Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc.)

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1 Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc.) Author: Contact Name and Job Title Directorate & Speciality Guidelines For Flushing A Indwelling Intrapleural Chest Drain Lucy Briggs ( Sister Rhona Al-Bazzaz, Respiratory Unit, QMC Dr William Kinnear, Respiratory Unit, QMC original authors, 2009) Respiratory Date of submission November 2015 Explicit definition of patient group to which it applies (e.g. inclusion This guideline applies to all registered and exclusion criteria, diagnosis) nurses who are developing and reviewing nursing practice guidelines Version 2 If this version supersedes another clinical guideline please be explicit 1 (2009) about which guideline it replaces including version number. Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? Evidence base: (1-6) 1 NICE Guidance, Royal College Guideline, SIGN (please state which source). 2a 2b 3a 3b meta-analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasiexperimental study 4 well designed non-experimental descriptive studies (i.e. comparative / correlation and case studies) 5 expert committee reports or opinions and / or clinical experiences of respected authorities 6 recommended best practise based on the clinical experience of the guideline developer Consultation Process Ratified by: Date: Target audience: 1, 5 and 6 Nursing Practice Guidelines Group, Ward Sisters/Charge Nurses, Practice Development Matrons (PDMs), Clinical Leads, Matrons, ward managers within respiratory, the matron, Barclay ward manager and deputy and the clinical educator on CICU, Infection Control, respiratory consultants Matron s forum November 2015 All Registered and non-registered nurses Review Date: (to be applied by the Integrated Governance Team) A review date of 5 years will be applied by the Trust. Directorates can choose to apply a shorter review date; however this must be managed through Directorate Governance processes. April 2020 This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date. 1

2 NOTTINGHAM UNIVERSITY HOSPITALS TRUST NURSING PRACTICE GUIDELINES GUIDELINES FOR FLUSHING A INDWELLING INTRAPLEURAL CHEST DRAIN Intrapleural chest drains are inserted to remove air or fluid. They are prone to blockage (Hooper and Maskel, 2010). Regular flushing reduces this (Davies et al, 2008). For example, 3 times a day. This will help to maintain patency of the drain. NB: These guidelines for flushing an intrapleural drain should be read in conjunction with the guidelines for Management of a patient with underwater seal chest drainage. Only registered nurses, who have been supervised and assessed as competent may undertake this procedure. EQUIPMENT LIST Small dressing pack, including sterile dressing towel 20ml syringe 20mls 0.9% sodium chloride for IV use 1 pair of sterile gloves 1 2% chlorhexidine swab A clean injection tray/trolley 2

3 ACTION 1. Explain the procedure to the patient and gain verbal consent RATIONALE Nurses should only flush drains with a 3 way tap. Check that patient got chest drain in situ. Is there a 3 way tap in place? 2. Are regular (e.g. 3 times a day) 0.9% sodium chloride flushes prescribed for drain? 3. In a designated clean area of the ward, draw up 10-20mls of 0.9% sodium chloride into a 20ml syringe. Double check, in accordance with the local policy. 4. Take the syringe of 0.9% sodium chloride to the patient, checking the identity of the patient in accordance with the local policy. 5. Position the patient to allow access to the chest drain, ensuring the patient is comfortable. Decision on indication/frequency lies with the responsible consultant. Do not flush if no prescription, as per NUH Trust policy. To reduce the risk of contaminating the saline flush. Amount to be flushed should be specified on the patient s drug card. To ensure patient safety. To facilitate the procedure. 6. Perform hand hygiene. To minimise the risk of infection. 7. Open the sterile dressing towel and place under the chest drain. To minimise the risk of infection. 8. Ensure 3-way tap is switched off to flushing port, remove bung. If there is a needleless bionector device on the 3-way tap, clean with 2% chlorhexidine wipe, for 30 seconds. Allow to air dry. 9. Clean hands and apply alcohol gel. To minimise the risk of infection. To minimise potential contamination of the drain and/or equipment used. 3

