placement documenting the PICC is ready for use! Thus, therapies are initiated sooner!!

▪ Has been used for over a decade in Europe for a variety of CVADs with excellent clinical outcomes!

▪ Can be used to place PICCs outside of the traditional “inpatient hospital arena”

▪ Cost avoidance of radiographic imaging

▪ Avoidance of radiation exposure to the patient!!!

References

1) Galloway M. Semin Oncol Nurs. 2010;26(2):102-112.

2) McKnight S. Medsurg Nurs. 2004;13(6):377-382.

3) O’Grady, N.P. et al. CDC 2011: 4-83.

4) Nakazawa, N. JAVA. 2010; 15(4).

5) Egan-Sansivero, G. Semin Oncol Nurs. 2010:26(2):88-101.

6) http://education.yahoo.com/reference/gray/subjects/subject/172

7) AVA website: www.avainfo.org

8) INS Standards of Practice 2011.

9) Information on file at Medcomp.

10) Pittirutti, M. et al. JAVA. 2008; 13(4).

11) www.vasonova.com

Thank you!!!

▪ Many thanks to Paul Stagg from Medcomp for supporting this presentation!!

Michele Biscossi, Michele Biscossi, Michele Biscossi, Michele Biscossi, MSMSMSMS, ACNP, ACNP, ACNP, ACNP----BC, RN, BC, RN, BC, RN, BC, RN,

CNLCNLCNLCNL, VA, VA, VA, VA----BCBCBCBCAcute Care Acute Care Acute Care Acute Care Nurse Nurse Nurse Nurse Practitioner, Practitioner, Practitioner, Practitioner, Interventional Interventional Interventional Interventional

RadiologyRadiologyRadiologyRadiologyVascular Access Vascular Access Vascular Access Vascular Access Expert Expert Expert Expert & Consultant& Consultant& Consultant& Consultant

Clinical Nurse Nurse Nurse Nurse EducatorEducatorEducatorEducatorCellCellCellCell: 518: 518: 518: 518----633633633633----1478147814781478

EmailEmailEmailEmail: : : : Michele@Biscossi.comMichele@Biscossi.comMichele@Biscossi.comMichele@Biscossi.com