UNIVERSITY HOSPITAL AND CLINICAL PROGRAMS
PROFESSIONAL NURSING ORGANIZATION
POLICY STANDARDS

ADDENDUM:    E.3
EFFECTIVE:      1/99
REVISION:        3/08
APPROVAL:      2/08

SUBJECT: INSERTION AND REMOVAL OF SPECIALIZED CATHETERS

SOURCE: Policy Standards, Section E, Administration/Organization of University Hospital and Clinical Programs

  1. Insertion and Removal of Peripherally Inserted Central Catheters (PICC) – catheters inserted via a peripheral vein with the tip presiding in the vena cava.
  1. Performed by registered nurses that provide documentation of successful completion of an approved program by a nationally recognized accrediting body which provides didactic instruction and a competency skills check off.  Documentation is submitted to credentialing office.
  2. Registered Nurses must demonstrate the skill in the clinical setting under supervision prior to independent performance of the insertion and removal. A clinical competency check off based on ASBN guidelines should be completed and placed in the employee’s personnel file.
  3. Registered Nurses that insert and remove PICC lines will follow specified protocols.
  4. Registered Nurses authorized to insert and remove PICC lines must have this skill specifically listed in their job description.
  1. Removal of central venous catheters, arterial lines, and pulmonary catheters.

  1. Only non-tunneled central venous catheters, arterial lines, and pulmonary artery catheters may be removed.
  2. A written physicians order must be present.
  3. Prior to the removal of a central venous catheter and arterial lines the registered nurse, physician extender, and APN must meet the following criteria on a annual basis:
    • Completion self study guide.

    • Passing score of 100% on the posttest graded and recorded by Staff Education.

    • Successful completion of an annual clinical competency check off as verified by another registered nurse competent in the removal of these lines.
  4. Registered Nurses who have successfully completed the above will follow the approved Procedure for Removal of Non-Tunneled Central Venous Catheter, and Arterial Lines, excluding Peripherally Inserted Central Catheters and Procedure for Removal of a Pulmonary Artery Catheter.  This is to be done only by RN's, physician extenders (with credentialing), and APN's (with credentialing) who have completed an annual competency check off

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