PICC Lines in Long-Term Care: What You Must Know
What are the risks and responsibilities when using a PICC line in a nursing home? Improper management can lead to infection, complications, or worse. In this week’s episode, nursing home abuse lawyer Rob Schenk welcomes guest Alice Darby to discuss how PICC lines are used in long-term care and what families should know about their safety.
Darby:
For routine flushing protocols, making sure that the lines are flushed so that they’re painted and they’re cleaned. Let’s see, and make sure that they don’t, they’re not occluded, strict aseptic techniques during dressing changes and access. Those are all big policies.
Intro
Schenk:
Hey, out there. Welcome back to the Nursing Home Abuse podcast. My name is Rob. I’ll be your host for this episode. Today, we’re talking all about PICC lines, what PICC means, what the thing does, how to make sure that the people that have them are okay. We’re certainly not having that conversation alone. No way that I could talk about PICC lines about myself.
We have Alice Darby on. Alice Darby is an RN, BSN, LNC. And is a seasoned nurse and legal nurse consultant with over 25 years of experience in critical care. She currently serves as a vascular access specialist at Emory Healthcare and leads AKD Legal Nurse Consulting, assisting attorneys with medical record review and expert witness services.
Her expertise spans pediatric neonatal and adult intensive care outside of work. Allison enjoys cooking, gardening, and traveling. And values lifelong learning and was a heck of a first base player in her softball league as a kid. And we’re so happy to have Alice and Allison, welcome to the show.
Darby:
Thank you, Rob. Thanks for having me.
What is a PICC line?
Schenk:
No problem. Everybody gets a softball at the beginning. You get one, you get the opening lineup. Super easy. We’re gonna start you off that way. What is a PICC line?
Darby:
Wow. Nice one. I thought it was gonna be hard and I used to play softball too.
Schenk:
Uhoh.
Darby:
Okay. A PICC line. A PICC line is a peripherally inserted central line catheter. It is a, I like to say the regular IVs that we place, that you can go into the ER and they place a nice little iv they’re about two inches, one to two inches, I wanna say that. But a PICC line can be up to about.
50 centimeters. Okay. What is that, about 25 inches? Or So we put them base, we cut them based on some measurements that we take that start from the upper arm and then they end all the way up to a place in now outside of your heart called the superior vena cava.
Quality-of-care failures related to infection prevention are discussed on the impact of preventive health measures in elderly populations in long-term care settings.
Schenk:
Oh wow. Okay.
Darby:
Yep. Yeah, that’s in short
What does PICC line treat?
Schenk:
It’s the, that’s the short version. So what is, what are we do? Like why is somebody getting a PICC line?
Darby:
A PICC line would be placed for patients that require central medication centrally given to them centrally like antibiotics, chemotherapy TPN or total parenteral nutrition.
If people can’t eat, if patients need to be discharged with antibiotics or whatever, fluids or whatnot. To go home. Doctors will will prescribe a, will order a PICC line for the patient to go home with it and be able to be discharged to home or a nursing home so that they don’t have to remain in the hospital.
Systemic contributors to infection risk are examined on the impact of preventive health measures in elderly populations affecting vulnerable residents.
Schenk:
I see. So it’s like a continuing iv. Like it’s, but a little more complicated,
Darby:
Yeah, it’s a comp, it’s a more complicated iv. Correct. It’s it’s and if they want to draw blood from there, they can do that as well. A lot IVs regularly. Your standard IV after perhaps the first or second use. They don’t draw back anymore.
Defense arguments related to infection inevitability are explored in Episode 205: Co-Morbidities, Unavoidability, and Pressure Injuries.
Schenk:
So in like when you’re talking about putting one in Okay. Correct. And maintaining it, is that something that only a physician does? Are nurses doing this?
Darby:
Nurses are doing it. I am a PICC line nurse in the hospital. You can, they can place them in nursing homes outpatient procedure rooms, but I place them specifically in the hospital.
Schenk:
Is there any type of special training that’s required for that?