4 ACTION 10. Apply the sterile gloves and attach the syringe of saline to the port. Ensure the 3 way tap is closed towards the drainage tubing on the chest drain system. Instil the 10-20mls of 0.9% sodium chloride into the chest drain. Turn off 3 way tap to injection port. 11. Remove the empty syringe from the 3-way tap. Replace with sterile bung if required. Ensure the 3-way tap is open to the drainage tubing on the chest drain system, checking that the fluid is draining from the chest drain. 12. Dispose of all equipment according to local policy. 13. If the drain is attached to an underwater seal drainage system, ensure the drain is patent by: RATIONALE To ensure the 0.9% sodium chloride is instilled along the diameter of the chest drain. STOP if there is resistance, do not FORCE through. Report to medical staff for review. Report any pain/discomfort and consider medical review before the next flush. To facilitate drainage of the flush and to check the patency of the chest drain. To prevent the risk of cross infection. To assess and monitor the patency of the drainage system. a) Ensuring the fluid level is fluctuating in the drainage tubing. (Allibone, 2003) b) ask the patient to cough and observe for fluctuation of the fluid in the drainage tubing. 14. Document administration of 0.9% sodium chloride on the patient s drug card To comply with good record keeping 4

5 ACTION 15. Observe the patient by monitoring the early warning score (EWS) 4 hourly (Allibone, 2003). In addition, monitor the patient for chest pain and/or discomfort and continue to assess the patency of the drainage system if the drain is attached to an underwater seal drainage system. RATIONALE To monitor the patient for any ill effects from the procedure and to facilitate the early detection of complications. If a chest drain is still not swinging, it requires medical review. Any pain on flushing should be reported to medical staff, and the drain should not be flushed again unless reviewed. EVIDENCE OF COMPETENCE The individual must have completed the nursing competence: Nursing care of the patient with an underwater seal chest drain before this skill is learnt. Individual competence remains with the individual practitioner, but initial competence must be assessed by suitably trained individuals i.e. those already competent. Advice should be sought from respiratory consultants trained in pleural procedures. 5

6 Details of competence Signature/Date I fee competent in this procedure: Signed/Date: Competence assessed by: Signed/Date 6

7 REFERENCES Allibone, L (2003) Nursing management of chest drains Nursing Standard Vol. 17 No. 22 pp Davies, H E Merchant S & McGown A (2008) A study of the complication of small bore seldinger intercostal chest drains Respirology 13(4): Hooper C and Maskel N (2011) British Thoracic Society national pleural procedures audit 2010 Thorax 66: Nottingham University Hospitals Trust (2015) Management of a Patient with Underwater Seal Chest Drainage Nottingham: NNPDG FURTHER READING Allibone, L. (2005) Principles for inserting and managing chest drains Nursing Times Vol. 101 No. 42 pp Avery, S. (2000) Insertion and management of chest drains Nursing Times Plus Vol. 96 No. 37 pp.3-6 Fox, V, Gould, D., Davies, N., Owen, S. (1999) Patient s experiences of having an underwater seal chest drain; a replication study Journal of Clinical Nursing Vol. 8 No. 6 pp Godden, J., Hiley, C. (1998) Managing the patient with a chest drain; a review Nursing Standard Vol. 12 No. 32 pp Parulekar, W., Di Primio, G., Fred, M.D., Dennie, C., Bociek, M.D. (2001) Use of small-bore versus large bore chest tubes for the treatment of malignant pleural effusions Chest Vol. 120 No. 1 pp Initial Authors: Sister Rhona Al-Bazzaz, Respiratory Unit, QMC Dr William Kinnear, Respiratory Unit, QMC November 2009 Reviewed 2015: 7

8 Lucy Briggs, Clinical Educator Respiratory Medicine. AUDIT POINTS Is the patient s safety effectively maintained with respect to chest drain flushing procedure? Has the patient s dignity and comfort been effectively maintained prior to, during and after the chest drain flushing procedure? Has the patient received timely analgesia prior to the chest drain flushing procedure? Has the patient received appropriate explanation prior to the chest drain flushing procedure? Is there evidence of prevention of infection throughout the chest drain flushing procedure? 8

9 POINTS FOR AUDIT 9