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1 Tools to Support an Evidence-Based Approach to Central Venous Access Device (CVAD) Care and Maintenance in the Home By Nancy Kramer, RN, BSN, CRNI PHARMACISTS AND PHARMACY TECHNICIANS This INFUSION article is cosponsored by Educational Review Systems (ERS), which is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. ERS has assigned 1.0 contact hours (0.1 CEU) of continuing education credit to this article. Eligibility to receive continuing education credit for this article begins January 1, 2017 and expires January 1, The universal activity numbers for this program are H01-P and H01-T. Activity Type: Knowledge-Based. CPE Accredited Provider NURSES Educational Review Systems is an approved provider of continuing nursing education by the Alabama State Nurses Association (ASNA), an accredited approver of continuing nursing education by the American Nurses Credentialing Center, Commission on Accreditation. Program # Educational Review Systems is also approved for nursing continuing education by the state of California, the state of Florida, and the District of Columbia. This program is approved for 1.0 hours of continuing nursing education. Eligibility to receive continuing education credit for this article begins January 1, 2017 and expires January 1, DIETITIANS Educational Review Systems (Provider number ED002) is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 1.0 hour or 0.1 continuing professional education unit (CPEU) for completion of this program/material. Eligibility to receive continuing education credit for this article begins January 1, 2017 and expires January 1, Dietitian Knowledge Level: 2 Dietitian Learning Codes: 5030 Home care 5460 Self-care management 7100 Institution/regulatory policies and procedures, HCFA,OBRA, Joint Commission, NCQA, OSHA, USDA 35

2 Approval as a provider refers to recognition of educational activities only and does not imply Accreditation Council for Pharmacy Education, ERS, CDR or ANCC Commission on Accreditation, approval or endorsement of any product. This Continuing Education Activity is not underwritten or supported by any commercial interests. This continuing education article is intended for pharmacists, pharmacy technicians, nurses, dietitians, and other alternate-site infusion professionals. In order to receive credit for this program activity, participants must complete the online post-test and subsequent evaluation questions available at. Participants are allowed two attempts to receive a minimum passing score of 70%. EDUCATIONAL LEARNING OBJECTIVES: 1. List and describe three ways in which CVAD care and infusion therapy for home-based patients differ from the acute site of care. 2. Review the key considerations for CVAD care and maintenance for the home-based adult patient. 3. List and describe how the NHIA CVAD Care & Maintenance Tool for the Adult Home-Based Patient can be used to promote a standard, consistent approach to evidence-based care in the home. AUTHOR BIO Nancy Kramer, RN, BSN, CRNI, is Vice President of Clinical Affairs for the National Home Infusion Association. She has more than 25 years of experience in the home infusion industry, both as a direct provider of patient care and in progressive nurse management roles for a national home infusion therapy provider. Her corporate responsibilities have included equipment, supply and formulary research and decision making, educational program development, and creation of policies and procedures based on best clinical practices. At NHIA, Nancy provides assistance and education for the Association s member organizations, working with provider and business firm volunteers on the NHIA Standards and Education Committees to share clinical and regulatory updates that impact the industry. AUTHOR DISCLOSURE STATEMENT The author declares no conflicts of interest or financial interest in any product or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. Questions or comments regarding this article should be directed to nancy.kramer@nhia.org. BACKGROUND For the home-based patient receiving infusion therapy, a vascular access device (VAD) represents a lifeline to treatment. Maintaining that lifeline to allow uninterrupted delivery of the prescribed infusion therapy is a primary goal of home infusion providers and is best accomplished through a standardized, evidence-based approach to care. Synthesizing available evidence has been made significantly easier by the work of the Infusion Nurses Society (INS), which published its revised Infusion Therapy Standards of Practice in 2016 (referred to as the INS Standards going forward). 1 For pediatric patient care, another recently revised resource is the Best Practice Guidelines in the Care and Maintenance of Pediatric Central Venous Catheters, 2 nd Edition, published by the Association for Vascular Access s (AVA) pediatric-focused expert network, PediVAN, in While both the INS Standards and the PediVAN Guidelines apply to all sites of care, there are differences unique to the home site of care that can impact decisions about how care is ultimately provided. One significant difference relates to the lack of published research supporting specific best practices in the home, unlike the acute care setting where most infusion therapy-related research is conducted. 