Is Modified Seldinger right for home use?
A word or two of caution from our experts
You have probably heard of the Modified Seldinger technique, but that may be the extent of your exposure to the alternative method of starting a peripherally inserted central catheter (PICC). It's important for any home infusion nurse to be aware of various procedures available, when such procedures are appropriate, and for which patients.
According to Deborah Richardson, RN, MS, CNS, the clinical nurse specialist for the Infusion Therapy Team at MD Anderson Cancer Center in Houston, most nurses have not developed the proficiency required to use the Modified Seldinger technique on patients.
"Most people have heard of it and are familiar with the procedure in terms of knowledge base but not in terms of their technical skills," says Richardson, who teaches PICC insertion classes in which the Modified Seldinger technique is addressed. "The majority of nurses I have interacted with stated they are not permitted, in their clinical environment, to do the Modified Seldinger procedure due to the issue of a nurse using a guidewire." (See related story for a list of the steps involved in the Modified Seldinger technique, p. 112.)
Nancy Moureau, BSN, CRNI, president of PICC Excellence of Orange Park, FL, notes that the technique has several advantages and disadvantages. She lists them as follows:
Disadvantages:
· more expensive (because more supplies are required);
· more time-consuming;
· more risk to the patient;
· greater liability for the nurse;
· more traumatic;
· bloodier insertion technique.
Advantages:
· can use a peripheral access or other access device;
· can gain PICC access with no vein visible or palpable;
· can access smaller veins;
· greater success rate;
· more options where there are no possibilities for peripheral access.
There are many areas of controversy in home infusion, but the appropriateness of the Modified Seldinger technique in the home is not one of them. In speaking with some of the country's top nurse educators, all agree that the approach should be used sparingly if ever in the home.
"It's not that it isn't feasible in the home; it certainly can be done," says Richardson. "But I prefer PICC lines be inserted in an environment other than the home."
There are several specific problems with doing the procedure in the home.
"I don't believe this is an appropriate procedure in the home setting due to the lack of a controlled environment and the need for a large, sterile field," says Richardson. "You have to use a wire and additional equipment, so you need enough space to make sure you have and maintain a sterile field, although it could be adapted."
Moureau points out that the Modified Seldinger technique isn't appropriate in the home, although there may be rare situations in which it is used.
"I discourage it in the home because of the potential for those using it who are not well-trained in the procedure," she says. "It's all well and good to be a CRNI, but what really matters is having the experience. The Modified Seldinger technique should not be done by anyone who is not very, very skilled with a traditional insertion method. The Modified Seldinger is an optional, more involved approach."
Moureau says the technique should be attempted only by home infusion nurses who have advanced PICC training, have applied the Modified Seldinger technique in a hospital, and have proven competency.
"It is rare in the home," she adds, "and I think we need to use careful consideration regarding the application."
But she is unwilling to say the procedure has no place in the home.
"I don't believe 'never' is appropriate, because we as nurses need to be flexible," says Moureau. "The more experience you have, the more flexibility it gives you. I would need to know what the nurse's experience is and about their patient population before I told someone whether I thought the technique was appropriate or not."
Lynn Hadaway, MEd, RNC, CRNI, principal of Hadaway and Associates, an infusion therapy consulting firm in Milner, GA, says the Modified Seldinger technique may have a place in the home, but such instances are rare.
"It has a definite place in patients that have more limited veins, but it is a little more tricky to insert because there are more steps and there is more equipment involved, so most nurses tend not to use the procedure," she says. "Then there's the issue of PICCs being inserted in the home, and I'm hearing that the number of PICCs being inserted in the home in general is going down."
Hadaway says one possible reason for the decreased number of in-home PICC insertions is that several industry groups have recently taken a stance strongly suggesting the use of chest X-rays to verify tip location. (See related story, Home Infusion Therapy Management, August 1998, p. 86.)
Kay Coulter, CRNI, of Coulter Consulting in Clearwater, FL, notes that because of the equipment required, a setting other than the home is preferred for the Modified Seldinger technique.
"For that complex of an approach where you're talking multiple steps, the ideal would be a controlled setting, such as an ambulatory infusion center, a doctor's office, or a hospital," she says. "The environment in the home is too unpredictable. It could be done, but it is difficult. When you start manipulating that many pieces of equipment and wires, one needs a large sterile field. It is not impossible, but must be done with great caution."
Coulter says the only time she would consider using the technique in the home would be for a hospice patient with very difficult access, but even that situation would require careful consideration.
Moureau adds that there is a greater application with pediatrics and geriatrics because of difficult access.
However, before you even consider becoming well-versed in the technique, Moureau says to consult your state board of nursing's nurse practice act to find out if your state even allows nurses to use wires, as many do not.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content