April 6, 2009

PICC Nurses in Practice
By Leslie C. Jenkins, RPA, RT(R)
Radiology Today
Vol. 10 No. 7 P. 5

There seems to be some confusion about the role of nurses inserting peripherally inserted central catheter (PICC) lines. The uncertainty involves the need for their services and the proper implementation protocol when starting a PICC line insertion service in a hospital or an interventional outpatient center. PICC nurses can add efficiency to an overwhelmed interventional radiology department, provide competent PICC line placement, reduce costs and procedure delays for the patient, and maintain a reasonable revenue stream to the facility.

Most interventional radiology departments prioritize their services and utilize their expertise on a wide variety of complex medical conditions. When it comes to a radiologist’s time, aortic stent grafts, inferior vena cava filters, arteriograms, tunnel catheter placements, and other highly skilled procedures must take priority over a PICC placement for antibiotic therapy. A properly trained PICC nurse can free a physician to better use his or her time and still provide quality service.

Making It Work
A protocol that I have seen work includes PICC nurses and radiology services working together. Once a nurse has been evaluated for skills such as basic life support and advanced cardiac life support, the nurse is taught the proper PICC insertion technique. After the class, the nurse will observe a select number of insertions and then perform a select number of insertions under an instructor’s supervision, which could be done by a radiologist or a previously certified PICC nurse. The number of observations and supervised insertions required is dictated by a hospital’s credentialing board and then by the instructor or radiologist. The PICC nurse also has access to a small ultrasound unit for vein localization, which makes it more efficient and comfortable by reducing the number of failed insertion attempts.

Once certified by the institution, the nurse is ready to perform PICC line placements. Although the nurse must be able to recognize the correct placement of the PICC line, in many facilities, they are not permitted to be the final word on the proper PICC tip position. This falls to the radiologist, or in some cases, the radiology practitioner assistant or radiology assistant. Once the nurse places a PICC, a single view chest radiograph is ordered and reviewed by the radiologist and the PICC nurse is then immediately notified of the PICC’s position and useability. These findings are documented in the patient’s chart by the nurse and in the official radiologist’s report on the chest radiograph.

If a PICC line is malpositioned, after three attempts to reposition it by the PICC nurse, repositioning can be performed in the diagnostic imaging department by a radiology practitioner assistant or radiology assistant. If insertion or reposition is completely unsuccessful, the patient can then be referred to the interventional radiology department.

By utilizing a PICC nurse service, the costs to the patients are reduced. In the example hospital, the price for PICC line placement by the nurse is 25% of the cost when performed by an interventional radiologist. In the example hospital, if the radiology practitioner assistant repositions the PICC, the cost is still only 50% of the interventional radiologist. The hospital still gets reimbursed for the PICC and the postprocedure radiograph. The radiologist is reimbursed for the postprocedure radiograph interpretation.

In many institutions, PICC nurses are needed and are valuable assets to the radiology department. In a busy hospital setting where the interventional radiology department services a broad range of critically ill patients, the service can free physicians and their extenders to focus on duties that they’re uniquely capable of providing.

— Leslie C. Jenkins, RPA, RT(R), is a radiology practitioner assistant at the National Jewish Health Institute for Biomedical Imaging in Denver.