NAVAN urges verification of catheter tip placement
Patient safety and provider liability at stake
If your staff are placing central catheters - catheters with tips in the superior vena cava or inferior vena cava - in home care patients without verifying tip placement by X-ray, you're not alone. But you're probably making a dire mistake.
Verifying tip placement for central catheters is crucial. And while it's not mandatory, more and more standards suggest that you verify tip placement for all central catheters regardless of the care setting.
The most recent group to come to that conclusion is the National Association of Vascular Access Networks (NAVAN), based in Draper, UT, which released its own position paper in June. "There have been quite a few references in this position paper indicating higher risk of thrombosis, etc., in tips that are left in the subclavian vessel or higher up in the superior vena cava," says Marcia Wise, RN, president of NAVAN. "So we're advocating that a true peripherally inserted central catheter [PICC] be placed in the lower third of the superior vena cava. And the fact that we're saying tip placement must be in the superior vena cava requires that it has an X-ray."
Debbie Benvenuto, RN, CRNI, nurse educator for intravenous therapy for the Intravenous Nurses Society (INS) in Cambridge, MA, says NAVAN's position now agrees with that of the INS. "We have our own position paper and have long supported tip verification prior to use," says Benvenuto. "Tips have migrated, eroded atrium and ventricle walls, or caused dysrhythmias. It's a liability and a major risk that could seriously impact patient safety and providers' business. It's not worth the risk."
Others agree. Sue Masoorli, RN, of Perivascular Nurse Consultants in Philadelphia, says the question of whether to verify central catheter tip placement is a no-brainer. "It's a necessity," she says. "Depending where your tip is, the patient will be predisposed to specific complications, so by knowing exactly where the tip is, it narrows the range of complications the patient will be a high risk for. It is CDC's [Centers for Disease Prevention and Control in Atlanta], INS', and NAVAN's position that you must know where the tip is before you can use the catheter."
And there is only one way to verify tip placement, she says. "The tip must be verified by X-ray," notes Masoorli. "People try and do it by measurement, but it has to be by X-ray."
Why the fuss?
Supporters of verifying tip placement via X-ray say there is no other way to be 100% sure the tip is in the superior vena cava. "Catheters are soft and can go in any vein without you knowing it," says Masoorli. "Even if you advance the catheter smoothly and you perceive no difficulty, the catheter can wind up in a mammary vein or in the jugular vein."
Masoorli notes that she has seen tips in the heart, as well as tips that have gone through the right subclavian vein and ended up in the left subclavian vein. "In 1998, everyone has taken the same stand that the subclavian vein is not OK, and the vena cava is the only correct place," says Masoorli. "New research has shown that tips in the subclavian vein have an increased risk of venous thrombosis, and there is a lot of literature confirming that, so nobody out there is saying it is OK to leave the tip in the subclavian vein, even for antibiotics."
Masoorli also has seen home care cases where a catheter went in without resistance but had curled around, leaving the tip in patients' lower forearms. In each instance, the catheter was used with the belief it was in the subclavian vein. Such mistakes are prevented with X-ray tip verification.
However, not all home infusion providers are jumping on the X-ray bandwagon. Masoorli says the majority of home infusion providers are not verifying tip placement of central catheters placed in the home. But failing to do so sets yourself up for major problems due to patient risk.
"If anything happens to the patient, the provider has no defense," notes Masoorli. "You are using catheters without knowing where the tip is, and any potential damage could be construed as lack of proper verification of the tip."
Cases against home infusion companies for improper tip placement are not rare. For example, Masoorli refers to a recent case in which a patient had a PICC placed that was used without tip verification. The patient received IV Dilantin, his condition worsened, and he eventually died. And the home infusion provider is shouldering the blame.
"The doctors are claiming that the catheter was inserted into an artery and never into a vein, and it caused the patient's death," says Masoorli. "There was never an X-ray to verify where the tip was, so there is no defense for the nurse. She can't say whether it was in the artery or it wasn't in the artery because she doesn't have an X-ray."
Move to the head of the class
Rich Lewis, RN, president of OptionCare in San Rafael, CA, says his agency occasionally has verified tip placement for central lines placed in home care patients for nearly eight years. "To verify tip placement is the benefit, along with not having to transport the patient to the hospital," he says. However, he prefers such placements to take place in a setting other than the home due to the following difficulties and disadvantages:
1. Inconvenience.
"If the X-ray shows that the line needs to be repositioned [because the] tip is not in the superior vena cava, this can lead to additional nursing visits," notes Lewis.
2. Cost and reimbursement.
In Lewis' area, the X-ray costs about $200, including transportation of the vehicle to the home and the reading. He notes that PICC insertions in the home sometimes are covered by private insurers but not by Medicare or Medicaid, so reimbursement becomes a major issue.
3. Nursing time.
"You usually have to call for the X-ray once the procedure is over and have one or two nurses available for the procedure and/or to reposition the line or start the infusion at a later time," notes Lewis. "You also can't often get the X-ray read right away, and the quality sometimes is too poor to visualize the thin catheter."
In rural settings, patients can be quite a distance from an inpatient setting. It's mostly for these patients that Baptist Hospital East Home Health in Louisville, KY, gets tip verification in the home. "There are times when it is inconvenient for the family because the caregivers can't drive or the patient is ill enough that it would be difficult for them to get in to the hospital," says Linda Russell, CRNI, manager of the IV infusion team for Baptist Hospital East Home Health.
When such a situation arises and a central line must be placed in the home, Russell says the process to get an X-ray is simple. "We fax the X-ray company demographics on the patient and the doctor's order, and they can usually be out there within a couple of hours," she says. "We are trying to keep with INS standards, so we want to be as accurate as we can with central and midclavicular catheters."
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