J. Fisher, C. Oakley

Durham Regional Hospital (UNITED STATES)
Problem: A PICC is one of the most common forms of intravenous (IV) access. A competency-validated Registered Nurse (RN) places the PICC. A chest radiograph (CXR) is taken to confirm proper placement of the PICC tip before beginning the IV therapy. Initiation of therapy can be delayed depending on the radiologist's availability. The vascular access specialty team (VAST) realized that action was needed to expedite PICC use.

Evidence: A literature review of nurses identifying PICC line tips was conducted. Infusion Nurses Society (INS) and Association of Vascular Access (AVA) workshops were attended. Networking with other hospitals resulted in knowledge of procedure with goal being the identification and implementation of a best practice.

Strategy: The information was presented to Nursing Leadership and Nurse Practice Council at our hospital. With the support of these groups and the radiologists, the team (VAST) consulted the North Carolina State Board of Nursing to determine scope of practice which it was. Approval was then obtained from the Medical Executive Committee and Risk Management. Staff attended a six-hour workshop presented by a radiologist and RN from an outside hospital using this practice and a sixty-minute conference on CXR review with one of their hospital's radiologists. Each member of VAST then performed 15 consecutive radiographic assessments monitored and deemed accurate by a radiologist.

Practice Change: VAST implemented this practice in October 2008.

Evaluation: Time is measured from when the CXR is taken until ready to be viewed by a VAST nurse.

Results: IV therapy is started within 15 minutes upon CXR completion in 98% of our patients with 99.6% accuracy out of 262 assessments.

Recommendations: Management support. Further data related to length of stay, patient outcomes be tracked to assess the long-term advance of this practice change. Work with finance to identify the financial impact to the organization.

Lessons Learned: Increased multidisciplinary collaboration. Identifying best practice models. Implementing these practices takes time and coordinated efforts.