Present on Admission

A patient arrived at a hospital receiving long-term vesicant therapy through a functioning peripherally inserted central catheter. Some days later the patient went home with no vascular access of any kind.

The device was never found to be infected, malpositioned, occluded, or symptomatic. It was removed because it had been inserted somewhere else.

The hospital could have placed a new one. The patient no longer had the veins.

This is not a big-hospital, small-hospital story. It happens facility to facility, in every direction. Organizations with vascular access teams and interventional radiology do it. So do organizations with neither. The only thing that changes is that the catheter crossed an organizational boundary. Nothing about the catheter changes in transit. What changes is who is looking at it.

Present on Admission is a coding field

Under the Deficit Reduction Act of 2005, hospitals paid under the inpatient prospective payment system report a Present on Admission indicator on every diagnosis. The purpose is attribution: what arrived with the patient belongs to the patient’s history, and what develops afterward belongs to the hospital, with payment consequences attached.

A PICC placed somewhere else is present on admission by definition. Refusing it is a way of keeping a device whose attribution is inconvenient at arm’s length. The stated reason is infection prevention. The guidance does not support it.

The rule being applied belongs to a different device

The concern behind refusal is legitimate: a facility cannot verify conditions of an insertion it did not perform. Federal guidance names that concern and prescribes the answer. When aseptic technique cannot be ensured, as with a catheter placed during a medical emergency, the CDC directs that it be replaced as soon as possible, within 48 hours.¹ The INS Standards add that such devices are to be labeled as placed under compromised conditions and exchanged within about 24 to 48 hours.²

Two things stand out. The criterion is the condition of insertion, not its location. Emergency, not building. And the prescribed response is to label and replace the specific devices that warrant concern, not to distrust every device that arrives from elsewhere.

A PICC cannot be placed in an emergency. It requires vessel assessment, ultrasound guidance, measurement, a full sterile field, and tip confirmation before use. Every one of those steps takes time an emergency does not give. No PICC has ever been placed in the time a resuscitation allows. Categorical refusal applies an emergency-placement rule to a device that cannot be emergently placed.

Clinically indicated is not the indicator

The Standards tie removal of a central device to clinical indication: an unresolved complication, or a treatment plan that no longer needs it.² That is what indicated means in a clinical sentence. The patient’s condition points to an action.

The indicator that drives institutional behavior is something else. It is a field on a claim. It says nothing about the vein, the site, the dressing, or the therapy still running. When a functioning device comes out on transfer, the question worth asking is which of the two was operating.

The patient was present too

The device arrives with a history. So does the person carrying it: the veins already spent, the prior attempts, the documented difficulty, and what that patient has said they will and will not have done to their body. None of that carries an indicator. None of it is scored.

And these patients are awake, alert, and oriented. We know because we chart it every shift. Capacity is not in question. Whatever explains a patient’s exclusion from the decision about their own line, it is not that they were unable to take part.

What to do instead

• Assess the device on arrival: site, dressing, external length against the documented measurement, patency, blood return, and what the patient reports.
• Read the record for tip location and how it was confirmed. If it is missing, that gap belongs to the sending facility, and verifying it is the fix, not removal.
• Name a clinician who decides the device’s disposition, so the decision is made rather than defaulted into refusal.
• Talk with the patient about their access history and wishes before anyone attempts venipuncture.
• If the device is declined, decide what happens to it. Use it or remove it. A central line left in place, unaccessed and un-redressed, is not a clinical decision carried through.

A facility that assesses a device and then declines it is on sound ground. The problem is the decision reached before anyone looked. None of this requires new resources. It requires a pathway, a named decision-maker, and a conversation.

Access is not a convenience being withheld. It is the route the treatment takes.

April Winborne, MSN, APRN, FNP-C, IVTMC, CPUI, CRNI, CCRN, CVAA(c), VA-BC. President and Founder, Northeast Louisiana Vascular Access Network (NELAVAN), a Network of the Association for Vascular Access (AVA). A full analysis of this practice is in preparation for peer review.

References

1. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193. doi:10.1093/cid/cir257
2. Nickel B, Gorski LA, Kleidon TM, et al. Infusion Therapy Standards of Practice, 9th Edition. J Infus Nurs. 2024;47(1S Suppl 1):S1-S285. doi:10.1097/NAN.0000000000000532