# Paramedics Inserting PICC Lines



## Fwgun (Jan 13, 2016)

Question... If a medical director agreed to it, could Paramedics insert PICC lines in the field for nursing homes?


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## chaz90 (Jan 13, 2016)

Oh boy. I'm really reluctant to even get into this. 

Why in the world would a paramedic be the most qualified person to do this type of procedure? We're supposed to be pre-hospital/emergency medical care professionals, not cheaper alternatives to whoever should be performing a procedure. 

You do understand many PICC line insertions utilize ultrasound initially right? You also understand that chest X-rays are used to confirm proper tip placement after they are inserted?

This isn't an emergent procedure in any sense. They're relatively slow to place, and offer few practical advantages in acute care. These are long term healthcare devices by nature, and I can't imagine what kind of paramedic would need to use one.

In short, I can't imagine why any medical director would authorize paramedic placement of PICC lines in the field or nursing homes.


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## Akulahawk (Jan 14, 2016)

Pretty much what Chaz said. If you've ever seen a PICC placed, you know it's not a speedy procedure. I've seen a few done and in another year or so, I hope to get certified to do mid and PICC lines. Sure, it can be done relatively fast, but we're not talking Peripheral IV fast. First off, they're usually placed using ultrasound to at least _find_ the insertion point and get it into a decent vein. Second, these are sterile procedures. Creating and maintaining a sterile field and conditions during placement is critical to preventing infection after placement. Inserting Peripheral IV lines are not... they're "clean" but not _sterile_. Then the US is used to be reasonably certain the tip is in the right place and didn't go up one of the jugular veins instead. 

Now then, I could see an utrasound-trained medic starting a mid-line or being able to place a peripheral IV in a deeper vein, but you have to be very cautious about those because it's _much_ more difficult to determine if whatever's being infused has extravasated. Quite honestly, if you're going to the trouble of placing a PICC, you might as well just do a central line, at least as a Paramedic. Don't get me wrong, PICC lines are wonderful after they're placed but they just shouldn't be done under relatively emergent conditions. If a facility doesn't have the personnel to insert a PICC and a patient needs one, they should be able to contact/contract with an outside agency to send a PICC-trained RN or PA to do the placement.


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## Underoath87 (Jan 14, 2016)

Sure. And then you could get cleared to perform appendectomies and cholecystectomies as well.


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## TransportJockey (Jan 14, 2016)

Emergent central lines (advanced until blood return is noted) makes way more sense for ems than a picc... and io makes more sense than them.


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## ERDoc (Jan 14, 2016)

You will probably be hard pressed to find any medical director that has put in a PICC line themselves, so it is highly doubtful that you will be given a protocol.  The others have pretty much given the best reasons.


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## k9Dog (Jan 15, 2016)

The risk for infection
Would be high. It's a surgical procedure that involves high level of training and assistance from surgical techs, anestesiologists, nurses etc. A paramedic with a relatively small amount of training is not the standard of care for this, and it's not what we do, we deal with emergencies.


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## chaz90 (Jan 15, 2016)

k9Dog said:


> The risk for infection
> Would be high. It's a surgical procedure that involves high level of training and assistance from surgical techs, anestesiologists, nurses etc. A paramedic with a relatively small amount of training is not the standard of care for this, and it's not what we do, we deal with emergencies.


I wouldn't consider it a "surgical procedure" per se, and it certainly doesn't require techs, anesthesia, or additional help from nurses during placement. 

It's not a level of training issue either. It's not that a paramedic isn't capable of learning to place one, but I stand by my earlier points. We shouldn't be placing them due to potential risks in a non sterile field environment, lack of available equipment to assist in placement, and no real immediate advantages over other venous access options.


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## Tigger (Jan 15, 2016)

I do not understand what, if any advantages PICC lines would provide over what is currently available for access.


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## Carlos Danger (Jan 15, 2016)

Maybe I misunderstood the OP, but my impression of the original question was whether it was possible for a paramedic to work as a "PICC tech", placing them in non-acute situations outside the hospital.

As others have said, PICCs aren't that big a deal to place, but they have no place in the prehospital setting because they are time consuming to place, present a substantial infection risk, and offer flow rates much slower than a PIC or shorter CIV.


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## Summit (Jan 15, 2016)

It is not an emergent procedure. It is a planned procedure.
It is not a short term solution. It is meant to stay in for weeks or months.
It is not a field procedure. It is a sterile procedure for a controlled environment.
It is not a procedure where you can gain or maintain competency doing one or two a year.

