Expect ongoing IV-specific training to be a must for nurses
You can’t just attend a PICC class and assume you are forever qualified’
For those waiting on official recommendations from the Cambridge, MA-based Intravenous Nurses Society (INS), the wait is over at least partially. By releasing a pair of position papers one on peripherally inserted central catheters (PICCs) and the other on midlines and midclavicular catheters the INS is making it clear that training and education specific to IV therapy are critical in providing optimum patient care. But you’ll still have to wait for the official standards, which will probably be published this summer.
Much of the paper on PICCs deals with qualifications and education.
"The INS specifies that a nurse must be qualified and demonstrate competency," says Nancy Moureau, BSN, CRNI, president of PICC Excellence in Orange Park, FL. While the paper doesn’t outline specifically how competency should be measured, it does provide some insight.
"They specify that the RN must have prior IV experience and then attend a PICC line educational program that includes both theoretical context and clinical instruction on anatomical models only," Moureau says.
The paper also stresses ongoing competency validation, and that validation should include the review of knowledge and the ability to perform the insertions safely and appropriately manage the lines. No frequency for validation is suggested, but the point the INS is trying to make is clear.
"You can’t just attend a PICC class and assume you are forever qualified," says Moureau. "It’s saying that there must be ongoing training; it can’t be static."
The paper also takes the competency and experience one step further by recommending that PICCs be removed by a physician or by a nurse trained in the procedure. If your agency has nurses who have not received IV-specific training who are providing IV therapies to your patients, the INS paper says you’re likely to receive less-than-optimal outcomes.
Training and certification aren’t all the PICC position paper addresses, though. It also states that dwell times can be up to a year. Moureau notes that in her PICC classes she has taught that PICCs can dwell up to six months, but one year is not inappropriate and is based on published information on PICC lines. Moureau notes that the papers are simply general guidelines recommended by the INS and are not standards. By presenting the position papers, the INS is hoping to provide infusion agencies with what it considers optimal care of the respective catheters.
"This information has been developed from using feedback from nurses across the country, and we feel this is the best way to provide safe practice with PICCs and mids," says Moureau. She adds that by following the guidelines set forth in the position papers, both individuals and organizations reduce liability problems.
Important aspects of the midline/midclavicular position paper address numerous clinical issues. For example, there’s good news for home infusion agencies who care for young children, says Moureau.
"Midlines are defined as a peripherally inserted catheter with the tip terminating in the proximal portion of the extremity," she notes. "That is slightly new because it doesn’t specify an upper or lower extremity, which is good because it includes pediatric and neonatal populations where we use lower extremities more often."
The paper also reinforces the optimal dwell time for midlines as two-to-four weeks, even though in the past, dwell times have ranged from four weeks to up to six months. The paper also puts forth the first formally recommended dwell time for midclavicular catheters at two to three months.
"This is based on various published outcomes and research," says Moureau. "We really didn’t know what the optimum dwell times for midclaviculars were. We would say somewhere in between mids and PICCs. INS’ conclusions give us a new framework for optimizing dwell times for these lines."
The PICC paper notes that radiological confirmation is needed only in the following specific situations for midlines:
• difficulty with catheter advancement;
• pain or discomfort after catheter advancement;
• inability to obtain free-flowing blood return;
• inability to flush the catheter easily;
• the guidewire is difficult to remove or is bent after removal;
The same situations apply to the insertion of a midclavicular catheter, with one addition:
• pain discomfort, feelings of fullness or coldness, or hearing gurgling sounds during flushing.
Regarding education, the paper follows the PICC draft in recommending that nurses inserting midlines and/or midclavicular catheters have "formal" education, as discussed in the PICC position paper.
Still waiting for INS standards
Although the INS released the position papers at its recent annual meeting, infusion professionals are anxiously awaiting the group’s standards, which are in the final stage of completion and will first appear on the INS Web page, which can be accessed by pointing your browser to http://www.INS1.com.
The position papers are a combination of new information and information published in Draft Guidelines For: Peripherally Inserted Central (PICC) Midclavicular and Midline Vascular Access Devices; Recommendations for Nursing Practice and Education, which was compiled in 1995 by an INS PICC task force and published only in draft form. The two recent position papers address topics similar to those in the guidelines in an attempt to formally standardize information on the use of PICCs, midlines, and midclavicular catheters.
"The draft of PICC guidelines that came out in 1995 was very conclusive," says Moureau. "It defined tip placement, nursing qualification, instructor and supervisor recommendations, curriculum and many other aspects of PICCs and mids. We should see some of the  draft details incorporated into the new standards."
"The PICC, midline, and midclavicular guidelines we wrote two years ago turned into two different [papers]," notes Lynn Hadaway, RN, CRNI, president of Lynn Hadaway and Associates of Milner, GA.
The first set of papers are the above-mentioned position papers, which provide general guidelines but less information than what originally appeared in the 1995 PICC guidelines. Procedural information from the 1995 guidelines that was not included in the position papers will become an INS-approved core curriculum for instructors, says Hadaway.
(Editor’s note: INS is also providing an outcomes monitoring tool for the above types of lines. For more information, contact the INS at (800) 694-0298. Moureau has just published, through PICC Excellence Inc., a PICC Pack, a quick reference guide for PICCs and mids that includes the INS position paper content as well as practical information on PICCs For information on the PICC Pack or classes, call (888) 714-1951.)