Darby:
The training that is required to become a PICC line nurse starts from you learning how to place an iv, a regular peripheral iv. Then after the peripheral IV training, then you, after some time, give it a, probably about a year or so when you’re skilled.
Then you learn how to place an ultrasound IV after the ultrasound iv. Then you learn how to place midlines, which is a shorter version of a PICC line, but a longer version of a regular standard ib. And then after you’re skilled in learning how to do that, then you will advance into learning how to do a PICC line.
Nursing-led infection control challenges are explored on the impact of preventive health measures in elderly populations in residential care facilities.
Schenk:
What is the, like what how long is a typical PICC line in.
Darby:
They can be in for upwards of a year. Oh, wow. Physicians? Correct. If there are no infections any line infections, any occlusions, any mal positions, if it doesn’t get mal positioned in, in, instead of going into the superior vein, indicated if it goes into, to your neck or gets shortened or disturbed in any way, it can stay in for upwards to a year.
Physicians. Typically will order them for patients if they need, if they require medications greater than about four weeks.
Practice improvement initiatives addressing catheter-related infections are analyzed on the impact of preventive health measures in elderly populations.
Schenk:
Is this appropriate for somebody that’s mobile? Or is are these people like just bedridden? You know what I mean? Or because if in my mind, it feels like it would be easy to move it around or mess it up if you’re moving.
Darby:
No, sir, we, it is nice and stabilized with a little a little, it’s called a stat lock with a lock that is placed on your skin. And then with a dressing on top of it as well. And it is nice and secure. Nice and secure. What are other people? Can people walk around with PICC lines and you don’t even realize it?
What are some of the common risks associated with a PICC?
Schenk:
I guess so. I guess I’ve learned something new every episode. Yeah. Okay. So then what sounds great. What are some of the risks involved in a PICC line then o other than it like, like moving where, and it shouldn’t be.
Darby:
Like what are these, some of the risks involved in having a PICC line,
Schenk:
Correct.
Darby:
So one of, let’s see, the, some of the risks would be phlebitis where you get infection of inflammation of the vein. Okay. Thrombosis, which would, which, which would be a blood clot in the vein. Catheter occlusion. If you know the pi, the people taking care of the PICC lines are not flushing them per pro, per policy.
Advanced wound diagnostics are examined in Episode 209: Fluorescence Imaging of Wounds in Nursing Homes.
And per. Per protocol, then they will occlude. And like I mentioned before, the malposition. If the, if for with, for any reason the pick itself inside was to migrate into a different location of the body then that would be another. Situation, or actually the biggest one would be an infection if it’s not taken care of properly, if it’s not flushed and cleaned properly. If the dressings are not changed as they should be then that would be a problem.
Risks associated with invasive lines are discussed on the impact of preventive health measures in elderly populations in medically complex patients.
Schenk:
If we’re looking at it, what dressing does it need? What is the, what does the, the wound site look like?
Darby:
The wound side is so you have your PICC line that’s inside of your arm. And then on, and then you have your little lock that locks it in place. And then after that you put a clear dressing called a Tegaderm on top of it. And that’s it.
Schenk:
So then I guess from the actual, from that standpoint, you’re just looking for signs and symptoms of infection. If it’s, if the correct, if the skin is red, things like that.
Darby:
Correct, correct. If there’s swelling, if there’s redness, if there’s drainage of any sort then that would be an issue.
Families often ask whether infections signal neglect, which is addressed in can a urinary tract infection be a sign of nursing home neglect.
Which staff are responsible for maintaining a PICC?
Schenk:
It sounds like, other than just looking okay, it looks good, like you’re really not doing anything. Like you’re not, there’s no maintenance involved in it.
Darby:
There, there is no maintenance from the patient. However we require that the PICC line itself is looked at by a skilled nurse, a registered nurse. Every day, couple at least twice a day to make sure that there’s the dressing intact, right? Clean, dry, intact. There’s no drainage, there’s no signs and symptoms of infection.
Infection risk overlaps with skin breakdown, as explained in Preventing Pressure Ulcers in Nursing Homes – Episode 118.