So why would a paramedic need this in their toolkit again and why is it a good idea?


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## Fwgun (Jan 16, 2016)

All of you are thinking emergency medicine, I am talking more about the community paramedicine part. Currently nursing homes pay $800+ to have an RN come insert the line at the nursing home, which is later confirmed by a third party via xray for placement. This would not be used on transport, purely for community paramedicine.


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## Summit (Jan 16, 2016)

Fwgun said:


> All of you are thinking emergency medicine, I am talking more about the community paramedicine part. Currently nursing homes pay $800+ to have an RN come insert the line at the nursing home, which is later confirmed by a third party via xray for placement. This would not be used on transport, purely for community paramedicine.


So an experienced RN (RNs who do PICCs typically do it as a specialty, vascular access nursing) is doing this procedure in a healthcare facility.

1. A planned sterile invasive procedure in a medical facility... how would that fall under the mission of community paramedicine?

2. Do you think the Paramedic will do it enough to remain competent, or enough to justify the training costs and equipment purchase?

3. What is the problem with the current system?


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## Fwgun (Jan 16, 2016)

Currently nursing homes in our area and paying private companies to come out and they have an RN, bring an ultrasound and all the supplies and insert the PICC lines at the facilities, in the patients rooms. Then transfer maintenance of it over to the nursing staff. The problem is they are extremely over charging and are so busy they can't be reasonable on times. There is no reason you can't give a paramedic that same specialty training on inserting the PICC line and an ultrasound machine is only about $6,000. Thus it would make it more present in the community, save nursing facilities money and provide the patient with a more rapid intervention allowing them to receive the medications they need through a patent line. 

I'm not saying allow everyone on the service to do it. But have a designated group of people that you have trained by certified staff at the hospital and keep them in the loop on Inservices to allow them to remain up to date on the practices.


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## TransportJockey (Jan 16, 2016)

in your opinion why do you think they're overcharging? A specialty skill comes with a price.


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## Fwgun (Jan 16, 2016)

$800+ for a PICC? Give me a break. That's more than a ALS transport to the hospital in most areas. I could charge half that and still be profitable. They monopolized the market in the area and have no one challenging it so they can charge whatever they want


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## chaz90 (Jan 17, 2016)

If you'd like to find a medical director and charge $400 for "discount PICC placement" by an inexperienced provider, be my guest. I, for one, will continue to pay the expected fee (with insurance of course) to receive the procedure from the right person, trained in the right way, at the right time. $800 seems like a perfectly reasonable price to pay for a long term healthcare device that has a significant risk of complication during placement and requires specialized skills and equipment to perform. 

This is in no way a paramedic skill. Again, we are not "jack of all trades" replacements for other healthcare providers. We as paramedics don't have a broad scope because we are magically gifted at all things medicine. IMHO, this is a solution to a problem that doesn't exist.

If you want to be a professional airway specialist, become an anesthesiologist or CRNA. If you want to be a paramedic, go to paramedic school. If you want to place PICC lines for a living, become a nurse and specialize in placing PICC lines.


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## STXmedic (Jan 17, 2016)

chaz90 said:


> If you'd like to find a medical director and charge $400 for "discount PICC placement" by an inexperienced provider, be my guest. I, for one, will continue to pay the expected fee (with insurance of course) to receive the procedure from the right person, trained in the right way, at the right time. $800 seems like a perfectly reasonable price to pay for a long term healthcare device that has a significant risk of complication during placement and requires specialized skills and equipment to perform.
> 
> This is in no way a paramedic skill. Again, we are not "jack of all trades" replacements for other healthcare providers. We as paramedics don't have a broad scope because we are magically gifted at all things medicine. IMHO, this is a solution to a problem that doesn't exist.
> 
> If you want to be a professional airway specialist, become an anesthesiologist or CRNA. If you want to be a paramedic, go to paramedic school. If you want to place PICC lines for a living, become a nurse and specialize in placing PICC lines.


This. Several times over.


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## Jim37F (Jan 17, 2016)

I fail to see how replacing the RN with a Community Paramedic will significantly reduce the price if that is what you're concerned with. The equipment is the same, you're still requiring the follow on specialty X-Ray by a third party. Considering $800 is the price of a BLS assessment here (not transport, that adds mileage and all that jazz, just a BLS assessment for an IFT) quite frankly I just don't see any significant cost savings...and unless you're expecting a community paramedic rig to be sitting around a station waiting for tones to drop to rush out code 3 in order to place the PICC, I don't see any time savings you mentioned either....


