requisitions and computerized or addressograph labels for patient

Transcription

1 PURPOSE Standards and prcedure fr bld sampling using the syringe methd frm central venus lines (CVL) including cuffed/uncuffed external central venus catheters (CVCs), peripherally inserted central catheters and implanted prts. STANDARDS Bld may be sampled using the syringe methd frm: External Central Venus Catheters (CVC) Implanted Prts Shrt-term External Central Venus Catheters Hemdialysis/Apheresis Catheters Peripherally Inserted Central Catheters (PICC) Single PICCs 3 French r larger Duble PICCs 4 French r larger using the larger lumen fr sampling (e.g. 4 French duble PICC has a 3 French (20 Gauge) lumen, and a 2 French lumen. Use the 3 French lumen fr drawing bld). The push-pull methd is the preferred methd f bld sampling frm a Hemdialysis CVC but ther methds can be used. Bld sampling frm a hemdialysis catheter is dne nly after cnsultatin with a renal unit nurse r nephrlgist. Bld sampling requires a prescriber s rder indicating bld samples t be drawn. Althugh the vacutainer methd is the preferred methd fr bld sampling frm central venus lines fr maintaining Bld and Bdy Fluid precautins, the syringe methd is used: fr all bld draws frm PICC lines if vacutainer methd is unsuccessful if small vlumes are required fr micrtubes fr drawing bld gas samples SITE APPLICABILITY Applicable in all areas where patients with central venus lines are cared fr. PRACTICE LEVEL/COMPETENCIES Central line care, including bld sampling using syringe methd frm a CVL is cnsidered a fundatinal nursing skill and is practiced nce the nurse has: EQUIPMENT attended the Vascular Access Wrkshp, practiced the prcedure in the lab setting, perfrms at least 3 bld sampling prcedures n patients under supervisin f a CVL cmpetent RN, and has cmpleted the CVL validatin tl at the bedside with the apprpriate clinical supprt persn (i.e. clinical nurse educatr, clinical resurce nurse). requisitins and cmputerized r addressgraph labels fr patient Page 1 f 6

2 surface disinfectant wipe discard and sample syringes chlrhexidine 2% in 70% alchl swabs x 3 apprpriate bld cllectin tubes glves, nn-sterile 10 ml syringe filled with nrmal saline (x 2 if implanted prt) sterile dead-end cap if interrupting infusin if heparin lcking, add: 10 ml syringe filled with heparin 10units/mL (x2 if duble lumen) Swabcap (x 2 if duble lumen) if drawing bld cultures, add: three mre chlrhexidine 2% in 70% alchl swabs bld culture bttles if required** **NOTE: With initial wrkup, 2 aerbic bld cultures shuld be drawn frm each lumen/prt f a central venus line. Anaerbic cultures need nly be drawn frm ne lumen r peripheral if rdered. Fr neutrpenic patients, a peripheral aerbic bld culture is als required; please see Fever and Neutrpenia Order sets. PROCEDURE RATIONAL 1. REFER t Bldwrk Test and Tubes quick Ensures crrect amunt f bld cllected, reference guide r the Department f Pathlgy elab sample placed in crrect tube and handled Handbk t determine apprpriate bld tubes and crrectly. Reduces need t recllect samples. vlumes and any special handling instructins. Fr bld culture instructins, REFER t Bld Culture Cllectin Prtcl and recmmended bld vlumes fr bld cultures chart t determine type f bttles and ptimal vlume f bld t add t each bttle. 2. IDENTIFY patient by cmparing name n requisitin Failure t crrectly identify patients prir t and labels t patient ID band. If patient des nt have prcedures may result in errrs. ID band (i.e. Ambulatry care patients), ask patient/caregiver fr identificatin infrmatin (name, birthdate). Pease refer t Plicy CC.07.02: Patient Identificatin 3. EXPLAIN prcedure. Evaluates and reinfrces understanding f previusly taught infrmatin and cnfirms cnsent fr prcedure. 4. CLEAN surface with disinfectant wipe. Rutine infectin cntrl practices. Reduces 5. PERFORM hand hygiene fr ne minute. transmissin f micrrganisms. 6. PREPARE equipment using aseptic technique. If drawing bld cultures, SCRUB tps f bld culture tubes with chlrhexidine /alchl wipes fr 30 secnds. Allw t dry fr 1 minute. 7. CLAMP catheter. If secnd lumen infusing, CLAMP secnd lumen. NOTE: If drawing bld thrugh a psitive pressure T reduce risk f cntaminating sample. Bth lumens must be clamped t ensure n cntaminatin f bld samples. Page 2 f 6