3 This means published findings or evidence about the longest-term access devices implanted ports, tunneled catheters, and peripherally inserted central lines (PICCs) that can dwell for months and sometimes years and the practices needed to keep them free of complications over such prolonged periods, is limited. Additionally, patients and lay caregivers in the home play an active role in not only the care and maintenance of CVADs, but also in the administration of therapy through the device unlike in the acute care setting, where licensed professionals perform all care. In the home-based setting a professional caregiver may be present in the patient s home just a fraction of the time on average just one to two visits per week. Lay caregivers family members, close friends, and the patients themselves are almost always involved in some aspect of the CVAD care, whether their role is limited to observing for/ reporting CVAD complications, or actually performing the CVAD dressing changes. Home infusion providers must take into account the complexity and variety of products available for CVAD care when designing a care regimen that will achieve the desired clinical outcomes in the simplest-to-use and most effective combination, given the wide range of caregiver ability and experience and the extensive need for patient and caregiver education. Since the earliest days of home infusion therapy in the late 1970s, home infusion clinicians have created training tools and resources to guide patients and caregivers in performing the self-care activities that are essential to achieving the desired outcome of therapy. 4 36

3 Another difference between acute care settings and home care is the coordination of nursing services from a variety of companies that is often required of the home infusion pharmacy. The pharmacy may service patients in a geographic radius of up to 200 or more miles by using a combination of local couriers and overnight shipping to provide patients with the prescribed and prepared medications. Nursing, on the other hand, is a more local service usually limited to a smaller geographic area in order to manage the costs associated with time and distance spent driving between visits. Results of NHIA s 2010 Provider Survey indicate that approximately 48% of home infusion patients are receiving nursing care from a home health agency (HHA) with whom the infusion pharmacy has either established a contractual relationship (18%) or who is acting independently of the home infusion pharmacy (30%), thus necessitating a close coordination of care between the home infusion pharmacy and the HHA. 5 Following the acute care trend of supply formulary development to limit product codes, focus staff training efforts, and thereby control costs, home infusion providers routinely identify preferred products, selecting specific items in each product category that their clinicians become very familiar with, and accustomed to using. 6 An HHA, on the other hand, typically works with several different home infusion pharmacies, and as a result, their nurse clinicians must become familiar with a much wider range of products and their respective instructions for use. Keeping up with a wide variety of products is just one challenge also knowing how frequently each home infusion pharmacy is anticipating tubing changes and CVAD dressing changes to happen, is another. The home infusion pharmacy must anticipate product usage each week, relying on internal policies and procedures for how many tubing/administration sets and dressing change kits to send a patient with each medication delivery. When the HHA nurse in the home follows a different change frequency protocol, the patient may run out of a critical supply item before the next regularly scheduled delivery, necessitating a costly unscheduled and potentially after-hours delivery by the pharmacy. Communication and agreement between the home infusion pharmacy and the HHA nurses on the frequency of supply usage are essential parts of the overall care coordination and cost-control process. The recently updated NHIA CVAD Care & Maintenance Tool for the Adult Home-Based Patient (referred to as Adult CVAD Resource Tool going forward, shown on pp ), and the pending pediatric version for patients under the age of 18 (which will soon be available via the NHIA website), were created to provide a common point of reference for all home infusion professional caregivers, facilitating a standard, evidence-based approach to the use and care of CVADs in the home. Formatted in an easy-to-read table, this resource tool synthesizes current evidence-based standards of practice and published guidelines, as well as expert opinion when evidence is lacking, to highlight key CVAD care and maintenance considerations. Home infusion pharmacies that provide this resource tool to HHAs with whom they coordinate care, will help to reinforce a consistent standard of care in the communities they serve. The remainder of this educational activity will highlight only those specific considerations within each section of the Adult CVAD Resource Tool that have changed or been added since the last revision in The 2016 INS Standards serve as the reference for the remainder of this document, unless otherwise noted. FLUSHING/LOCKING Avoiding Plunger Rebound. Upon completion of the final flush, the catheter should be locked to prevent blood from backing up in the tip, which can contribute to catheter occlusion. The lock procedure should be performed in a manner that minimizes plunger rebound, a phenomenon that can occur when the rubber syringe plunger tip is completely compressed as the syringe is emptied, causing it to slightly rebound and pull a small amount of blood back up into the distal tip of the CVAD as pressure on the plunger is released. Some prefilled syringes are specifically engineered to minimize plunger rebound. Clamping the CVAD before the syringe is emptied, known as positive displacement flush technique, can also help to overcome plunger rebound, however it is not recommended when flushing through a positive-displacement needleless connector (see needleless connector section on page 38 for more). Leaving a small volume of lock solution (0.5 ml) in the syringe, and following the correct clamp/syringe removal sequence based on the needleless connector in place, is recommended. Saline vs. Heparin Lock. The 2016 INS Standards note that either saline or heparin (10 units/ml for all CVADs) can be used as a lock solution, with insufficient evidence to recommend one solution over the other, and that a standardized lock solution for each patient population should be established organization-wide. Monitoring platelet counts for heparin-induced thrombocytopenia (HIT) is not recommended in patients whose only exposure to heparin is in the form of a catheter lock solution due to a very low incidence of HIT (1% or less). 