Acebecker Posted May 28, 2014 Share Posted May 28, 2014 All - is it standard pratice at your institution to require a SP's cosignature before the outpatient clinic will place a PICC? I work in wound care on an oupatient basis. I have had the nurses who run our outpatient clinic refuse to place PICCs on two of my patients with osteomyelitis until a doctor signed the order as well. This may be an issues whereon I have to resign unless this is standard practice for PAs. I got the, "You're just a PA. We need a doctor to order this." My head nearly exploded. Link to comment Share on other sites More sharing options...
rcdavis Posted May 28, 2014 Share Posted May 28, 2014 Had similar problems. Eventually had to go to president medical staff and exec committee after first confirming that I was indeed credentialed to order what was in question. The receiving department countered it was not me or PAs in general they had a problem with, it was Medicare, who would not pay for any procedures ordered by a non physician. So they had extrapolated that fact into a philosophy that PAs COULDNT order such and such. So, I would advise two things: check and assure that you are credentialed to infact order these things at your institution. If not, fix that. If cannot get fixed, then you are stuck. If you are credentialed, then ask the surgical clinic what is the basis for their denial? If is Medicare or reimbursement the reason? If so, continue ordering and let institution fight Medicare If not, then what is reason.. And bring their response to credentials and executive committee for institutional policy change. Good luck. Link to comment Share on other sites More sharing options...
Acebecker Posted May 28, 2014 Author Share Posted May 28, 2014 Sounds like this is going to suck. Thanks for the input, though! Link to comment Share on other sites More sharing options...
FBIDoc Posted May 28, 2014 Share Posted May 28, 2014 Quit sending them to nurses and send them to your local friendly IR PA =) Link to comment Share on other sites More sharing options...
Moderator ventana Posted May 28, 2014 Moderator Share Posted May 28, 2014 I commonly use "it is a delegated task" with in practice and I am ordering it. If they refuse look into as RCdavis says if they still are closed minded find a different clinic to send them too Link to comment Share on other sites More sharing options...
UGoLong Posted May 28, 2014 Share Posted May 28, 2014 I order PICCs in hospitals and LTACs without an issue. No occasion to try it on outpatients though. Link to comment Share on other sites More sharing options...
FBIDoc Posted May 28, 2014 Share Posted May 28, 2014 Ace I should qualify that I am a hospital-based interventional radiology PA and place PICCs all day, as well as order them...In previous lives I worked in ED, trauma/vascular/neuro-surgery, and critical care and have practiced in OR, WA, VA, MD, and ID...I have never run into this problem...what state are you in might I ask? Link to comment Share on other sites More sharing options...
Acebecker Posted May 28, 2014 Author Share Posted May 28, 2014 This is a critical access hospital in Idaho. Because of the rush to get me hired my credentialing was issued on a temporary basis; my hope is that once credentialing is complete this will go away. Unfortunately we don't have an IR anybody in our hospital. I would jump to that in a heartbeat. do you perform bone biopsies? Link to comment Share on other sites More sharing options...
FBIDoc Posted May 28, 2014 Share Posted May 28, 2014 PM me your contact info... Link to comment Share on other sites More sharing options...
burnpac Posted May 29, 2014 Share Posted May 29, 2014 No issues ordering PICCs on patients of all ages at our facility. All orders are ultimately signed by the attending electronically, but the order is valid the minute I generate it in the CPOE system. These sorts of problems are minimized when you have a surgeon business partner like mine (who happens to be chief of surgery), who will cut a nurse a new a**hole if she gives me any grief about orders.... But at out facility, the nurses love PAs, and find us much more approachable and accessible than physicians. We never have a problem with orders of any type. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
coloradopa Posted May 29, 2014 Share Posted May 29, 2014 This is a critical access hospital in Idaho. Because of the rush to get me hired my credentialing was issued on a temporary basis; my hope is that once credentialing is complete this will go away. Unfortunately we don't have an IR anybody in our hospital. I would jump to that in a heartbeat. do you perform bone biopsies? Learn how to do PICCs yourself. Provide the service for the patients. Cut the nurses out of the picture. Bill for the procedure and make extra money. For bonus yuks have the hospital administration make the nurses show you how to do PICCs. Link to comment Share on other sites More sharing options...
delco714 Posted May 31, 2014 Share Posted May 31, 2014 No problems inpatient or out. I've even ordered outpatient at a different hospital entirely and they had no issue. For the most part in Maine np/pa are treated right and highly regarded. The only thing my docs can do and I can't is the surgery itself I guess. But then again, they can let me do the most of it anyway :-P. I do have a close relationship with IR and picc team for when I need them, which is fairly frequent. Every so often I do need to name drop the MD just to expedite though Also a PA can't just start doing picc lines even if they get certified. The supervising physician has to be doing them and privileged to do so as well..then you have all the supplies, etc. Out patient private office, May be more feasible, but in a hospital or hospital-owned practice,I doubt it would fly. I'd live to be able to do these, it'd be pretty convenient! Steve PA-C, Maine, urologic surgery Link to comment Share on other sites More sharing options...
