PICC lines

[Hork Bajir]

Anyone on here place them? If so, how did you learn and go about getting credentialed by your hospital? What kind of follow up/keeping track of lines do you do? Is it a money maker for you/your group?

Obviously the procedure itself shouldn’t be too challenging for anyone facile with lines and ultrasound. Seems like something we could offer some of our patients at my place (ex: IVDU difficult stick who is getting admitted for a debridement or whatever and will remain inpatient for some time on IV abx... and yes before anyone says it, I’m fully aware that any procedure will not be a money maker in this uninsured patient population).

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[Planktonmd]

Why would your group want to become the PICC line team of the hospital?

 

[Hork Bajir]

Value added, service to the surgeons/our patients, pushing the scope of practice, and financial incentives are the reasons that come to mind.

Also, I’m not necessarily saying that I’d want to be responsible for all of the PICCs in the hospital. Not even something I’ve given a ton of thought... Just curious if anyone has any experience with doing them, and putting the question out there to those more experienced than myself

 

[Maverikk]

I’ve thought the same. I rotated with the picc team for a short time, it’s not hard just ultrasound IV access. It’s more of an equipment/staff/expectations issue, having dedicated staff to make sure you have everything, the smaller more flexible wires when you need it etc, that stuff would just grow dust in a pre-op area and every anesthesiologist would either be expected to know how to do it, otherwise why have a picc team. It’s not an overly complex procedure, but the equipment/staff/expectations are the things you have to manage. What happens when you’re picc is clotted on the floor and tpa doesn’t work, when there’s a bloodstream infection and the primary service wants it replaced? One hospital I was at had the private ER group with a picc team of PAs as well as a private IR group, both groups refused to see each different groups piccs and the ER PAs were 7-5, so ER docs were in a clinch after 5. It’s like setting up a regional service with catheters vs just doing single shots with your preop travel nurse.

 

[Mikkel]

Just wait until the "value add" doesn't make financial sense to continue, but you already committed to "helping out" and don't want to burn bridges by getting out.

 

[BLADEMDA]

I recommend midlines for some patients. Physicians or nurses can place them preop and they are good for weeks. Easier to place than PICC and more than adequate for surgery patients

 

[BLADEMDA]

A midline catheter is 3 inches (7.5 cm) to 8 inches (20 cm) in length, and it's inserted via the veins near the antecubital fossa into the basilic, cephalic, or brachial veins (see Site selection for midline catheters). The tip is advanced no farther than the distal axillary vein in the upper arm

 

[ryanjmy]

As an intern I learned how to place them. My residency hospital had a pic line rn but they could charge more if an MD did them. It’s really easy. I taught an icu NP how to place them with the thought of starting a picc line service but never realy followed up. There was some resistance from IR as the didn’t want to give up that business.

I don’t think its very lucrative. Plus you’d have to have some way to follow up with the pts that are discharged with a picc line for IV abx.

 

[norski]

MIDs are so much easier to do, it's ridiculous. Yes, they can't stay in situ as long as a picc (would depend mostly how you drape and clean the insertion site), but inserting a 30cm line perpherally vs a 12-20cm line is a hell of a lot more hassle. I like an insertion site somewhere along the distal 10-20% portion of the humerus.

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[fittipaldi1of1]

I’ve wondered the same thing. We are often having to put in peripheral IVs with US anyway cuz the nurses can’t get access.. so why not just put a PICC and charge for it?

 

[drmwvr]

I’ve wondered the same thing. We are often having to put in peripheral IVs with US anyway cuz the nurses can’t get access.. so why not just put a PICC and charge for it?

If you're going to treat a PICC like a PIV in terms of duration of need (ie patient will be discharged on a short term basis without their IV) can you bill for a PICC? Putting one in on that basis seems like overkill anyway....

 

[Consigliere]

Complete and utter stupidity and a decision you will definitely regret. We started a PICC line service for all the aforementioned reasons and regretted it within 6 months. Terrible reimbursement, constant phone calls (you are on the hook for the life of the PICC line), requests for PICCs at the most inconvenient times to name a few. Once the surgeons caught wind of this, the number of central lines they placed dropped precipitously and we became the "go to" for central venous access. Terrible, terrible mistake. Most real hospitals have RN led PICC line teams for a reason.

 

[jwk]

A midline catheter is 3 inches (7.5 cm) to 8 inches (20 cm) in length, and it's inserted via the veins near the antecubital fossa into the basilic, cephalic, or brachial veins (see Site selection for midline catheters). The tip is advanced no farther than the distal axillary vein in the upper arm

This sounds similar to the old-fashioned "long arm CVP" lines we put in 40 years ago. Big needle, single lumen catheter about 12" long threaded through the needle. The catheter had a hub, so the needle was withdrawn and then a snap-on plastic guard was put over the needle and the whole assembly taped in place.

 

[IlDestriero]

Our group looked into it a couple years ago.
It is a money loser.
It requires a lot of time re placements and follow up, calls, etc.
IR refused to deal with problems in any lines we placed. TPA, rewire, etc.
We abandoned the practice to the IV team and IR. In a real emergency, if there is ever a picc line emergency, IR can come in and place one while we do what we do best. Zzzzz.

 

[PTPoeny]

We have one anesthesiologist who places PICC line in select patients and it is awesome. The PICC team (already established) does all the follow-up both inpatient and outpatient (if needed) and troubleshooting, dressing changes, etcetera. I don't know anything about the billing aspect.

 

[BLADEMDA]

PICC lines run slow as crap. I like 18 Gauge Midlines or even 16G Midlines. A PICC is useful for induction and low risk cases. A Midline ( I insert them) can even be a 6 French catheter ( yes, I've put those in).

So, if it is all about the money I can see PICC but if it is PATIENT CARE then go with a Midline.

 

[BLADEMDA]

 

[chudat]

IR in my hospital tried to get rid of their picc responsibilities....too late for them lol

 

[BLADEMDA]

This kit was $10 and comes in multiple sizes including 4 French and 5 French.

 

[Arch Guillotti]

What is all the extra crap for?

View attachment 284346


This kit was $10 and comes in multiple sizes including 4 French and 5 French.

 

[nimbus]

What is all the extra crap for?

USG seldinger.

 

[ScarfTheVerb]

I use the femoral a-line kit from time to time. We have 18 and 20g catheters, about 10cm long. I’ve never bothered trying to bill for them. Perfect poor man’s PICC.

 

[Hork Bajir]

Thanks for all the insight, everyone- sounds like doing this would be more hassle than it’s worth.

I also like the femoral art line kit for a makeshift midline. Always wanted to try putting a triple lumen CVC into the basilic vein, but haven’t had a good excuse to do it thus far...