7 Use of a heparin lock solution (10 units/ml) is recommended in the Adult CVAD Resource Tool for all CVADs except implanted ports, based on expert industry opinion. A concentration of 100 units/ ml is noted for locking an implanted port. While hemodialysis and apheresis catheters are not included in the Adult CVAD Resource Tool, INS Standards addressing their flushing and locking have changed on the basis of new evidence and should be incorporated into applicable organizational policies and procedures. 37

4 Valved catheters (e.g. Groshong, PASV valve technology) do not require heparin locking in accordance with manufacturer s guidelines, however, a lock solution may still be prescribed by the physician if the provider s (or patient s) experience includes occlusions with these catheter types when flushed only with normal saline. When heparin is contraindicated as a lock solution, other agents such as sodium citrate 4%, ethylenediaminetetra-acetic acid (EDTA), and tissue plasminogen activator (tpa), may be used with caution and specific physician s orders regarding volume, concentration, dwell time, and removal recommendations. Alternative Lock Solutions. Alternative lock solutions including antimicrobial, antiseptic (ethanol, taurolidine, citrate, 26% sodium chloride, methylene blue, fusidic acid, EDTA) and anti-thrombotic (recombinant tissue plasminogen activator) are not included in the Adult CVAD Resource Tool because information about their use is extensive and difficult to condense for a general resource tool of this nature. The 2016 INS Standards recommend the prophylactic and therapeutic use of antimicrobial lock solutions in patients with: long-term CVADs; a history of multiple catheter-related bloodstream infections (CRBSI); high-risk patient populations; and in facilities with unacceptably high rates of central-line associated bloodstream infection (CLABSI) despite application of other methods of CLABSI reduction. 1 Home infusion providers are advised to incorporate alternative lock solution information in their organizational policies, procedures and patient education tools as applicable to the patient populations they serve. Pulsatile Flush Technique. The notion that short bursts of flush solution (e.g., 1 ml) are more effective at clearing a CVAD lumen as a result of the turbulence created, has been debated among clinicians for many years. This technique is now endorsed in the INS Standards based on several recent studies that found reduced rates of catheter colonization following pulsatile flushing compared to bolus or steadyrate flushing. 8,9 waiting until the disinfectant has completely dried before accessing the connector. Passive Disinfection Cap Use. While the INS Standards acknowledge that passive disinfection caps used on the end of needleless connectors have been shown to reduce intraluminal microbial contamination and reduce the rates of CLABSI, they do not offer specific recommendations regarding their use. One home infusion provider who studied the use of these devices in a small patient population reported a dramatic reduction in CLABSI rate among patients who used the disinfection cap properly including patients receiving parenteral nutrition (PN), a long-term therapy that has been associated with increased incidence of CLABSI In the provider study, impact on CLABSI reduction was diminished in patients who did not use the disinfection cap properly, and/or who did not follow instructions for needleless connector disinfection between uses. 10 It is important to note that use of a passive disinfection cap does not confer prolonged protection from microbial ingress into the cap after it is removed. Rather, the only time the needleless connector does not need to be manually disinfected before use, is the first access after a passive disinfection cap has been removed. Every other access that follows will require routine disinfection of the needleless connector. Needleless Connector Flush/Clamp Sequence. As mentioned earlier in the Flush section, educating nurses about when/whether to clamp during the flush sequence can be challenging particularly for the home health agency nurse who must work with many different providers of infusion therapy and supplies, and who therefore encounters the most types of connectors. Exhibit 1 illustrates the movement of fluid at the tip of the CVAD that occurs when the syringe or tubing is removed from the connector as well as the recommend clamping sequence for each type of displacement. BLOOD SAMPLING FROM A CVAD NEEDLELESS CONNECTORS Disinfection of the Needleless Connector. A number of studies seeking to identify the most efficacious duration of time to scrub the end of the needleless connector before each use ( scrub the hub ), have demonstrated positive results with times ranging from five to 60 seconds. Because no consensus on the ideal length of time was reached, and the study using a five-second scrub time was limited to a single type of needleless connector, the NHIA expert panel is recommending a minimal scrub time of 15 seconds for any needleless connector. Equally important for disinfection is the pause that must be taken after each scrub, Discard Volume. The volume of blood to discard when sampling from a CVAD is based on the device type (see Adult CVAD Resource Tool, page 43-44). The exception to this discard volume rule is when sampling from the CVAD for blood cultures, in which case no discard is obtained before the sample. For patients who are anemic and/or experiencing frequent lab draws, the push-pull method of blood sampling is described in the INS Standards as an alternative to specimen discard. This method entails aspirating and immediately reinfusing a small amount of blood in several cycles to clear the CVAD of infusate or lock solution before obtaining the specimen. While evidence regarding the specific volume to withdraw or the 38

5 Exhibit 1 Needleless Connector Fluid Displacement NEEDLELESS CONNECTOR TYPE FLUID MOVEMENT WHEN SYRINGE/TUBING IS REMOVED FROM CONNECTOR WHEN TO CLAMP CVAD Positive Displacement After syringe or tubing is disconnected Negative Displacement Before syringe or tubing is disconnected Neutral Displacement Not required number of cycles to perform is inconclusive, volumes of 3-5 ml of blood withdrawn and reinjected for five cycles are the most commonly used. Therapeutic Drug Levels. A dedicated lumen should be used to obtain therapeutic drug level samples, specifically one that has not been used to administer the drug being tested to avoid the potential for falsely elevated results. Consider obtaining coagulation study specimens from a peripheral draw if all lumens of the CVAD have been locked with an anti-coagulant such as heparin. ADMINISTRATION SETS Set Change Frequency. How often to change an administration set (AKA, tubing ) or an add-on device, is a frequent question among providers of home infusion therapy. The dilemma with change-frequency is this: opening an access device to frequent manipulations can result in the introduction of bacteria into the device, so ideally a closed system should remain closed as long as possible to minimize this risk. The Adult CVAD Resource Tool (see page 43-44) includes a table describing set change frequency based on the drug/solution to be infused, and whether the set remains continuously attached to the CVAD, or is intermittently disconnected. While INS Standards note that a continuous set should be changed no more often than every 96 hours, no maximum use time is provided. However, the Centers for Disease Control and Prevention (CDC) 2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections advises a maximum use of seven days, which is consistent with long-standing industry practice. 14 Add-On Devices. Add-on devices such as flow-regulators, filters, extension sets, and needleless system components follow either the administration set or needleless connector change rule, depending on where they are added. Addon devices attached between the CVAD and the needleless connector are changed at least every seven days, unless the manufacturer recommends a more frequent change. Add-on devices added to the administration set, such as air-eliminating filters or flow-control devices, should be changed when the administration set is changed or in accordance with specific manufacturer instructions. Filters themselves pose an interesting dilemma with regards to the previously stated tubing change rules. Filters can be composed of a variety of materials, all of which are intended to trap particles such as microbes or drug precipitates that are larger than the filter pore size, to prevent their administration into the patient s bloodstream. Many 39

6 filters approved for vascular use are also air-eliminating designed to remove air bubbles that enter the filter, venting the air outside of the filter in an unidirectional fashion (when the filter has been properly primed according to manufacturer recommendations). Only filters labeled as endotoxin-retentive are capable of also retaining the endotoxins that are byproducts of gram-negative bacterial cell death and lysis when the microbes have been trapped by the filter. If not labeled as endotoxin-retentive, the filter should be changed every 24 hours (or as recommended by the manufacturer). Most filters that are endotoxin-retentive can remain in place for up to 96 hours (or as labeled by the manufacturer). 15 DRESSING CHANGE Skin Antisepsis. The preferred antiseptic, based on a number of short-term and primarily acute-care studies, is a >0.5% chlorhexidine gluconate (CHG) in alcohol solution. Alternatives if CHG is not tolerated include tincture of iodine, iodophor, or 70% alcohol. Clinical research regarding patient tolerance of various antiseptics, when used for prolonged periods of time in a variety of climates and patient activity-levels, is lacking in the home site of care. In the absence of such research, infusion providers are called to examine their patient outcomes data to identify a dressing regimen, including antiseptic solution that is best tolerated by their patient population. For some patients, prolonged use of CHG-containing antiseptics or dressings will result in skin irritation around the catheter exit site. For other patients, iodine and iodophor-containing products will have a similar irritant effect. The availability of a variety of combination antiseptics that include alcohol to enhance drying time now offer patients more options than ever in their quest for an antiseptic that is effective, well-tolerated, and simple to apply. Skin Protectants. For many patients, use of a skin