Acebecker Posted May 31, 2014 Author Share Posted May 31, 2014 'nother question. I ordered a single lumen as we're just treating osteo and there is lower risk of PICC infection with single lumen. The CRNA who finally placed the PICC said, "I only do double lumen PICCs," so that's what she placed. Any thoughts on this? Andrew Link to comment Share on other sites More sharing options...
Derbingle Posted May 31, 2014 Share Posted May 31, 2014 PAs and NPs both can order piccs in our ER and the radiologist on call will put it in....double or triple lumen. Ps. The patient usualy comes from OP clinic with an RX from infectious disease or oncology requesting a line. Then we order it. Link to comment Share on other sites More sharing options...
Dunedain Posted May 31, 2014 Share Posted May 31, 2014 'nother question. I ordered a single lumen as we're just treating osteo and there is lower risk of PICC infection with single lumen. The CRNA who finally placed the PICC said, "I only do double lumen PICCs," so that's what she placed. Any thoughts on this? Andrew As a RN I much rather have a double or triple lumen PICC. While it makes sense that only one lumen has a lower infection rate with proper infection control techniques and cap replacement I don't see an issue of 1 vs 2 vs 3. With osteo sometimes 2 to 3 ABX/fluids are ordered and its nice to have different lumens to run meds into because a lot of ABX can't be piggybacked on to each other, Just saying I can see why the CRNA (former staff nurse most likely) put in a double. At my hospital nurses (Or IR with difficult cases) put in all of the PICCs and they are usually triple lumen. I am actually signed up for a PICC course soon... Link to comment Share on other sites More sharing options...
Acebecker Posted May 31, 2014 Author Share Posted May 31, 2014 Where does one find a PICC course? Link to comment Share on other sites More sharing options...
delco714 Posted May 31, 2014 Share Posted May 31, 2014 Just skip over my statement where I state I'm pretty sure a PA can't just start doing picc lines, it has to be a privilege thing as well as involving your SP Steve PA-C, Maine, urologic surgery Link to comment Share on other sites More sharing options...
FBIDoc Posted May 31, 2014 Share Posted May 31, 2014 'nother question. I ordered a single lumen as we're just treating osteo and there is lower risk of PICC infection with single lumen. The CRNA who finally placed the PICC said, "I only do double lumen PICCs," so that's what she placed. Any thoughts on this? Andrew Ask her if she's going to manage the increased DVT risk and higher line clotting that comes with multiple lumen PICCs Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 3, 2014 Moderator Share Posted June 3, 2014 UE DVT is a real issue I used to place a lot of picc's - rarely would we put in a double or triple - even a little increase in size is a sig increase in DVT risk..... Most places don't realize that an UE DVT with a picc in place is not a DVT that needs lifelong blood thinning...... so not only do they get a DVT, then if they are not treated correctly they might be sentenced to a life of anticoag and all the testing with it, and bleeding risks an expense....... Link to comment Share on other sites More sharing options...
rcdavis Posted June 4, 2014 Share Posted June 4, 2014 Just as an aside, Jeff, what is the proper tx? The PICC associated clot is not due to an inherent congenital coagulopathy, I consider it akin the a DVT of immobility.. 3-6 mos anticoag ( I like xaralto or any of the factor xa inhibitors in young otherwise healthy patients who are not going to be playing sports or subjecting themselves to head trauma over Coumadin), then stop. But, once it occurs there still is the risk of clot fragment.. And, IMHO, the PICC Must come out. Which means either another PICC or a portacath. I am excluding any extrinsic hyper coagulate state: eg cancer from this conversation. Comments? Link to comment Share on other sites More sharing options...
Moderator ventana Posted June 5, 2014 Moderator Share Posted June 5, 2014 1- remove picc 2-start heprin 3-start coumadin 4-d/c coumadin in 3 months 5- do a hypercoag panel after they have been off anticoag for a while - the 'system' needs to reset (talk to Heme is you have a question) I would always look at a CXR just to ensure no cervical rib..... in younger patients you have to counsel on not getting head trauma..... seriously... Link to comment Share on other sites More sharing options...
rcdavis Posted June 5, 2014 Share Posted June 5, 2014 Very nice. I agree. Link to comment Share on other sites More sharing options...
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