Title: Peripherally Inserted Central Catheters (PICC)
Advisory Ruling Number: 9301
The Massachusetts Board of Registration in Nursing (Board) is created and authorized by Massachusetts General Laws (M.G.L.) c. 13, §§ 13, 14, 14A, 15 and 15D, and G.L. c. 112, §§ 74 through 81C to protect the health, safety, and welfare of the citizens of the Commonwealth through the regulation of nursing practice and education. In addition, M.G.L. c.30A, § 8 authorizes the Board to make advisory rulings with respect to the applicability to any person, property or state of facts of any statute or regulation enforced or administered by the Board. Each nurse is required to practice in accordance with accepted standards of practice and is responsible and accountable for his or her nursing judgments, actions, and competency. The Board’s regulation at 244 CMR 9.03(6) requires all nurses to comply with any other law and regulation related to licensure and practice.
Date Issued: January 29, 1993
Date Revised: July 10, 2002; July 13, 2011; March 11, 2015
Scope of Practice: Registered Nurse, Licensed Practical Nurse
To guide the practice of the Registered Nurse (RN) whose clinical responsibilities include the insertion, management, and withdrawal of a Peripherally Inserted Central Catheter (PICC).
To guide the practice of the Licensed Practical Nurse (LPN) whose clinical responsibilities include PICC management.
A PICC is a long intravenous access device inserted into one of the superficial veins of the peripheral vascular system and advanced until the tip rests within the superior vena cava (SVC) near its junction with the right atrium or, if placed via the femoral vein, the tip dwells in the inferior vena cava (IVC) above the level of the diaphragm.
PICC management activities include:
- Dressing the PICC insertion area
- Accessing the PICC (e.g., blood draws, tubing change)
- Administering solutions and medications via PICC when prescribed by a duly authorized prescriber
The RN will assume only those duties and responsibilities within RN scope of practice and for which the RN has acquired and maintained necessary knowledge, skills and abilities to competently insert, manage and remove a PICC in accordance with accepted professional standards.* It is not within the scope of practice for a Registered Nurse to operate fluoroscopy or radiographic equipment.
The LPN will assume only those duties and responsibilities within LPN scope of practice and for which the LPN has acquired and maintained necessary knowledge, skills and abilities to competently manage a PICC in accordance with accepted professional standards.* It is not within the LPN scope of practice to insert or remove a PICC or to operate fluoroscopy or radiographic equipment.
In the context of the care of the patient requiring PICC insertion, maintenance, and withdrawal, the nurse is responsible and accountable for:
- Verifying that orders are written by a duly authorized prescriber
- Completing a theoretical and practical formal educational program that includes, but is not limited to, advanced knowledge in:
- Patient assessment/screening
- Safe equipment use
- Insertion/withdrawal techniques (RN only)
- PICC management strategies
- Anticipating and recognizing potential complications
- Recognizing and appropriately reacting to emergency situations
A RN that completes a formal education program that includes a theoretical and practical component for each PICC insertion activity may include in RN practice, but not be limited to:
- Any Seldinger technique
- Suturing the line for stabilization
- Using real-time visualization techniques such as ultrasound and fluoroscopy
- Using adjunct devices
- Assessing a chest radiograph to determine PICC tip placement
For inclusion of the activity of assessing a chest radiograph to determine PICC tip placement, the RN must complete a formal education program that includes appropriate theoretical and practical component with oversight from the organization's department of radiology. It is not within the scope of RN practice to operate fluoroscopy or radiographic equipment, to otherwise interpret the chest radiograph, to provide a comprehensive radiographic report, or to make a medical diagnosis.
The nurse in a management role must ensure the availability of sufficient resources to provide for safe implementation, including, but not limited to organizational policies that provide for:
- Protocols for assessing and documenting the advanced education and validation for RN or LPN initial and continued competency for each activity
- Protocols for provision of clear, complete and culturally appropriate informed consent
- Nursing care responsibilities, including, but not limited to patient assessment, monitoring, medication administration, potential complications, and documentation criteria
- Emergency protocols including, but not limited to, immediate, on site availability of emergency equipment, medications and personnel
- Detailed policies and procedures, pursuant to appropriate statute and regulation, that account for radiation protection and personnel who will operate the fluoroscopy equipment when PICC insertion requires fluoroscopy guidance
* Professional Standards and references include, but are not limited to the following:
- Infusion Nursing Standards of Practice (2011), (Journal of Infusion Nursing, Infusion Nurses Society)
- Policies and Procedures for Infusion Nursing 4th Edition, (2011) (Infusion Nurses Society)
- Association for Vascular Access Position Statements: The Use of Seldinger or Modified Seldinger Technique, in Combination with Real-Time Imaging Modalities for Peripherally Inserted Central Catheter and Midline Placements by Clinicians (2011), Cannulation of the Internal and External Jugular Veins by Registered Nurses and Other Qualified Healthcare Professionals (2011), The Use of Ultrasound Guidance by Registered Nurses for Central Venous Catheter Insertion (2010) http://c.ymcdn.com/sites/www.avainfo.org/resource/resmgr/Files/Position_Statements/The_Use_of_Seldinger_or_MST.pdf accessed 2/26/15