Prescribed PICC Unnecessary at SNF – Nurse Clinicians in Action – 40

Prescribed PICC Unnecessary at SNF involves a case at a SNF (ie, Skilled Nursing Facility) where a PICC was ordered to administer two weeks of IV antibiotics, however after reviewing the medical history and visually assessing the patient, the Vascular Wellness clinician determined that the prescribed PICC was an unnecessary procedure and not needed, and after conversing with the provider, the provider changed the order.

Prescribed PICC Unnecessary at SNF

– Clinical Case

An elderly patient in a Skilled Nursing Facility with a diagnosis of pancreatic cancer, skin cancer, a history of pulmonary embolisms, and unspecified chronic kidney disease was prescribed two intravenous (IV) antibiotics for an infection. There was no nephrology following the patient at this time, so the Nurse Practitioner ordered a PICC line to administer the antibiotics, Daptomycin and Aztreonam.

The Vascular Wellness Clinician arrived soon after, and as in every patient case, the vascular access clinician reviewed the patient’s medical history, planned or possible future medical procedures/needs, conducted a thorough visual assessment, and spoke with the patient about the procedure. The visual assessment revealed a right chest port which was in place for chemotherapy.

A port (short for port-a-cath) is a type of central line or central venous catheter (CVC) that is implanted under the skin. Ports and PICCs are similar in that they are both CVCs and involve placing a catheter inside the vein and that ends in the distal SVC/cavoatrial junction, and they are both used to administer medications or fluids. Ports can be in place for years, while PICCs are typically for shorter term use (usually weeks). Ports are completely implanted under the skin, requiring less frequent maintenance to ensure it works properly, while PICCs require more maintenance because they have an external tail that is accessed to administer therapy. Additionally, ports are a surgical procedure, whereas PICCs are a sterile procedure that can be performed at the patient’s bedside with no cutting involved.

As a vascular access specialist, the Vascular Wellness clinician knew that a port could be used for the prescribed antibiotics, making the ordered PICC line – which is an invasive medical procedure – not needed. In addition, after reviewing the medical history, the clinician determined that placing a PICC line in this patient was, in fact, contraindicated.

Prescribed PICC Unnecessary at SNF 

– Diagnosis and Treatment

The Vascular Wellness clinician discussed her findings with the Nurse Practitioner and staff and explained that not only could the prescribed medications be safely administered through the existing port in her chest, but that based on the patient’s history of kidney disease and pulmonary embolisms, performing a new vascular access procedure was contraindicated, meaning it could be harmful and create unnecessary risks. The clinician explained the reasons for her determination, which included:

Second Central Line Increases Risk of Deep Vein Thrombosis (DVT): It is typically not advised to place a second central line over or in addition to an existing central line. In this patient case, the port was the existing central line, and the ordered PICC line would be a second central line. While the placement of a second central line or CVC is sometimes needed (for example, this can happen in an ICU if a patient is not stable), it is not advised due to the increased risk of deep vein thrombosis (DVT), which is when a blood clot forms in a deep vein.

Patient History of Pulmonary Embolisms (PE): A pulmonary embolism occurs when a part of the DVT blood clot breaks off and travels to the lungs, causing a blockage in an artery. Patients with a history of pulmonary embolisms are at a much greater risk of forming a second one, and procedures that present a risk of DVTs and pulmonary embolisms – such as placing a second central line over an existing one – should be avoided unless there are no other alternatives.

Patient History of Chronic Kidney Disease (CKD): Vein preservation is critically important in patients such as this one who have chronic kidney disease or renal failure. Repeated insertions of any type of IV or blood draws can damage veins and make them unusable if a future procedure such as an arteriovenous (AV) fistula or graft is needed for hemodialysis. Because arms are used for PICC lines, fistulas, and grafts, placing a PICC line in this patient could potentially take away a fistula or graft site for the patient if it is needed in the future.

The NP was unsure and felt more comfortable deferring the decision on ordering the port access and canceling the PICC order, so the Vascular Wellness clinician and the facility staff reached out to the patient’s oncologist and oncologist nurse for approval. The clinician stayed at the facility while they waited for the return call. After approximately 30-40 minutes, the oncologist nurse called and gave the okay to have the port accessed for the prescribed therapy.

With this approval in hand, the order for the PICC line was canceled and the care team was able to begin the antibiotic therapy using the existing right chest port. The facility and the patient were very appreciative of the extreme patience the Vascular Wellness clinician showed while dealing with delays and making sure the patient got the correct line, as well as helping ensure the patient received the clinically best care, along with all the information and education provided.

Vascular Access Experts

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Key Points

As Vascular Access Experts, our clinicians are not only trained and precepted in placing Ultrasound-Guided PIVs, Midlines, PICCs, and Small and Large bore advanced central lines but also in identifying contraindications during visual assessments and medical history reviews that take place before any procedure begins. This extensive training and deep skillset enables our clinicians to help recommend the most clinically appropriate line – including when that means no line – which is evident in this “Prescribed PICC Unnecessary at SNF” NCIA case.

The recommendation to cancel the ordered PICC line and access the existing chest port prevented the patient from having an unnecessary secondary central line or midline inserted. It also averted the contraindications associated with chronic kidney disease and the heightened risks associated with a patient who has a history of pulmonary embolisms.  In sum, no line meant no potential complications and no unnecessary fees (ie, cost savings) for the Skilled Nursing Facility.

Unlike many of our competitors, our nurse clinicians are hospital credentialed, skill verified semiannually, Vascular Access Board Certified, and salaried W2 employees who are not paid on a per-procedure basis. All of our clinicians are trained to perform a comprehensive medical history review to ensure the clinically appropriate line before sticking, and it is not unusual for us to collaborate with the medical team and offer recommendations based on the medical history review and treatment plan. These recommendations are often accepted by the treating doctors and providers, such as in this case with our recommendation to use the existing chest port.  Through this comprehensive training and focus on the patient and client versus getting to the next procedure, our clients and patients get superior quality at the bedside derived from the hundreds of thousands of lines placed since inception.

Learn more about Vein Preservation and Kidney Disease.

Nurse Clinicians in Action is a spotlight series highlighting some of the interesting cases that Vascular Wellness clinicians have encountered and participated in treatment. These cases involve challenging situations or intriguing clinical presentations and may involve more than one Vascular Wellness clinician, as our clinicians have the ability to consult each other while in the field, as well as an on-call Clinical Administrator via a HIPAA (Health Insurance Portability and Accountability) compliant communication app. In addition, our extensive training program and diverse client base, including Level 1 Trauma Centers, Short Term Acute Care Hospitals, Long Term Acute Care Hospitals, and Skilled Nursing Facilities, provide our clinicians with a wide array of clinical experience and why we believe our clinicians, as a group, are the most experienced and best trained and supported vascular access clinicians.

If you require Vascular Access or want to learn more, speak to the team at Vascular Wellness today.
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Vascular Wellness provides:
(1) Comprehensive vascular access services to North Carolina, Oklahoma, South Carolina, and Virginia; and
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(3) Support vascular access services to Ohio and Kentucky.