Intravenous Medication Administration via a Central Venous Line

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1 Standard Operating Procedure 11 (SOP 11) Intravenous Medication Administration via a Central Venous Line Why we have a procedure? This procedure is to assist/ inform healthcare professionals on how to ensure the safe and appropriate administration of the prescribed medication via a central line. The procedure intends to mimimise the infection risk and complications of managing a central venous line and provides standardised guidance based on best practice. What overarching policy the procedure links to? Children s Community Nursing Team Operational Policy Which services of the trust does this apply to? Where is it in operation? Group Inpatients Community Locations Mental Health Services all Learning Disabilities Services all Children and Young People Services all Who does the procedure apply to? All community nurses in CYPF group who have received recognised training and maintained their competencies in all aspects of intravenous drug administration should undertake this procedure. Regular updating of knowledge and skills is essential to maintain competency. This is the individual s responsibility to ensure this competency is maintained with the support from their line manager. It is also the individual s responsibility to ensure that the correct equipment is available for the child. When should the procedure be applied? The requirement for medication will depend on the child s individual needs as assessed by their Hospital Consultant or Community Paediatrician and should be documented in their care plan. How to carry out this procedure Sterile Intravenous syringes must be used and be clearly distinguishable from enteral syringes Prescriptions for injections of intravenous medication must clearly specify the medicine name, dose, frequency and route of administration. When administering Intravenous Medication Administration via a Central Venous Line Page 1 of 8 Version 1.0 April 2016

2 Medicines to children the British National Formulary for Children (latest edition) must be used. An aseptic/ aseptic non-touch technique MUST be used at all times It is possible to rupture the catheter by the application of excessive pressure during the drug administration. Such pressures can be minimised by taking the following precautions: - The use of sterile intravenous syringes of 10ml capacity where possible - Avoid excessive force if catheter blockage is suspected. Advice should be sought from the appropriate personnel. If catheter is blocked the patient may require Urokinaise prescribing to be locked in the line for 12 hours. The central line must be labelled clearly stating that Urokinaise has been locked in the line, what time it has been locked in and the practitioner must draw back the drug before flushing the line on next use. To try and prevent line blockage heparin (100units/ml) should be locked in the line when the line isn t being accessed regularly. On request from the patients clinician 10units/ml of heparin can be used A three stage technique should be used involving: - Thorough hand washing using the Ayliffe (1980) technique is essential - Identification and non-contamination of key parts. A key part is any part of equipment that comes into direct contact with the liquid infusion or the patient e.g. needle, syringe tips - Ensure a needle-free closed system is used (e.g. bionectors/ claves) where possible as the port at the end of the line should not be used to access the line - Protection of yourself and the service user by wearing sterile gloves, apron and any other protection required - When preparing injectable intravenous medicines they should always be administered immediately after preparation. All syringes must be labeled immediately, the exception to the rule is where the preparation and administration is one uninterrupted process and the unlabeled product does not leave the hands of the person who prepared it - Ensure Bio-Patches are used at first instance when exudate is observed at the exit site - Ensure parents have had training in regards to caring for the central line on a daily basis i.e. what to do in an emergency. For example, if the line splits they should use x2 clamps, clamping in the opposite direction which they should carry with them at all times to prevent the patient bleeding out or if the central line is pulled out then apply firm pressure and call 999 Equipment Required to Access the Line Sodium Chloride 0.9% injection Prescribed medication and appropriate diluent Clean tray/ work surfaces disinfect with 70% Isopropyl alcohol Heparin100units/ml (2ml ampoule) x 1 per lumen Drug information sheet and prescription card 10ml Intravenous sterile syringes Needles including filter needles Intravenous Medication Administration via a Central Venous Line Page 2 of 8 Version 1.0 April 2016