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## Flying (Jan 17, 2016)

As far as I understand, community (para-)medicine is about keeping people out of hospitals, not bringing the hospital to them. Placing a specialized cath in someone isn't a part of that mission.


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## akflightmedic (Jan 17, 2016)

Fwgun said:


> Currently nursing homes in our area and paying private companies to come out and they have an RN, bring an ultrasound and all the supplies and insert the PICC lines at the facilities, in the patients rooms. Then transfer maintenance of it over to the nursing staff. The problem is they are extremely over charging and are so busy they can't be reasonable on times. There is no reason you can't give a paramedic that same specialty training on inserting the PICC line and an ultrasound machine is only about $6,000. Thus it would make it more present in the community, save nursing facilities money and provide the patient with a more rapid intervention allowing them to receive the medications they need through a patent line.



I see your angle now and since everyone addressed their replies from the medical aspect, I will enlighten you with the business mind. Your reasoning is flawed. Very.

You seem to think you can just buy a 6K ultrasound, get some training and then do PICC lines for half price (maybe 2 for 1 Tuesdays)?

The rates charged are what Medicare and Medicaid allow. If this is the government standard, why on earth would you charge less? In all seriousness, the government does not care about cost savings, especially on this level. This is not even a blip on their radar. But aside from that you also seem to be putting yourself into the role and you falsely assume every person who assumes this role going forward would be as equally trained or diligent. While you yourself may be more than capable, do we want that precedent when we already agree the paramedic curriculum unto itself is inadequate?

So...to do PICC lines you need:

*Training*: How much will this cost, where will you get it and who will pay for it?
*Ongoing training* to prove competency: Same questions as above
*Medical Direction*: A MD who is willing to allow this of his/her paramedics might not be all that cheap.
*Medical Malpractice Insurance*: With the infection risk and the potential perception of allowing a lower educated person to perform a "nurse" skill, you better have some good insurance to cover anything and everything.
*Workers Comp Insurance:* Thats right, even another insurance to protect you in the event of an on the job injury.
*Communications:*This is all encompassing, you need cellphones, IT support, gadgets and gizmos....and you need to have HIPAA compliant policies and procedures in please before you can use any of it and also secure servers.
*Ultrasound:*Ok, so you buy ONE ultrasound. What do you do when it needs servicing or breaks? This means you need redundancy in your equipment. Wait! You also need a certified biomed technician otherwise you cant bill for your services as you are not qualified.
*Transportation:* Yep you need work vehicles and insurance and maintenance. And you insurance needs to be the higher work related insurance in case you get in a crash while en route to perform a procedure.
*Supplies:* You need vendors! Many of them as you want to get the cheapest price available so you often have to pit them against one another, but you also need volume in order to demand that.

So now we need an IT Team, Biomed person, a MD, and you the PICC placer. Do you need an assistant??

Anyways, this is a very SHORT list of the many flaws in your reasoning, I simply do not have the time to continue on.

And if you meant to say all of this would be incorporated into an existing EMS Service so its already covered...good luck getting the Risk Manager to sign off on this.

Its business....quite frankly, $800 sounds dirt cheap when you factor in all that overhead.


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## Summit (Jan 17, 2016)

Fwgun said:


> $800+ for a PICC? Give me a break. That's more than a ALS transport to the hospital in most areas. I could charge half that and still be profitable. They monopolized the market in the area and have no one challenging it so they can charge whatever they want


*Consider the OPERATIONAL COST for an uncomplicated PICC insertion IN-HOSPITAL (cheaper) is about $400.*

This is a 1-2 hour procedure on average. And you want to send the provider to the patient at an outside facility? $800 is cheap as heck!

So we've come down to the real basis which is "Paramedics should do it because they are cheaper!!!" Well, why don't we have community paramedics learn to suture and have them respond to ambulatory surgery centers to close? They'll be cheaper than PAs or RNFAs!

You think you can offer cut-rate service because you are paying the Paramedic $20/hr instead of $30/hr for the RN? Give me a break! And to save that $20 you are using a less experienced provider when the stakes are high.

RNs who do this do it all the time (1-4 insertions/shift) and were doing sterile procedures for years usually coming from ICU or OR. The experienced PICC RN will be faster, have lower infection rates, and lower failure rates. What is the price of failure? An ambulance ride to the hospital so the PICC can be placed in Interventional Radiology... and an ambulance ride back. The price for a line infection is much higher still.