protectant to form a barrier between the adhesive in the dressing/tape and their skin will help to minimize any irritation experienced beneath a long-term dressing. For all patients, the single most important step in reducing skin irritation beneath any dressing is taking the time to allow all solutions, both antiseptic and skin protectant, to dry completely and naturally between steps in the procedure. Dressing materials and tapes applied to damp skin cause maceration, eventually leading to skin breakdown. A gauze dressing should be used until the broken skin has healed, avoiding antiseptics and skin protectants that contain alcohol (which can delay healing and sting when applied to broken skin). Prevention of this complication can be achieved through education of nursing personnel and patients/caregivers who perform their own CVAD care. Antimicrobial-impregnated Dressings. Antimicrobial disc patches and transparent dressings impregnated with CHG 40

7 have been shown to reduce the risk of CLABSI when the primary source of catheter-related bloodstream infection is from the extraluminal route. Since most newly tunneled CVADs are healed within two weeks of placement, the extraluminal route is primarily a risk for peripherally inserted central catheters (PICCs) in the home setting. Careful assessment is warranted to ensure skin irritation does not develop with prolonged use of CHG-impregnated dressings around the catheter exit site. STABILIZATION Stabilizing a CVAD is associated with several benefits, particularly in the home environment where patients can be significantly more active than in the acute care setting. Adequate stabilization can prevent or minimize catheter pistoning, which is the movement of the catheter in/out of the exit site (associated with microbial ingress along the catheter track). Adequate stabilization can also reduce the incidence of CVAD dislodgement, which can interrupt therapy administration and lead to unscheduled or after-hours nursing visits. Use of an engineered stabilization device (ESD) should be considered, with adhesive-based ESDs preferred over sutures for PICCs. However, selection of the most appropriate product/method of securement should consider the patient s age, skin turgor and integrity, previous adhesive skin injury, and the presence of any drainage from the insertion site. SPECIAL CONSIDERATIONS BY CVAD TYPE PICC/Midline Catheters. Because PICC and midline catheters lack the subcutaneous cuff that tunneled catheters feature, the skin tract through which they pass before entering the vein remains a portal for bacteria into the bloodstream as long as the PICC/midline is in place. Consequently, some providers opt to utilize antimicrobial dressings around the catheter exit site as an added precaution, particularly if their catheter outcomes data reveals higher rates of CRBSI with these catheters compared to other types (see Dressing Change section above for more information). One change in the 2016 INS Standards is in the evaluation of drug appropriateness for peripheral and midline catheter infusion on the basis of osmolality. Previously, 600 mosm/l was considered the upper limit that could be administered via a peripheral or midline catheter; in the 2016 INS Standards this has increased to 900 mosm/l. While this represents a change in the INS Standards, it is consistent with the recommendation made in the earlier version of the NHIA Adult CVAD Resource Tool. Tunneled CVADs. Special considerations for tunneled CVADs relate to repair of these devices, as well as to the dressing change procedure. Many manufacturers produce repair kits that are available by catheter size, allowing infusion providers to achieve a semi-permanent repair of the catheter should it become damaged. Because of the many sizes and multi-lumen configurations of these catheters, not to mention the number of brands, it is not feasible for home infusion providers to stock every possible repair kit. Some providers have worked with their local hospitals where these tunneled CVADs are placed, to limit the choices of catheter type/ size/lumen count, thereby making stocking of the repair kit more feasible. In some areas of the U.S., it is common practice to utilize a clean dressing technique after the catheter tunnel is healed, or approximately two to three weeks after the catheter has been placed (with a physician s order). Because tissue adheres to the percutaneous cuff of the catheter, preventing the migration of bacteria along the catheter and into the blood vessel, the usefulness of an aseptically applied external dressing is questionable. Evidence is lacking to support this practice, however, and it is not described in the 2016 INS Standards. Non-Tunneled CVADs. Like PICCs, non-tunneled CVADs can be removed in the home with a physician s order. A petroleum-based ointment dressing should be applied immediately following catheter removal to minimize the risk for an air embolus until the skin tract and opening in the vein have closed. When removing any CVAD, the length of the catheter removed should be measured, recorded, and compared to the length of catheter inserted (whenever possible) to ensure the catheter is intact. Additional information was added to this section of the resource tool to describe the proper patient position for non-tunneled CVAD removal supine flat and instructing the patient to perform Valsalva maneuver (unless contraindicated) as the catheter is withdrawn to minimize the risk of air embolism during the procedure. Implanted Ports. Non-coring needles (previously referred to as Huber needles) must be used to access an implanted port, and should be bent at a 90-degree angle if the port is to remain accessed in the home. While INS Standards note there is insufficient evidence to recommend an optimal time for needle replacement, NHIA s resource tool maintains the needle should be changed at least every seven days when left in place for ongoing use, in accordance with long-standing industry practice. INS Standards also no longer advise a frequency for routine access/flushing when an implanted port is not in use. ONS Guidelines advise every four to eight weeks or in accordance with manufacturer recommendations. 41

