I am a Registered Nurse who works on the IV team and provides venous access for patients during the hours of 7pm to 7am at the only hospital in Owensboro, Kentucky. We are an extremely busy organization who has a bed limitation of 300. Keeping the patients safe and to do no harm is a promise we all strive for (Clancey, 2011). By giving medications in a timely manner is a way of providing safety. Patients expect quality care and this nurse wants to provide the best treatment in the most efficient and efficient manner.
Regrettably, there is an area of decreased productivity which is causing a delay in intravenous medications. Patients who we consider “frequent flyers” or who have long- standing medical issues such as diabetes, pancreatitis, renal failure, chronic obstructive pulmonary disease, or heart disease tend to have many readmissions. Grievously, this means these patients likely have poor intravenous access. If I am not able to achieve a good working peripheral IV then this causes a delay in treatment.
In an emergency situation, this could be potentially life-threatening. The purpose of this paper is to convey that if this nurse had training in peripherally inserted central catheters (PICC) there would no longer be delays in medication treatments. Current Issue The current issue is the need for this nurse to have training in inserting PICC lines. When a patient is first admitted to the hospital, venous access is one of the first treatments. Acutely ill patients require intravenous medications for pain, nausea and antibiotic therapy until they become stable.
I work with the IV department and am contacted through the teletracking system when a patient in the hospital needs IV access. Owensboro Health’s teletracking system is the hospitals way of keeping electronic track of my departments productivity. It is surprising that telenursing has existed for 35 years and it has proven to remove time and distance barriers since it only requires a co- worker to enter the job into the computer then it is transmitted to the IV teams cell phone within minutes (Scholachta-Fairchild, Varghese, Deichkman, & Catelli, 2010).
I pick up the job through teletracking by making a phone call to locate what department is needing my services. Patients have the reassurance of my skills because I am considered the expert at accessing veins with peripheral catheters. Currently, if it is unfortunate that I am not able to access a vein, then the patient is without a life line. This is when a PICC line would be prudent. By not being able to administer needed medications this could put the patient in a critical situation, potentially lengthen the patients stay and increase hospital cost (Nwachukwu, 2012).
Workflow Analysis The current workflow in my department for PICC access is when a patient no longer has peripheral venous access a floor nurse will either pass the information on to a day shift nurse or if this occurs on day shift the nurse will simply call the physician unless she expects to see him or her on the floor later in the day. If emergent the IV PICC team will be called immediately. The procedure for PICC access only occurs on day shift. If the need occurs on night shift and the physician is contacted and deems it necessary they will then give a verbal order to consult IV team for PICC access.
The IV department receives a facsimile at 5am for all patients that have orders for PICC access. The team will pick the orders up at 7am. After the PICC nurse verifies the order, the chart is then reviewed to see if the patient is a candidate. To qualify for a PICC line the patient has to have poor access, IV sites that do not last, frequent blood draws, diagnosis that indicates IV therapy is needed post discharge, and caustic IV medication orders. If bleeding times are extended, the patient would be disqualified unless the physician states the patient is at a higher risk by not having one and gives an order.
Risk associated with insertion are air embolism, nerve injury, and infection. These risk are discussed with the patient. When the PICC is inserted, the procedure is done under a sterile field. An ultrasound is used and this long slender tube is advanced into a large vein in the upper arm until it reaches the superior vena cava. A chest x-ray is obtained for confirmation of placement. Whether it is day or night shift delays occur but a longer delay is on nights and this could be partially eliminated by having me trained in the procedure. This would reduce potential patient harm and delay in life saving medications.
Articulation of Suggested Change The change I suggest would be to allow this nurse to enroll in PICC training immediately. Fundamentally, I would obtain permission from my manager. I would explain the advantages of having me trained to insert PICC lines on night shift. The advantages would be patients would receive their intravenous pain mediations in a timely manner and this would lead to higher patient satisfaction scores. I would emphasize the benefit of having one PICC insertion that is numbed with lidocaine verses the possibility of numerous peripheral attempts without lidocaine.
Studies show that patients rate their satisfaction as very good when staff responds to their complaint even if there is not an actual reduction in pain (Downey & Zun, 2010). Multiple intravenous sticks are one of patients greatest fears. When patients present for healthcare it often causes them both physical and mental distress (Andrews & Shaw, 2010). Having me insert PICC lines on night shift would be an asset to the hospital, would reduce patient anxiety, and reduce delays in treatment.
Basis for Decision Making In the decision making process, I utilized the balance theory of wisdom by Robert J. Sternberg. His theory “treats wisdom as skill in applying tacit knowledge to the task of achieving the common good. ” “Wisdom is also relevant to the attainment of particular goals people value, although not just any goals, but rather, a balance of responses to the environment-adaptation, shaping and selection-so as to achieve the common good for all relevant stakeholders. “The common good is all the staff, including management by doing the right thing for the patient.
By having similar interest and a balance of environmental context of adaption we can all achieve a similar goal. This ultimate goal is often to maximize one’s self interest (Sternberg, 2009). This particular self interest of mine is to insert PICC lines for the good of the patient. This goal leads to improved patient satisfaction by decreasing the number of IV sticks utilizing the use of PICC lines. Change Integration My additional skill of being able to insert PICC lines will occur over a couple of schedules. First I have to approach my manager to request training in the insertion of PICC lines.
From the time I receive approval from my manager to the time it takes to study, take the exam, and then have one of my skilled co-workers to further train and shadow me, the integration will take two months. After training it will be difficult to get chances to actually practice what I have learned due to working night shift and I will try to stay over when I know there is an insertion scheduled for that morning. The change will be easily accepted by my co-workers, the physicians, and especially the patients who will mostly benefit.
Impact of Change I will be an asset to the hospital since I will be the first and only nurse to access PICC lines on night shift. Satisfaction scores will increase since patients will have less anxiety knowing they will not have multiple intravenous IV sticks and they will have long term access during their admission to the hospital. Patients will receive their pain medications, antibiotics, and if needed, total parental nutrition in a more timely manner resulting in a decrease in length of stay. Ultimately, this impacts costs, so the hospital saves dollars.
The quality department keeps up with these issues so they will be able to measure the outcome. Illustrated after the reference page is Appendix I which is the current process, Appendix II is the change in the process. Conclusion Intravenous access is a lifeline for all acute and longterm patients in the hospital setting. The longterm patients generally have poor venous access to start with due to poor health, IV’s that do not last, frequent blood draws, diagnosis that indicates therapy is needed post discharge and caustic IV medications. These are just a few good reasons to consider a PICC insertion.
It is physically painful and psychologically distressing for patients to have numerous IV sticks. Repeated IV sticks can lead to phlebitis and hematomas that can cause the patient extra pain and longer recovery time. It is also very costly to keep charging the patient for all the supplies needed for multiple IV sticks. It would be in the best interest of the patient to recognize the poor venous access and warning flags by simply numbing an insertion site, insert a PICC line, follow up with a chest x-ray and then have the crucial life line until the patient is discharged.
Perhaps the patient is on long term antibiotics and if necessary the patient is discharged with the PICC line and it is retained until it is no longer needed. The patient is then seen by a home health nurse for PICC maintenance. In the past a PICC line has been seen as a last resort but we need to change the way health care providors view this procedure and rally for it to be used as a first line treatment.