3 cap, d nt clamp catheter until after remving IV tubing. 8. PAUSE infusin pumps r ACTIVATE the delay infusin feature if mre than 2 minutes is required fr bld sampling. By clamping first, then stpping infusin, psitive pressure is established. 9. DON nn-sterile glves. Rutine infectin cntrl practices. 10. REMOVE IV tubing and attach sterile dead-end cap t pen end t keep cvered. SCRUB the needleless cnnectr fr 30 secnds with a chlrhexidine/alchl wipe. Allw t dry fr 1 minute. OR REMOVE Swabcap and prceed t next 11. INSERT vacutainer int needleless cnnectr. 12. UNCLAMP catheter and PRESS discard red-tp tube nt vacutainer needle. If experiencing difficulty with bld sampling frm ther central venus lines refer t Plicy CV.03.25: Management f a Nn- Functining Central Venus Lines Remves slutin frm catheter t ensure uncntaminated bld specimen. Ensure apprpriate amunt f bld fr discard: TYPE OF CVL AMOUNT OF DISCARD Cuffed CVC < 10 kgs 1.5 ml Cuffed CVC > 10 kgs Shrt-term CVC 1.5 ml Implanted Prt PICC and cuffed PICC <10 kg 1.5 ml PICC and cuffed PICC >10 kg Hemdialysis/Apheresis 13. CLAMP catheter. REMOVE discard bld tube and DISCARD. 14. PRESS sample bld tubes n t vacutainer needle in the fllwing rder: bld cultures Na Citrate blue tp (cagulatin studies) red tp heparin green tp (chemistries) EDTA tube lavender tp (hematlgy, transfusin medicine) grey tp ther tubes as required T btain ttal amunt fr transferring t apprpriate tubes. UNCLAMP catheter and allw each tube t fill up with adequate amunt f bld required fr lab test. Refer t nline elab handbk fr required amunts f bld Page 3 f 6

4 15. MIX each tube immediately after drawing bld int it. GENTLY invert each tube 10 times. 16. CLAMP catheter and remve vacutainer. 17. ATTACH nrmal saline syringe nt needleless cnnectr UNCLAMP catheter and with thumb n plunger f syringe and ther hand n clamp, give tw quick pushes, then with cntinuus mtin, FLUSH int cap and catheter with remaining nrmal saline: Ensures bld cells are mixed with additives in the tubes. D nt shake r will cause cell lysis. Creates psitive pressure t maintain catheter patency. Tw quick pushes creates turbulent flw t clear catheter and help maintain patency. Type f CVL Cuffed CVC < 10 kgs Cuffed CVC > 10 kgs Shrt-term CVC Implanted Prt PICC and cuffed PICC < 10 kgs PICC and cuffed PICC > 10 kgs Hemdialysis/Apheresis Saline Flush 9 ml 18 ml (use 2 x 10 ml) 9 ml 9 ml 18. RECONNECT infusin set and cmmence infusin r heparin lck line as rdered. - If secnd lumen is in use, UNCLAMP secnd lumen and RECOMMENCE infusin. 19. LABEL specimen tubes at the patient's bedside. Label must include MRN, first and last name, date f birth, date and time sample drawn and RN initials. May use cmputerized r addressgraph labels if available, except fr Grup & Screen and Crssmatch.* NOTE *Grup & Screen and Crssmatch cllectin prcedure: Natinal Standards fr safe transfusin practice require specimen labeling at the bedside Cnfirm patient identificatin - name, DOB, MRN n patient ID band matches with the requisitin. Reslve any discrepancies prir t cllectin When pssible, ask patient his/her name and DOB Specimen MUST be hand labeled at bedside nly by the persn wh cllected the specimen Resumes therapy as rdered. Safe bld sampling and transfusin practices. Refer t Transfusin medicine manual. Page 4 f 6