Making sure, and also that it’s, it remains intact. Sometimes if you have a confused patient, they might pull on it nicely. And it might get out.
Recurrent infections may raise red flags, as explained in whether multiple urinary tract infections are a sign of nursing home neglect.
Schenk:
I see, but it doesn’t have to be cleaned or am I wrong about that? You’re like, does it need to be flushed out or
Darby:
It does. It does. It does In per policy. Every hospital has its own policy, but it should be generally speaking, it should be flushed between every medication and or once. A shift by a registered nurse. And when they flush it, they also clean the little hub where the syringe and the saline meet and they clean it for 20 seconds and then they flush it. And that makes sure that the line is patent.
Pandemic-related policy changes are reviewed in coronavirus laws affecting nursing homes.
Schenk:
Sure. Okay. And again, all of this is nursing, like this wouldn’t be a nurse aide, this would be a nurse or hire.
Darby:
This is not a nurse’s aid, this is a registered nurse or hire.
What policies should long-term care homes follow when using PICC lines?
Schenk:
I see. Okay. So Alice, you mentioned policies. So what would be like the typical policy with respect to PICC lines in a nursing home?
Darby:
A big one would be staff education. A staff typically does annual competencies in relation to their specialty, such as PICC lines. The floor nurses would also make sure that they know what to do, as far as assessing them. As well. That is making sure that they’re competent in assessing how to assess and how to address a PICC line with an infection.
Prevention strategies are discussed in Preventing Catheter-Associated UTIs: What to Know.
How to address a PICC line that has been dislodged out of the arm, things like that. Okay. Another one would be a policy for dressing changes. Dressing changes need to be done every seven days or as needed if it’s soiled. By a registered nurse that is skilled in PICC line dressings. That’s a whole nother thing.
Severe infections may escalate quickly, which is why our page on sepsis in Georgia nursing homes outlines potential legal claims.
Okay. Root, like I think I said before about routine flushing protocols, making sure that they’re the lines are flushed so that they’re painted and they’re cleaned. Let’s see. And making sure that they don’t, they’re not occluded. Another one would be strict aseptic techniques during dressing changes and access. Those are all big policies.
When untreated infections turn fatal, this article explains whether a urinary tract infection can lead to death.
Schenk:
When you say Peyton, what’s Peyton mean?
Darby:
Making sure that, that it’s cl clear, if I see when we attach the saline that we can flush it and it moves freely.
Schenk:
I see. I got one final question. What position did you play when you played softball?
Darby:
Oh, first, first base. Oh, you’re taking me back to third? Yeah. First base. You’re taking me back to third. Third through sixth grade.
Georgia-specific infection control practices are covered in Preventing UTIs in Georgia Nursing Homes – Episode 87.
Schenk:
Oh my goodness. Okay. Yeah, so so did you play in a league,
Darby:
I did travel ball.
Schenk:
Wow. Travel. So you must have been pretty good. Yes,
Darby:
I was pretty good.
Schenk:
So you were, if you’re a first base, that means you were the heavy hitter, like you were the
Darby:
I was. And I could catch it.
Schenk:
Okay. There you go. Okay. Alice, we really appreciate you coming on the show and sharing your knowledge with us today.
Darby:
Thank you so very much. I appreciate you.
Schenk:
Folks, I hope you found this episode educational. If you have an idea for a topic that you would like for me to discuss, please let me know.
If you have an idea for someone you’d like for me to talk to, please let me know that as well. Be sure to enter to win the nursing home on podcast mug and new episodes come out every single Monday. And with that, folks, we will see you next time.
Thanks for tuning in to the Nursing Home Abuse podcast. Nothing said on this podcast either by the host or the guest, should be construed as legal or medical advice, nor is intended to create an attorney-client relationship between the host or their guest and the listener. New episodes for now are available every other Monday on Spotify, apple Podcasts, or on your favorite podcast app, as well as on YouTube and our website, nursing home abuse podcast.com.
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Alice Darby’s Contact Information: