Implications of Precise Nancy Moureau is an Speaker Bureau - PDF document

Nancy Moureau, BSN, RN, CRNI, CPUI, 4/29/2012 VA-BC About the Speaker Implications of Precise  Nancy Moureau is an  Speaker Bureau educator, legal consultant and for: clinician with 30 years of PICC Tip Location: The New 3m – vascular access experience Access Scientific –  PICC Trainer and expert Gold Standard in Clinical Practice? AngioDynamics witness in legal cases for more – than 21 years Teleflex, Inc. –  IV/PICC Team prn staff nurse Cook – with Greenville Memorial Excelsior Nancy Moureau, BSN, CRNI, CPUI, VA-BC –  CEO and Owner of PICC PICC Excellence, Inc. Excellence – an educational company Accuracy versus Precision Objective  Accuracy – the degree of closeness/proximity to the true value  Evaluate clinical practices and legal implications of tip positioning for most accurate and precise placement of High accuracy low precision – peripherally inserted central catheters Close to value, but no bulls-eye  Precision – reflects the degree of reproducibility/ repeatability in accomplishing the target value High precision low accuracy – All in one area, but no bulls-eye Wikipedia http://en.wikipedia.org/wiki/Accuracy_versus_Precision accessed 4/6/12 Hostetter, et al. Precision in CVC Tip Placement. 2010. JAVA 2010;15(3):112-125. Accuracy versus Precision Accuracy AND Precision Matter Suboptimal tip placement increases Migration  Why do we need both accuracy and risk of many complications precision? Looping  Thrombosis up to 16x higher  Ideally CVC placement is both accurate Azygos and precise with terminal tip both close to Vein  Higher rates of occlusion and and positioned at the target area loss of function Tip on the TM wall 2cm  Increased risk of infection Because, medically with relationship to speaking, close is just AV Node thrombosis not good enough anymore  Malposition – flipping into Tricuspid Valve internal jugular more common Target Superior Vena Cava/Cavoatrial Junction 1

Nancy Moureau, BSN, RN, CRNI, CPUI, 4/29/2012 VA-BC Goals of Terminal Tip Why is Tip Location Important? Confirmation 45.2% 87% Designed to:  Verify placement in vein versus artery 19% 31%  Reduce complications associated with malpositioning  Reduce liability from terminal tip complications 18% 4.2%  Establish catheter tip into optimal high flow area  Promote patient safety 1.5% 0-2% Why Distal SVC near Cavo Atrial Junction?  Established as standard by FDA CVC Working Group in 1994 5.6% 5.6%  Included in instructions for use by manufacturers  Reduces potential for malpractice Caers J, et al. Catheter Tip Position as a risk factor for thrombosis associated with the use of subcutaneous ports. Support Care Cancer 2005 13:325-331. Petersen et al, Silicone Venous Access Devices Positioned with Their Tips High in the Superior Vena Cava Are More Likely to Malfunction, Am J Surg 1999, 178:38-41 (Special thanks to Lorelle Wuerz) Case Study  Situation - Emergency transport  Background – 10 year old boy receiving long-term medications at home. MD ordered recheck of PICC placement after 4 months when pt having mild SOB. Prior Clinical Applications to X-ray pt developed acute SOB, anxiety, then cardiac arrest.  Cause Catheter was positioned in right atrium – Potential for Malpractice Eroded through the heart wall – Resulted in cardiac tamponade –  Action 911 – Patient died en-route to hospital –  Malpractice potential, huge, which was why I was contacted. Original confirmation was deep.  Solution – Accuracy and Precision the first time Pinpointing for Safety and Precision Matters – What Position for X-Ray? Reduced Liability Upper RA placement increases risk Factors Moving Tip Upward or Downwards External Landmark Without • Catheter induced Guidance Afib or V-Tach • Other RA wall 2 cm 2cm Magnetic Tip Navigation related complications • Irritation from TPN SVC and other high ECG Guidance osmotic solutions 2-4 cm creating thrombosis risk ECG with Doppler • Increased infection risk - Cavo Atrial thrombosis and Junction infection related 1. Trerotola et al. J Vasc Interv Radiol 2007; 18:513-518 2. Naylor JAVA 2007:12:1:29-31 1-2cm 3. Starr et al, Ann Surg, 1986:673-676 4. Salmela et al. Acta Anaesthesiol Scand 1993: 37:26-28 5. Hostetter, et al. Precision in CVC Tip Placement. 2010. JAVA 2010;15(3):112-125. R Atrium 2

Nancy Moureau, BSN, RN, CRNI, CPUI, 4/29/2012 VA-BC Case Study Target Area Superior Vena Cava/CAJ  Situation – Friday 4pm PICC placement requiring confirmation prior to use • Cardiac Arrythmias  Background – 72 yo female requires PICC for fluids, K+ and medications. Radiologist • Arterial Access leaves at 16:30, PICC nurse not authorized to read films. X-ray report dictated PICC Complications • Erosion through vein wall in the IJ • Thrombosis • Erosion through heart wall  Action choices • Pulmonary Emboli • Cardiac Tamponade Remove (patient required access) – Wait for catheter to drop (no PICC nurse available S/S) – – Pull back to alternative position (K+ is an irritant) • Positioning too deep, malposition or in artery • High position of terminal tip Replace with new insertion or exchange – Cause Left sided position without making downward turn into SVC  Nurse pulled catheter back – no X-ray recheck • Irritation to vein wall. Suboptimal position high in SVC, subclavian or collateral veins  Response – LOC change within 24 hours, pt confused, died within 48 hours • Positioning in the right atrium or ventricle • Coagulation and thrombotic development resulting in emboli blocking pulmonary artery into lungs  Cause – Arterial placement • Erosion of catheter through heart wall allowing infusion of solutions into the pericardium  Potential for Malpractice – Radiologist misread film (too difficult to differentiate vein Result from artery up the neck – final report PICC in vertebral artery), Nurse did not correct • Atrial fibrillation, flutter, premature ventricular contractions , emboli, stroke or confirm the placement, cleared the line for use. Nurse suspended from work. • Infusion into pleural space. • Failure to achieve blood return Patient’s family sued, hospital settled for undisclosed amount. • Pneumonia, infiltrates, abscess • Poor function, lack of blood return, pulmonary emboli, post thrombotic  Solution – Better forms of confirmation that allow location pinpoint during insertion, sequellae • Compromise of heart function, cardiac tamponade with 70% mortality and vein and artery differentiation. • Difficulty breathing, chest pain, palpitations and sudden death • Pericardial effusion results in pressure on the heart resulting in decreased cardiac function and death Measuring Liability Liability Issues Performing tip confirmation: Where is the risk? Where is the  Levels of success with Landmark: 46-75% 2,3,4,5 safety?  Success with Magnetic navigation: 80% 3 X-ray – The Current Standard ECG Confirmation ECG with Doppler Confirmation  Success with ECG: 55-88% 6,7 • Simple chest X-ray confirmation • Greater accuracy and precision • Same advantages as with ECG • Frequently difficult to read • Requires discernible P-wave and • Indicates position or malposition interpretation with flow indicator  Since SA node is located near the CAJ in the • General area validation. Placement frequently too deep or too shallow • Measures changes in P-wave once • Detects arterial flow (10-15%) reaching superior vena cava posterior wall of the right atrium, the P-wave • Combined use designed to measure • Malpositions: 5-8% in IJ, 3-5% • Requires understanding of target location and provide all clear contra- lateral or “looped back” P-wave polarization and Blue Bullseye indication acts like a beacon used to guide a catheter tip, depolarization • 1D flat film reading missing Azygos • Broad application for accuracy and and other malpositions • Unable to detect arterial placement precision with cardiac patients towards the CAJ • More than 50% need some kind of • Improved accuracy and precision • No interpretation required adjustment after first placement  ECG and Doppler potential success 95% or • Failure to differentiate arterial placement greater 8 References: 2. Trerotola et al. J Vasc Interv Radiol 2007; 18:513-518 3. Naylor JAVA 2007; 12:1:29-31 4. VSN Market Research 5. Hostetter, R. et al JAVA 15:3, 114-123 6. Starr et al, Ann Surg, 1986; 673-676 7. Salmela et al. Acta Anaesthesiol Scand 1993; 37:26-28 8. Clinical data on file at VasoNova, Inc. 15 Doppler Principles for Tip Position Reducing Potential for Malpractice Diastolic Systolic How can you effectively reduce the potential for malpractice? inflow inflow  By developing processes that promote consistent outcomes greater than 95% of the time SVC Pulse Doppler S  Provide confirmation in timely manner with insertion while ruling D out arterial placement  Put the tools in the hands of the inserter Flow in veins is pulsatile driven by heart cycle X-Ray – General location for terminal tip – Accurate most of the time – Is that good enough? hemodynamics ECG/EKG – Greater accuracy and precision, applicable to most patients A with P-wave Atrial ECG/EKG + Doppler – Achieves maximum accuracy, precision and safety, greatest application Contraction 3