Home invasive lines: What nurses need to know
Becoming familiar with different equipment, managing infection sites can be challenges
When faced with an invasive line, ED nurses often feel out of their comfort zone. "It can be pretty anxiety producing," says Gabrielle Rutkowski, RN, CEN, staff nurse at Swedish Covenant Hospital in Chicago. "Nurses need to feel more confident handling patients with the various IV accesses that we’re seeing in the ED now, which is increasing because of home use."
Here are some tips on managing home invasive lines:
Be sensitive to family member’s needs. When a child is brought in with a complication, ED nurses should remember that the parents have been managing the line at home. "Parents are trained to care for those lines, and most of them are novices so they do things by the book," explains Neil Ead, RN, MSN, CPNP, pediatric nurse practitioner in the department of pediatric surgery at Hasbro Children’s Hospital in Providence, RI. "The parent will watch the nurses draw blood from a line or change the dressing, and, if the nurse doesn’t follow the exact steps the parent was taught, the parents get very alarmed."
Nurses can avoid this unpleasant scenario by mirroring the way the parent does it. "Allow the parent to access the line so you can see how they’ve been doing it," says Ead. "The parent might wipe with alcohol or put Betadyne ointment on the site. As long as it’s just a subtle difference, do it their way. It shows them you value their opinions and avoids a lot of heartache."
Be familiar with common complications from patients with home IV access. ED nurses need to become familiar with managing site infections, clogged lines, or phlebitis.
"More and more, care that was traditionally acute is now community-managed," says Ead. "Some of the newer percutaneous central lines have enabled us to successfully send pediatric patients home earlier. If a patient needs to be treated with a two-week course of antibiotics, typically we’d keep them in hospital for the duration. Now, we might send them home with a PICC [peripherally inserted central catheter] line."
When phlebitis is seen in patients, there is a tendency to want to pull the line immediately, but that is not usually necessary, according to Ead. "About 80% of the phlebitis can be resolved in 24-48 hours with warm compresses, but you have to be vigilant," he says. "If you put a warm compress on and it cools down and doesn’t get replaced, the line may end up being pulled unnecessarily."
Know your equipment. "With a higher population of home health patients having all kinds of central lines and IV therapies, ED nurses need know the difference between a PICC line and a Groshong catheter," says Rutkowski. "You need to know how to access them, how to flush them, and which ones you normally wouldn’t use, like a Quinton catheter, which is used only for dialysis."
Make sure lines are secure. ED nurses need to make sure the patient’s line is securely placed, stresses Ead. "Sometimes physicians don’t suture those lines, and there is a tendency to lose the line if it’s not sutured," he says. "You have to be very sure you are taping them down well so the line doesn’t get dislodged."
Reduce risk of infection. Keep in mind this is a long-term line, and the chances of infection are really great, because of catheter location," says Renee S. Holleran, RN, PhD, chief flight nurse and clinical nurse specialist at Cincinnati (OH) Medical Center and immediate past president of the Emergency Nurses Association, in Park Ridge, IL.
Sterile technique should be maintained during the insertion procedure as well as when applying the dressing, she says. "You definitely should exercise more caution than you normally would, since a central line is direct access into the patient and leaves them at great risk of systemic infection."
Consider additional training. "If there is anything about invasive lines a nurse isn’t comfortable with, he or she should seek out some continuing education," advises Rutkowski. "You need to have an attitude of confidence that you can handle a catheter," she explains. "If you have a patient who is just being admitted for antibiotics with a portacath, and you can take the time to prep the site, flush the needle, and insert it, that’s fine, but when it’s an emergency situation, it’s better if you’ve had experience with them."
Rutkowski developed annual skill credentialling for central lines in Swedish Covenant’s ED. The training covers various types of IV access and catheters, troubleshooting, flushing, blood sampling, and medication administration.
Another way to receive ongoing education in invasive lines is to network with ICU or IV therapy nurses. "Many of the companies that market these products offer classes in how to use the equipment," Holleran says.