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Learning Scope #367
1 contact hour
Expires Sept. 12, 2013
You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate; take the test online; grade and certificate are available immediately after taking the test. 2) Mail your completed exam (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the completed exam to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Matters, Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Matters Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
The goal of this CE is to provide nurses with information about PICC line care for home care patients they can apply to their practice. After reading this article, you will be able to:
1. Discuss the routes of an infection via a PICC line.
2. Describe the teaching plan for a patient with a PICC line in the home, by the nurse to the caregiver.
3. Discuss how to assess and document problems associated with a PICC line.
More than 30 years ago, home healthcare expanded in response to the introduction of diagnostic-related groups (DRGs), which changed the reimbursement for hospitals from a retrospective reimbursement to prospective reimbursement system.
Hospitals discharged patients home sooner and sicker, which required follow-up care in the home. This expansion included the development of home infusion therapy for patients who required continued infusion therapy after discharge.
The types of venous access devices initially available for the home care patient included peripheral IVs as well as central venous catheters such as tunneled catheters and implanted ports. Each had unique advantages, but also had disadvantages. Peripheral IVs required changing every 48-72 hours to prevent complications such as infiltration and phlebitis. Tunneled catheters, such as Hickman, Broviac and implanted ports, required insertion by a surgeon in an operating room. These central venous catheters also placed the patient at risk for a pneumothorax or infection, and were intended for long-term therapies.1
Emergence of PICC Lines
In the 1980s, technology in infusion therapy advanced with the introduction of the peripherally inserted central catheter (PICC). The PICC was first used in neonatal care then was introduced and widely accepted in home infusion therapy. PICCs had many advantages, including that they could be inserted in the various settings such as homes, clinics, physician's offices and hospitals, and by specially trained registered nurses rather than physicians.
They were appropriate for use in multiple infusion therapies. The care and maintenance required weekly nursing visits for dressing and cap changes. And the incidence of infection was minimal compared to other central venous catheters. PICCs also were more suitable for patients who required infusion therapy for more than 1 week but not on a long-term basis.
PICCs were popular in home infusion therapy long before they were introduced for use in the hospital setting. Today, PICCs continue to be widely used in home infusion therapy but are now inserted in the hospital setting for easier confirmation of placement, as well as easier identification of the vein for insertion through the use of ultrasound.
One of the most important aspects of PICC line care and maintenance in the home care arena is infection control. If a patient and/or their designated caregiver(s) are not properly educated in the basics of infection control, a PICC line can rapidly become a source of major complications.
As reported in Emerging Infectious Diseases, there are approximately 1.2 million infections annually in U.S. home care patients.1 The main risk factor is the "presence of a medical device." It is the responsibility of the home care nurse to provide the necessary education and observe correctly done repeat demonstrations of tasks such as hand washing to promote the reduction of these infections.
As discussed in Infusion Nursing: An Evidence-Based Approach, patient motivation, ability and willingness to participate in care are all assessed as part of the care planning process.2 A portion of this planning process must include elements of infection control.
The environment in which home care is provided will in most instances be less than optimal when compared to a healthcare facility. Issues such as air circulation and sanitation are usually less stringent when compared to a hospital setting. As a result, it is imperative nurses be well informed on how to address any obstacles and overcome them. In addition to Infusion Nursing: An Evidence-Based Approach, other excellent resources available for home care nurses include:
• Infusion Nursing Society Policies and Procedures for Infusion Nursing (3rd ed.)3
• Guidelines for the Prevention of Intravascular Catheter-Related Infections, 20114
• Guidelines for Hand Hygiene in Healthcare Settings5
• Infusion Nursing Standards of Practice6
Routes of Infection
There are four primary routes by which a catheter may become infected:
1. The migration of organisms found on the patient's skin from the site of insertion of the catheter and then along the cutaneous tract of the catheter to the catheter tip where they can colonize.
2. Catheter or catheter hub contamination through direct contact with improperly cleansed hands and/or contaminated fluids or other devices such as injection caps.
3. The seeding (hematogenously) from another site of infection.
4. Infusate contamination, though this rarely occurs, can also lead to catheter-related bloodstream infections (CRBSI).7
By being knowledgeable of these potential risks that can result in a CRBSI, nurses can act proactively to help prevent them rather than reacting and assisting in treatment when an infection occurs.
The first step in infection control, for healthcare workers as well as non-professional caregivers such as family members, is proper handwashing.
The CDC has designated the recommendation of the proper hand-hygiene technique as a Category 1B, which is "strongly recommended by certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale." This recommendation can be utilized in a home care setting where a caregiver's hands would not be expected to be soiled with blood or other body fluids. The recommendation reads: "If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands."4
The actual technique is described as "when decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry."4
This technique is easy to follow in a home care setting and does not require the caregiver to purchase expensive sterile or cleansing equipment, and does not require a high level of education or training. Proper hand hygiene is vital to the prevention of a wide variety of infections, including CRBSI.
Once the nurse is confident the patient and caregiver have received education and training in hand hygiene, the next step of instruction is establishing a clean and safe environment during the administration of therapy.
The caregiver should be instructed regarding equipment necessary for therapy administration and the need for all required items to be at hand and easily available. A dose-by-dose inventory should be reviewed and the use of a written checklist can be helpful. The correct number of flushes, alcohol prep pads, gauze, injection caps, etc. should be established by the nurse. With all equipment at hand, therapy can be comfortably administered.
The surface where the equipment is held during therapy should be maintained as clean and dry as possible. By now the caregiver should have properly performed hand hygiene, cleansed the work surface and obtained everything needed for the task at hand. The nurse should reinforce with the caregiver that none of these tasks require special equipment or training to perform properly.
The next step to promote infection control is the actual handling of the equipment being utilized. Intravenous administration sets should be used immediately upon removal from their sterile packaging. If the packaging has been compromised, the set should be discarded and a new one used. The protective cap over the tubing "spike" needs to remain in place until ready to "spike" the IV bag to purge the administration tubing of air and to run the infusate fluid through.
It is imperative the spike not be touched or compromised prior to penetration of the infusion bag. If the spike becomes contaminated and is still used, chances of the patient developing a CRBSI increase dramatically. The caregiver has to be instructed to remember whatever happens to the infusate happens to the patient.
The protective cap at the end of the administration set, the male connector, must also remain in place until ready to be connected to the PICC to prevent contamination of a sterile part. The frequency of replacing intermittently used administration sets is an unresolved issue with the CDC, so nurses should observe their organization's protocols and instruct patients and caregivers as such.
The current standard of care is to change the tubing no more frequently than every 72 hours. An exception to this standard is for tubing used in the administration of blood, blood products or fat emulsions. These are to be changed within 24 hours of initiating infusion. In the event of compromise to the administration set, it must be changed as soon as possible.
The patient/caregiver must also be instructed to scrub the access port with an appropriate antiseptic to minimize contamination, which is a Category 1A recommendation of the CDC. Best practice calls for the access port to be scrubbed vigorously for 15 seconds.
Catheter site dressing changes play an important role in infection control of PICC lines. According to the Infusion Nursing Standards of Practice, "Sterile gloves should be worn when performing CVAD site care. The use of a mask during access is often recommended; however, it remains an unresolved issue due to lack of research."6
Caregivers may or may not be instructed in the actual dressing change procedure, as that is an organizational policy. Due to the technical and professional skills required to properly change a PICC line dressing, most agencies permit only registered nurses to perform this task. However, caregivers must still be instructed in catheter site dressing observations and emergency reinforcement techniques.
Transparent dressings should be changed at least every 7 days as per CDC guidelines and Infusion Nurses Society standards of care. If gauze is used, the recommendation is to change the dressing every 2 days.
PICC lines should not have any antibiotic ointments or creams placed on insertion sites due to their potential to promote fungal infections and antimicrobial resistance.8 There is an exception when caring for hemodialysis catheters.
Caregivers need to be instructed on the signs and symptoms of infection to PICC lines. Other potential PICC complications include occlusion, upper extremity deep vein thrombosis (DVT), air embolism, catheter migration, catheter damage, catheter dislodgment and superior vena cava syndrome.