3 2% Chlorhexidine gluconate in 70% Isopropyl alcohol solution or 70% Isopropyl alcohol wipes Sharps bin Sterile gloves and protective apron and goggles Clean bung (if appropriate) Appropriate dressing, gauze and cleaning solution if to be changed Dressing pack Actions and Action 1. Explain to the child and family what you are going to do using age appropriate language. Ensure verbal consent is taken and documented in the child s notes 2. If child/ family is going to assist with clamping and unclamping the line ensure they wash their hands 3. Check heparin prescription and appropriate medication prescription is present in the child s home notes. Check child s name, address and date of birth with the parent/ carer who is present. Check expiry date of the drug and the dose. If you are administering an opioid medicine please be aware of the relevant NPSA alert RRR05 4. Wash hands as per Trust guidance, dry thoroughly. Collect all equipment. Apply protective clothing 5. Establish a clean area e.g. tray/ surface, disinfect with 70% Isopropyl alcohol and allow to dry. Tip out dressing pack onto work surface 6. Wash hands again as per Trust guidance, drying thoroughly. Open the dressing pack touching only the outer edges. Open sterile equipment onto dressing pack using non-touch technique. If using 2% Chlorhexidine gluconate in 70% Isopropyl alcohol solution pour into gallipot or open 70% Isopropyl alcohol wipes 7. Check and open sodium chloride 0.9% vial and heparin vial and place next to sterile field 8. Open sterile gloves onto dressing pack. Alcogel hands, allow to dry and then apply sterile gloves To minimise distress and encourage child and family co-operation Ensure safe drug administration Intravenous Medication Administration via a Central Venous Line Page 3 of 8 Version 1.0 April 2016

4 Action 9. Draw up and mix any prescribed medication as directed. Draw up 0.9% sodium chloride and heparin in separate intravenous syringes. Label all syringes appropriately. Use filter needles for glass vials 10. Discard needles directly into sharps bin. Expel air from intravenous syringes 11. Encourage parent/ carer to prepare their child as required. Help the child get into a comfortable position. Ask child or parent/ carer to expose line 12. Check the catheter, clamp and bung for damage or displacement. Check the catheter exit site for pain, redness or swelling 13. Place dressing towel under the line. If the bung needs changing use 2% Chlorhexidine gluconate in 70% Isopropyl alcohol solution or 70% Isopropyl alcohol wipe to clean bung and end of central line then discard bung. Allow to dry for at least 30 seconds. Prime new bung with 0.9% saline and attach to end of central line. Flush through with at least 3mls of 0.9% saline using 10ml IV syringe. Clamp on positive pressure 14. If the bung doesn t need changing. Clean the end of the line with 2% Chlorhexidine gluconate in 70% Isopropyl alcohol solution or 70% Isopropyl alcohol wipe ensuring the whole connector is cleaned. Allow to dry for at least 30 seconds 15. Use saline-labelled 10ml IV syringe to flush the line with at least 3mls. Close clamp on positive pressure, remove syringe and replace on the edge of the sterile field. If there is any resistance or pain close clamp and seek advice Ensure correct drug and dose are given. To prevent glass particles being drawn into injectable solutions To prevent needle stick injury. To prevent air embolus To encourage child and family participation To enable the detection of a displaced damaged catheter. To ensure it is safe to proceed. Ensure bung is changed at each central line flush To check the line patency and to expel previous hepsal Intravenous Medication Administration via a Central Venous Line Page 4 of 8 Version 1.0 April 2016

5 Action 16. Administer the drug slowly according to recommendations. If more than one drug is to be given, each should be clearly labelled and flush given between each one with 3-5ml sodium chloride 0.9%. Remember to close clamp on positive pressure when not injecting 17. Slowly inject the heparin, do not empty the IV syringe completely. When there is 1ml left in the IV syringe continue to inject, but at the same time, close the clamp i.e. still exerting positive pressure. Repeat for each lumen if required 18. Secure the central line ensuring the end is covered for protection when appropriate. Make sure the child is comfortable and replace clothing 19. Clear away all equipment. Dispose of used syringes in sharps box and other waste as household waste 20. Wash and dry hands, apply Alco gel as per hand washing guidance 21. Ensure prescription is signed and care is recorded in the nursing documentation To ensure the correct administration of prescribed drugs. To prevent the mixing of potentially incompatible drugs. To prevent backflow of drug or blood and reduce the risk of air embolus To heplok the central venous line. To prevent occlusive clot formation To minimise the risk of line displacement. To maintain a safe environment To ensure compliance with medication regime and document any problems that may have arisen Equipment Required to Change the Central Line Dressing Clean tray/ work surfaces disinfect with 70% Isopropyl alcohol Sterile gloves and protective apron Appropriate dressing, gauze and cleaning solution Dressing pack IV3000 (with Biopatch Disk if required from BCH) chlroprep Central Line Dressing Change Action 1. Explain to the child and family what you are going to do using age appropriate language. Ensure verbal consent is taken and documented in the child s notes 2. Wash hands as per Trust guidance, dry thoroughly. Collect all equipment. Apply protective clothing To minimise distress and encourage child and family co-operation Intravenous Medication Administration via a Central Venous Line Page 5 of 8 Version 1.0 April 2016