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## Akulahawk (Jan 17, 2016)

From the business aspect of things, AK is pretty much on the money, so to speak. If you're looking at the actual item cost of placing a PICC (tray, x-ray shot, etc) then you probably do think that you could train someone to place a PICC and charge "just" $400/placement. Unfortunately there's a LOT of overhead that is built into doing these procedures. You have to pay for a medical director. You have to have (or contract for) biomed service. You have to acquire sufficient US machines to do the job and sufficient back-up machines that will allow you to continue working uninterrupted until you can get your primary unit back from either biomed service or manufacturer service. Those machines also need to be serviced/calibrated periodically. You need to pay for initial training in the procedure and ongoing training as well. You may also need to pay for chart audits to ensure that the PICC lines are placed consistently and properly. You have to pay for various forms of insurance (including malpractice), and so on. What AK didn't touch on at all is that assuming you actually are able to get the service up and running, there's still a ramp-up time where you'll have to pay for someone to be ready to place a PICC but you won't yet have the business yet and then once you do have facilities utilizing your services, there's still the issue of billing for said service. When you send out the bill, you may not see a dime from that for a few weeks. 

So what I'm also saying is that start up costs would be significant and you'd have to reimburse _someone_ for the start-up loans you'll need and that can only come from your future earnings that you wouldn't have in hand yet. 

Since there are private RN-PICC companies out there now, experience has shown how much funding it takes to keep those businesses up and running successfully. Just one of those things is that those companies won't likely hire someone that doesn't already have PICC placement training because then someone else bears the cost of initial training so all the company has to do is verify a competency as opposed to training someone to an appropriate level of competency.

So, in addition to the medical aspect of things, it's just not a good business move unless you've got a large fortune that you're willing to turn into a much smaller fortune to get something like this up and running.


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## Akulahawk (Jan 17, 2016)

Summit said:


> You think you can offer cut-rate service because you are paying the Paramedic $20/hr instead of $30/hr for the RN? Give me a break! And to save that $20 you are using a less experienced provider when the stakes are high.
> 
> RNs who do this do it all the time (1-4 insertions/shift) and were doing sterile procedures for years usually coming from ICU or OR. The experienced PICC RN will be faster, have lower infection rates, and lower failure rates. What is the price of failure? An ambulance ride to the hospital so the PICC can be placed in Interventional Radiology... and an ambulance ride back. The price for a line infection is much higher still.


Totally agree with this. Considering that an experienced RN doing these may actually be worth north of $60/hr considering the local market and experience... while using a Paramedic might be "cheaper" by maybe $40, the Paramedic just doesn't normally have the requisite experience base. I'm not saying that a Paramedic can't learn to place a PICC, there's something to be said for experience working in a sterile field. One of those experiential things is knowing how to move sites... Once upon a time there was a PICC nurse that was attempting to place a PICC. Unfortunately the first placement failed. So the RN had to change to an alternate site and do it without breaking sterility. It was done and the second attempt went beautifully, but it wasn't easy and I had the unenviable task (at the time) of watching _everything_ to ensure that the sterile field wasn't broken. It won't be easy teaching a Paramedic that hasn't had much (if any) experience working in a sterile field how to do exactly this. 

In the the long run, it might be cheaper to start up an Interventional Radiology company as a fixed-place of business, attach an ambulance company to it and shuttle patients to the IR company for various procedures, including PICC placement... but remember that means taking a large fortune, turning it into a small one, in the hopes of building back up a large fortune...


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## Summit (Jan 17, 2016)

Fwgun said:


> I'm not saying allow everyone on the service to do it. But have a designated group of people that you have trained by certified staff at the hospital and keep them in the loop on Inservices to allow them to remain up to date on the practices.



He isn't interested in forming a company with medics who do this full time (that would be boring after-all). He wants this to be "yet one more skill" for a special-few-elite Community Paramedics to do every couple weeks/months.


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## akflightmedic (Jan 17, 2016)

Correction Summit.....2 weekends a month, 2 weeks a summer! 

Hoo-Ah!


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## Tigger (Jan 17, 2016)

The flashy skills are simply not going to make community paramedics effective. As an industry, I believe we need to partner with the people that do the flashy things for a living and help them. And then there's the whole part about just keeping people of hospitals which is cheap and does not require an enormous training outlay.


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