A daily inspection of the integrity of the dressing and the appearance of the catheter insertion site should be conducted. The dressing should be clean and dry during the 7-day period between changes. The insertion site should remain clean and dry. Extensions used in conjunction with a PICC line or injection caps should be changed at the same time as the dressing.
Patients who experience any redness, pain, swelling or pus-like drainage at the catheter/skin site, or develop fever and chills, should be instructed to contact the nurse immediately. These signs and symptoms could be indicative of an infection and should be assessed immediately by the nurse and reported to the physician for early intervention.
Patients and caregivers must be instructed in signs and symptoms of sluggish infusion, which could be due to a partial occlusion, or complete inability to flush or infuse, which could be a total occlusion. If either of these situations occurs, patients and caregivers should be educated to make sure all clamps are open on the catheter or IV administration tubing and there are no kinks. If this troubleshooting does not resolve the problem, the patient and caregiver should be instructed to contact the nurse. Early intervention with Cathflo Activase could prevent further complications such as CRBSIs.
The patient/caregiver must also be instructed to report to the nurse immediately if the patient experiences swelling in the neck, face, chest or arm, or pain in the arm. The patient may have an upper extremity DVT or may be experiencing superior vena cava syndrome, which is rare but can occur. Either one requires immediate assessment and intervention.
Although a great deal of education is provided to patients and caregivers in the prevention of an air embolism, it is imperative patients and caregivers are instructed in the signs and symptoms so immediate action can be taken. Instruction should include identification of rapid heartbeat, heart palpitations, difficulty breathing and coughing. In such an event, the patient/caregiver should call for emergency services immediately. While waiting for assistance, the patient should lie down on his left side with feet elevated until emergency personnel arrive.
Catheter migration, dislodgment and damage must be reported immediately to the nurse for immediate assessment and intervention. Patients and caregivers should report any of the following: difficulty with infusion; inability to flush or infuse; leaking at the catheter exit site; swelling, burning or pain during the infusion; "ear gurgling" during flush/infusion; headache, swelling, redness or pain in the shoulder, arm or neck; or a wet dressing. They should stop using the catheter and, if there is a visible crack or leak, apply a clamp above the site close to the catheter exit site, if possible.3
Patients in home care receive intermittent nursing visits for assessment, so education is crucial while receiving infusion therapy at home. Education should include not only measures to prevent complications but also instruction in signs and symptoms for any potential complication that can occur with a PICC line so appropriate interventions can be implemented immediately.
The care and maintenance of PICC lines can be entrusted to a properly trained and educated caregiver. All training should be documented along with properly performed repeat demonstrations of tasks. Due to changes in reimbursement and the limited number of nursing visits authorized for home care patients, it is vital an appropriate caregiver be designated and trained by the home care nurse.
The caregiver should be independent in:
• hand hygiene in principle and practice;
• knowledge of all items required for therapy administration;
• maintaining a clean, dry and orderly work space when performing therapy;
• care and use of equipment needed, such as administration set tubing and any add-ons such as extension tubing and/or injection caps;
• performing daily inspection of the PICC line dressing and insertion site;
• reporting to the nurse any sign and symptoms of inflammation or infection such as redness, tenderness, pain or discharge at the insertion site or along the path of the PICC line; and
• securing a dressing that has become compromised until a nurse can arrive and assess the situation.
PICC lines can be cared for without complications and permit patients who require the presence of a central venous access device to be discharged to home from an institution once they are stable. By observing the principles outlined in this article, the patient can complete the course of therapy ordered in the comfort of their home without the burden of an extended hospital stay. All it takes is a properly trained nurse and a motivated caregiver.
To view the Course Outline and take the test online, click here.
For a printer-friendly version of the exam you can print out, complete and mail in to ADVANCE, click here.
References for this article can be accessed here.
Marvin Siegel is director of nursing at Town Health, a home infusion company. Joan Kraemer-Cain is an ambulatory surgery staff nurse at Good Samaritan Hospital Medical Center, West Islip, NY. The author has completed a disclosure form and reports no relationships relevant to the content of this article.