8 Conclusion With limited published research describing optimal care and management of long-term catheters in the home setting, clinicians must evaluate existing guidelines and practice standards with their organization s infection and catheter outcomes data, to arrive at best practices for specific patient scenarios. The NHIA CVAD Care & Maintenance Tool for the Adult Home-Based Patient provides a concise, easy-to-apply format for a standardized approach to basic CVAD care by infusion providers and home health agencies alike. Standardizing the provision of care is just the first step in the sharing of patient outcomes that will ultimately lead to improvements in patient care and the advancement of the home infusion industry. References 1. Gorski L, Hadaway L, Hagle ME, McGOldrick M, Orr M, Doellman D. Infusion Therapy Standards of Practice. J Infus Nurs. 2016;39(suppl 1):S1-S Doellman D, Buckner J, Garret JH, Catudal P, Frey AM, Lamagna P, Runde DA, Schears GJ, Whitehead M. Best Practice Guidelines in the Care and Maintenance of Pediatric Central Venous Catheters, 2nd Edition. Association for Vascular Access, Masotti et al. (2010) Adverse events experienced by homecare patients: a scoping review of the literature. International Journal for Quality in Health Care. 22(2): Dudrick SJ, O Donnell JJ, Englert DM, et al. 100 patient years of ambulatory home PN. Ann Surg. 1994; 199: Kramer N, Santaromita K, Shelton J. NHIA Industry-Wide Data Initiative Phase I 2010 NHIA Provider Survey Comprehensive Aggregate Analysis Report. 2011, National Home Infusion Association, Alexandria, VA. 6. Ventola CL. Challenges in Evaluating and Standardizing Medical Devices in Health Care Facilities. Pharmacy and Therapeutics. 2008;33(6): Linkins LA, Dans AL, Moores LK, et al. Treatment and prevention of heparin-induced thrombocytopenia: antithrombotic therapy and prevention of thrombosis, 9 th ed: American College of Chest Physicians evidence-based clinical practice guidelines, Chest. 2012;141(suppl 2):e495S-e530S. 8. Ferroni, A. et al., Pulsatile flushing as a strategy to prevent bacterial colonization of vascular access devices. Medical Devices: Evidence and Research : Guiffant G, Durussel JJ, Merckx J, Flaud P, Vigier JP, Mousset P. Flushing of intravascular access devices (IVADs) efficacy of pulsed and continuous infusions. J Vasc Access. 2012;13(1): Leone M, Pratt M. Preventing central line-associated bloodstream infections in home infusion patients through the use of disinfection caps. Infusion. 2011; 17(6): Ross VM, Guenter P, Corrigan ML, et al. Central venous catheter infections in home parenteral nutrition patients: Outcomes from Sustain: American Society for Parenteral and Enteral Nutrition s National Patient Registry for Nutrition Care. Am J Infect Control Dec 1;44(12): Buchman AL, Moukarzel A, Goodson, B, et al. Catheter-related infections associated with home parenteral nutrition and predictive factors for the need for catheter removal in their treatment. Journal of Parenteral and Enteral Nutrition (1994) 18(4), Santarpia L, Alfonsi L, Tiseo D, et al. Central venous catheter infections and antibiotic therapy during long-term home parenteral nutrition: an 11-year follow-up study. J Parenter Enteral Nutr May- Jun;34(3): O Grady NP, Alexander M, Burns LA, et al. Guidelines for the Prevention of Intravascular Catheter-related Infections. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America. 2011;52(9):e162-e Richards C, Grassby PF. A comparison of the endotoxin-retentive abilities of two 96-h in-line intravenous filters. J Clin Pharm Ther, 1994; 19: Access Device Guidelines: Recommendations for Nursing Practice and Education (3rd Ed.), by D. Camp-Sorrell (Ed.), 2011, Pittsburgh, PA: Oncology Nursing Society. Copyright 2011 by ONS. EDITOR S NOTE: NHIA appreciates the time and expertise shared by the following reviewers of the NHIA CVAD Care and Maintenance Tool for the Adult Home-Based Patient: Jennifer Charron, RN, MSN, CNE, New England Life Care Craig Farris, BS, RN, CRNI, Home Parenteral Services of SEMO Melissa Leone, BS, RN, BSN, Coram CVS Specialty Infusion Services Martha Michael, RN, CRNI, Jefferson Home Infusion Service Kevin L. Ross, RN, BSN, Soleo Health Felicia Schaps, MSN-ED, RN, CRNI, OCN, CNSC, IgCN, BioScrip, Inc. 42

9 NHIA Central Vascular Access Device (CVAD) Care & Maintenance Tool for the ADULT Home-Based Patient Continuing All CVADS Education Flushing/ Locking Needleless Connector Care Flush using a pulsatile technique before and after each medication with PF 0.9% sodium chloride (NS) or compatible solution (e.g., 5% dextrose); limit bacteriostatic NS (containing preservatives) to 30 ml in 24-hours; follow 5% dextrose flush with NS do not allow dextrose to sit in the lumen; do not use sterile water as VAD flush. Min. flush volume = 2 x the internal volume of CVAD + all add-on devices (e.g., extension sets), usually 3-5 ml; viscous solutions (e.g., blood, PN) may require larger volumes. Lock CVADs with heparin 10 units/ml when not in use to maintain patency; lock volume = internal volume of CVAD + all add-on devices + 20%, usually 3 ml. Unless the final flush/lock syringe is designed to minimize plunger-rebound, disconnect