6 Action 3. Establish a clean area e.g. tray/ surface, disinfect with 70% Isopropyl alcohol and allow to dry Tip out dressing pack onto work surface 4. Wash hands again as per Trust guidance, drying thoroughly. Open the dressing pack touching only the outer edges. Open sterile equipment onto dressing pack. Open saline solution and poor into gallipot 5. The nurse removes the old dressing line secure onto the child s chest. The IV3000 dressing is removed by loosening a corner or edge of the film and stretching the dressing parallel to the patient s skin, while holding the catheter in place. (Two practitioners may be required to ensure the child is immobile and the catheter is held in place.) The dressing is repeatedly stretched and peeled back until removed. The BioPatch will come away with the IV3000 film without dislodging the catheter providing the BioPatch was placed with the slit underneath the catheter 6. The exit site may be swabbed and if necessary because of blood or serous fluid oozing, clean with saline soaked gauze using a single wipe per gauze swab. The area is dried with dry gauze, single wipe per swab 7. The area is wiped with a chlorprep ensuring that the whole area is cleaned using a left to right technique Allow to dry for at least 30 seconds 8. Apply IV3000 ensuring that the whole exit suit is covered and the central lines are secured 9. Clear away all equipment. Dispose of used syringes in sharps box and other waste as household waste 10. Wash and dry hands, apply Alco gel as per hand washing guidance To mimimise the risk of displacement To maintain a safe environment To observe and investigate signs of infection To minimise the risk of line displacement. To maintain a safe environment Intravenous Medication Administration via a Central Venous Line Page 6 of 8 Version 1.0 April 2016

7 Additional Information/ Associated Documents Medicine policies Waste Management Policy Medical Devices Policy Infection Prevention and Control Assurance Policy The Royal Marsden hospital Manual of Clinical nursing procedures 2011 BNF for children NPSA/2008/RRR002 Intravenous Heparin Flush Solutions Where do I go for further advice or information? Team Leader Pharmacy Team BCH central venous line clinical trainers Duties All healthcare professionals are responsible for their own actions and must exercise their own professional judgment at all times. Any decisions that vary from the agreed Trust procedures or guidelines should be documented in the service users care plans and include the reason for variance and the subsequent action taken. The team leader is responsible for ensuring that this procedure is made available to the staff they manage; who are involved in the care of children. Training and Competencies All healthcare professionals should have basic life support training every year. All health professionals who are responsible for accessing the central line should have completed the Peripheral Intravenous Medication/ Fluid Administration study day and competencies. Monitoring / Review of this Procedure In the event of planned change in the process(es) described within this document or an incident involving the described process(es) within the review cycle, this SOP will be reviewed and revised as necessary to maintain its accuracy and effectiveness. Data Protection Act and Freedom of Information Act Please refer to overarching policy Intravenous Medication Administration via a Central Venous Line Page 7 of 8 Version 1.0 April 2016

8 Standard Operating Procedure Details Unique Identifier for this SOP is State if SOP is New or Revised BCPFT-CYPF-SOP-OP-11 New Policy Category Executive Director whose portfolio this SOP comes under Policy Lead/Author Job titles only Committee/Group Responsible for Approval of this SOP Month/year consultation process completed Review and Amendment History Version Date Description of Change 1.0 Apr 16 New SOP for BCPFT Children s Services Executive Director of Nursing, AHPs and Governance Team Leader, Community Paediatric Specialist Team Quality and Risk Safety Group March 2016 Month/year SOP was approved April 2016 Next review due April 2019 Disclosure Status B can be disclosed to patients and the public Intravenous Medication Administration via a Central Venous Line Page 8 of 8 Version 1.0 April 2016

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