5 Cmputer generated labels are nt t be used Label must cntain patient name, DOB, MRN, date and time f cllectin and RN initials Sign requisitin and recrd date and time f cllectin. Signing requisitin cnfirms yu have crrectly identified the patient. 20. COMPLETE apprpriate labratry requisitins indicating the site where bld sample was btained, RN initials, and date and time. On the transfusin medicine requisitin: sign, date and time the requisitin in the apprpriate space. Yur signature MUST include full last name, and first name r first initial. Persn wh cllects sample must be the persn wh signs the requisitin. NOTE: Indicate n culture bttles and requisitins which lumen the sample was drawn frm and indicate patient's weight n requisitin. 21. COMPLETE site t surce safety check f IV infusin system: Site assessment ( TLC ) Trace tubing frm bag/bttle/syringe t site t ensure right slutin/medicatin is infusing via right channel and at right rate Check tubing fr leaks, kinks, air bubbles, lse cnnectins, breaks in system, etc Check that clamps are pened/clsed as apprpriate Check that needless cnnectr attached t end f central line and at tp f syringe line t maintain a clsed system (except in PICU). 22. REMOVE equipment and DISPOSE apprpriately and PERFORM hand hygiene. 23. PLACE specimens in transprt bags and ARRANGE fr transprt t lab Infusin nursing standard f care. Rutine infectin cntrl practices. DOCUMENTATION DOCUMENT n apprpriate recrd(s): prcedure and time patient's respnse t prcedure if unusual REFERENCES Page 5 f 6

6 Byce, J.M. and Pittet, D. (2002). Guideline fr Hand Hygiene in Health-Care Settings: Recmmendatins f the Healthcare Infectin Cntrl Practices Advisry Cmmittee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Frce. Centers f Disease Cntrl and Preventin. MMWR Recmmendatins Reprt. 51(RR16):1-44. Clinical and Labratry Standards Institute (frmerly NCCLS) Prcedures fr the Cllectin f Diagnstic Bld Specimens by Venipuncture: Apprved Standard Fifth Editin Hs-A5. Farj, L. (2003). Bld Cllectin frm Peripherally Inserted Central Venus Catheters. Jurnal f Infusin Nursing.26(6): Infusin Nurses Sciety. (2011). Infusin Nursing Standards f Practice. Jurnal f Infusin Nursing. 34(1S). Knue, M., Dellman, D., Rabin, K. and Jacbes, B.R. (2005). The Efficacy and Safety f Bld Sampling Thrugh Peripherally Inserted Central Catheter Devices in Children. Jurnal f Infusin Nursing. 28(1): Larwd, KA, Anstey, CM and Dunn, SV. (2000). Managing Central Venus Catheters: a Prspective Randmised Trial f Tw Methds. Australian Critical Care. 13(2): Newman, CD. (2006). Catheter-Related Bld Stream Infectins in the Pediatric Intensive Care Unit. Seminars in Pediatric Infectius Diseases. 17(1): O Grady, N.P. et al. (2011) Guidelines fr the Preventin f Intravascular Catheter-Related Infectins. Centres fr Disease Cntrl and Preventin. Retrieved February 25, 2013, frm : Ogstn-Tuck, S. (2012). Intravenus therapy: guidance n devices, management and care. British Jurnal f Cmmunity Nursing, 17(10): Registered Nurses Assciatin f Ontari (2005). Nursing Best Practice Guideline: Care and Maintenance t Reduce Vascular Access Cmplicatins. Trnt, Canada: Page 6 f 6