syringe before completely empty to avoid blood reflux into CVAD tip; follow appropriate sequence for flushing, clamping and disconnecting final flush/lock syringe based on type of needleless connector used and manufacturer s recommendations. Flush/lock valved CVADs per manufacturer s recommendation. NOTE: Valved CVADs may need heparin lock when used long-term. Flush/lock CVAD at least once per day when not in use. Use 10mL syringe (or equivalent) for initial flush to establish CVAD patency (e.g., + blood return, no resistance); once confirmed, smaller syringes may be used if needed for IV push drug-dose accuracy; do not forcibly flush a CVAD (could cause damage/breakage); patients/caregivers are not routinely taught to assess for patency via blood return. Vigorously scrub needleless connectors with disinfecting agent (e.g., 70% IPA, povidone-iodine, or >0.5% CHG) for at least 15 seconds and allow to dry before every use If a passive disinfection cap is used, additional disinfection of the connector is not needed before the first access following its removal; multiple accesses require disinfection before each subsequent entry through the connector; discard passive disinfection caps after removal (do not reuse). Change needleless connector at least every 7 days, but no more often than every 96 hrs, and when removed for any reason; if damaged or malfunctioning; after blood sampling (unless cap is clear and fluid path can be visualized to observe all blood is flushed through); per mfg s recommendations, or organizational policies and procedures. Blood Sampling Tubing/Set Change Dressing Change See box for discard volumes; push-pull method is an alternative to discard for pts with frequent lab draws/at risk of anemia; no consensus on # cycles or volume of blood to use. Adult CVAD Type: Discard Volume Non-tunneled 6 ml Tunneled 9 ml Implanted Port 9 ml (inconclusive) Flush with at least 10-20mL saline immediately following lab draw. Therapeutic drug level accuracy > from a dedicated lumen not used to infuse the drug; use caution with coag studies from heparinized CVADs; consider peripheral draw. Stop all infusions for 10 minutes, and flush lumens with ml saline before obtaining discard then samples from largest lumen exiting farthest from the heart. EXCEPTION: blood cultures samples should be obtained after needleless connector is removed, before VAD is flushed, and without any discard. See box for administration set change frequency. Change add-on devices (e.g., extension sets) with set change, or when damaged/ compromised. Change filters Q24 hrs unless endotoxin-retentive (use up to 96 hrs) per mfg instructions. Devices added to the CVAD (between the CVAD and the needleless connector) should be changed when the connector is changed, or at least every 7 days. Blood Products Q 4 hrs Assess, or teach patient/cg to assess, CVAD site at least once per day for s/s complications. Change dressing at established intervals (per table to the right), or when damp, loosened or soiled. Parenteral Nutrition (PN) Q 24 hrs + each new PN container IV Fat Emulsion (IVFE) Q 24 hrs + each new container; DEHP-free DRESSING CHANGE FREQUENCY BY TYPE Transparent Semipermeable Membrane (TSM) Change at least every 7 days Primary & Secondary Continuous (set connected without interruption) No more often than Q 96 hrs; up to 7 days with same solution container Gauze Change at least every 2 days or 3x/week Gauze beneath a TSM dsg = a gauze dsg (unless folded beneath non-coring needle wings for support, leaving the needle insertion site visible) Preferred skin antiseptic is >0.5% chlorhexidine (CHG) in alcohol solution; tincture of iodine, iodophor (povidone-iodine) or 70% alcohol are alternatives if CHG not tolerated. Allow all antiseptics (and skin protectants, if used) to dry completely and naturally before applying dressing. Primary Intermittent (set disconnected following infusion) Q 24 hrs + place new sterile cover on tubing end if it will be re-used Apply all antiseptics to the skin with friction (scrubbing motion) to penetrate epidermal layers, even if applying in a circular motion from exit site outward. Antimicrobial products such as CHG-impregnated dressings or patches at CVAD exit sites are recommended for PICCs and until tunneled CVAD tracts have healed. If skin irritation develops beneath a TSM or any adhesive dressing/tape, apply a gauze dressing until skin has healed, and:»» Avoid adhesives on irritated skin until healed; consider applying skin protectant solution that is safe for irritated skin if adhesive use cannot be avoided.»» Avoid alcohol on irritated skin (may be in the antiseptic or skin protectant solution) it can further delay healing. 43

10 ALL CVADS Stabilization Stabilize CVADs to minimize movement in/out of the insertion site, in a manner that allows assessment (visualization) of the site. Consider use of an engineered stabilization device (ESD) to minimize movement of the CVAD at the exit site; use adhesive-based ESDs with PICCs instead of sutures. Do not use rolled bandages to secure any type of CVAD due to potential for circulatory impairment. Given the range and diversity of ESDs currently on the market, knowledge of manufacturer recommendations is imperative for proper removal and replacement at established intervals and/or when the CVAD dressing is changed. Tubular gauze mesh may be used by the patient/caregiver to contain dangling extension or administration sets for added protection from accidental dislodgement. SPECIAL CONSIDERATIONS BY CVAD TYPE PICC/MIDLINE TUNNELED NON-TUNNELED IMPLANTED PORT Pt should avoid: lifting >10 lbs, BP checks, and peripheral lab draws with accessed arm Each dsg change: measure external length & compare to length recorded after insertion. Each dsg change: monitor upper arm for s/s phlebitis, and measure circumference (10 cm above antecubital fossa) for change from baseline. Blood sampling may be done through PICCs 3 FR and larger, with physician order. MIDLINE CATHETERS: Considered long peripheral catheter; do not infuse medications greater than 900 mosm/l; consider PICC when > 4 weeks of therapy anticipated, or when infusing known vesicants/irritants. REMOVING PICC/ MIDLINE: Apply digital pressure to site with dry sterile gauze until hemostasis achieved, approx. 