Paramedics Inserting PICC Lines

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Fwgun

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Question... If a medical director agreed to it, could Paramedics insert PICC lines in the field for nursing homes?
 
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.
 
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.
 
Sure. And then you could get cleared to perform appendectomies and cholecystectomies as well. ;)
 
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.
 
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.
 
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.
 
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.
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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.
 
I do not understand what, if any advantages PICC lines would provide over what is currently available for access.
 
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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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?
 
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.
 
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.
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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?
 
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.
 
in your opinion why do you think they're overcharging? A specialty skill comes with a price.
 
$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
 
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.
 
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.
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This. Several times over.
 
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....
 
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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