3-5 min (time will vary based on patient s coag status). Apply petroleum-based ointment + dressing to seal the skinto-vein tract. Record length of PICC/midline removed and condition of tip. If resistance is met stop, apply warm pack to upper arm x 15 min, then re-attempt removal. If unsuccessful, wait 24 hrs before another attempt. If still unsuccessful, notify prescriber. Can be repaired by an experienced clinician using a mfg repair kit. Sutures may be removed from a tunneled CVAD insertion site 2-3 wks after insertion, with prescriber order. Tunneled CVADs that are well-healed may not require a dressing. Can be removed with prescriber order. REMOVING NON-TUN- NELED CVAD Pt in supine flat position should perform Valsalva maneuver as CVAD is withdrawn, unless contraindicated. Apply digital pressure to site with dry sterile gauze until hemostasis achieved, followed by a petroleum-based ointment dressing to seal the skin-to-vein tract. Record length of CVAD removed & condition of tip. Use only non-coring needles and aseptic technique (+ sterile gloves and mask) during access. Change needle at least every 7 days, or as needed. WHEN NOT IN USE: Access/flush Q 4-8 wks (or per mfg recommendations), locking with 5mL of heparin 100 units/ml. Key: + = positive; CG = caregiver; coag = coagulation; CRBSI = Catheter Related Bloodstream Infection; dsg = dressing; FR = French; hr(s) = hour(s); IPA = isopropyl alcohol; L = liter; lbs = pounds; LIP = Licensed Independent Practitioner; mfg = manufacturer; min = minimum; PICC = peripherally inserted central catheter; PF = preservative-free; pt = patient; Q = every; S/S = signs/symptoms; tubing = administration set; wks = weeks; x = frequency Engineered stabilization device: A device or system placed subcutaneously or on top of the skin; specifically designed and engineered to control movement at the catheter hub. 44 GLOSSARY Passive disinfection cap: Cap containing disinfectant (e.g., isopropyl alcohol) that is placed over needleless connector when not in use to prevent contamination. Pulsatile flushing technique: Repetitive injection of short (e.g., 1 ml) pushes, followed by a brief pause to create turbulence in the VAD lumen. Push-pull method of blood sampling: Method for blood sampling through a VAD that eliminates the need for a discard by withdrawing a small amount of blood (e.g., 3-5mL) and immediately re-injecting it, repeating this procedure at least 5 cycles. Do not reinfuse blood that has been withdrawn into a syringe and allowed to sit for any period. Skin protectant: Solution applied to the skin after skin antiseptic has dried, to create a barrier between the skin and the adhesive in the dressing to be applied. Choose protectants without alcohol when applying to broken skin. REFERENCES: 1. Gorski L, Hadaway L, Hagle ME, McGoldrick M, Orr M, Doellman D. Infusion Therapy Standards of Practice. J Infus Nurs. 2016;39(suppl 1):S1-S Access Device Guidelines: Recommendations for Nursing Practice and Education (3rd Ed.), by D. Camp-Sorrell (Ed.), 2011, Pittsburgh, PA: Oncology Nursing Society. Copyright 2011 by ONS. 3. Leone M, Dillon LR. Catheter outcomes in home infusion. J Infus Nurs 2008 Mar-Apr;31(2):84-91 DISCLAIMER: The National Home Infusion Association (NHIA) produces resource tools as an educational aid to good clinical practice that reflects the input of its members and experienced clinicians in the field. Clinical material offered in this tool is intended as a guide for information purposes only and does not replace or remove clinical judgment or the professional care and duty necessary for each specific patient case. The information contained within this tool has been prepared using a multidisciplinary approach examining pertinent information available/identified at the time of preparation. While great effort has been made to assure all information is complete and accurate as of the time this tool is issued, given the continuously evolving health care environment and the particular circumstances of individual cases, no assurance is given that the information is entirely complete or accurate in every conceivable respect (and, as such, NHIA and its board members, committee/work group members, officers and employees disclaim all liability for the accuracy or completeness of this tool, and disclaim all warranties, express or implied to their incorrect use). Additionally, clinical care carried out in accordance with this tool should be provided within the context of a prescriber s oversight and orders, locally available resources and expertise, and all relevant regulatory requirements within the professional scope of practice. This tool does not address all elements of standard practice and, as such, presumes and necessitates that individual clinicians have the responsibility to: discuss all care with patients/consumers in an environment that is culturally appropriate and which enables comfortable and confidential discussion; apply standard precautions, and additional precautions as necessary, when delivering care; and seek out newer information that might affect the diagnostic and treatment recommendations contained within this tool.