PROCEDURE FOR FLUSHING TOTALLY IMPLANTED INTRAVENOUS ACCESS DEVICE PORTS FOR ADULTS

PROCEDURE FOR FLUSHING TOTALLY IMPLANTED INTRAVENOUS FOR ADULTS First Issued Issue Version Purpose of Issue/Description of Change Planned Review Date One To ensure a safe and effective procedure for the Flushing of Totally Implanted Intravenous Access Device Ports for Adults 2013 Named Responsible Officer:- Approved by Date Medicines Governance Pharmacist Quality and Governance Service Section: - Patient Safety PS N o 01 Risk and Governance Group October 2011 Target Audience Community Nursing UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

CONTROL RECORD Title Procedure for flushing totally Implanted Intravenous Access Device Ports for Adults Purpose To ensure a safe and effective procedure for the Flushing of Totally Implanted Intravenous Access Device Ports for Adults Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Medicines Governance Pharmacist Advanced Practitioner Document Librarian QGS Groups consulted with :- Medicines Management Group Infection Control Approved Date formally approved by Risk 3 rd Oct 2011 and Governance Group Method of distribution Email Intranet Archived Date: October 2011 Location: S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Lisa Knight Annie Baker R/TC Updated procedure for sitimplant information and different strength of heparin Status New / Revised / Trust Change 2/13

CONTENTS Contents Page Introduction 4 Target Group 4 Training 4 Related Policies 4 Advantages of Implanted Venous Access Devices 4 Disadvantages of Implanted Venous Access Device 5 Contraindications for Implanted Venous Access 5 devices Procedure for the Flushing of a Totally Implanted 5-9 Venous Access Device (Portacath or Sitimplant) Equipment 5 Sodium Chloride 0.9% Flushes 6 Heparinised Saline 6 To Prepare Heparinised Saline 500 units per ml 6 Safety Checks Prior to Conducting this Procedure 6 Clinical Incident 9 Trouble Shooting 9 Vulnerable Adults 10 Equality Impact Assessment 10 References 11 Appendix 1 - Diagram Stabilising and Accessing a 12 Port Appendix 2 Cross Section of an Implanted Port 13 Accessed with a Non-coring Needle 3/13

INTRODUCTION An implanted port e.g. Portacath or Sitimplant is a small medical appliance that is implanted beneath the skin that comprises of a portal body and a catheter. The portal chamber is a hollow housing of titanium or plastic that contains a compressed latex septum. The portal chamber is connected via a small tube to a polyurethane or silicone catheter and is usually inserted in the upper chest, just below the clavicle or collar bone (Dougherty 2006). Implanted ports are venous access devices used for intermittent use and/or long term access for patients, who require vascular access. The most common veins used are subclavian, internal and external jugular veins, cephalic or femoral veins. Ports can also be inserted in the antecubital area of the arm (Dougherty 2008). TARGET GROUP All registered community nurses employed by the Trust who are required to carry out this procedure as part of their role. TRAINING In each service, managers will ensure that there are sufficient named assessors who will conduct assessments of their own team when there is a patient on the caseload requiring this intervention, using the Trust s intravenous competency framework. The Quality and Governance Service will hold a supply of models for staff to practice their skills as required, as it is appreciated that there may be months between caring for patients requiring this procedure. Staff may need to visit the discharging hospital to meet the patient, receive a handover and watch the procedure prior to patient being admitted onto caseload; to ensure that all necessary equipment is discharged with the patient and staff are competent in carrying out the procedure. RELATED POLICIES Please refer to relevant Trust policies and procedures ADVANTAGES OF IMPLANTED VENOUS ACCESS DEVICES The main advantage that implanted ports have over other devices is that they are implanted under the skin and are therefore not external to the body. This is an advantage for the following reasons: Promotes good positive body image compared with external catheters An implanted port can be used for long term venous access for all types of therapies, both continuous and intermittent and if patients have problems with venous access (Dougherty 2008). When not in use implanted ports may only require flushing once a month or bimonthly in certain circumstances, making them more suitable for intermittent 4/13

therapies Ability to continue with sports/swimming/bathing) No dressing required Reduced risk of infection DISADVANTAGES IMPLANTED VENOUS ACCESS DEVICES The tissue over septum can become scarred over time and with loss of sensitivity. Also, requires surgical removal that can leave a scar Patient requires a general anaesthetic (GA) therefore the patient needs to be well enough to undergo a GA Increased risk of inoculation injury for staff Higher risk of extravasation due to needle dislodgement when compared with other central venous access devices Ports are usually single lumen, although double lumen ports are available. Double lumen ports have two septums and therefore require needle access into each septum. The self sealing silicone septum can be accessed 1000-3600 times depending on the size of the needle used, refer to manufacturer s instructions. The needle gauge is selected dependant on the type and rate of infusion as well as the location of the port. CONTRAINDICATIONS FOR IMPLANTED VENOUS ACCESS DEVICES Patient non compliance Needle phobic Previous damage to site /scar tissue Presence of known infection Inadequate body tissue (malnourished patient) PROCEDURE FOR THE FLUSHING OF A TOTALLY IMPLANTED VENOUS ACCESS DEVICE E.G. PORTACATH OR SITIMPLANT PORTS This procedure requires two staff one of whom must be a registered nurse. Standards for Medicines Management Standard 20 (NMC 2010) EQUIPMENT Sodium chloride 0.9% ampoules for injection (see below) Heparinised saline required for flushing (see below) Single use sterile dressing pack 2% chlorhexidine and 70 % Alcohol impregnated applicator (Chloraprep) Two Filter needles Two 10ml Luer lock syringes Non coring gripper needle with needle free system Patient Medicine Administration Chart Nursing Health Records Sharps container Additional pair single use disposable sterile gloves 5/13

SODIUM CHLORIDE 0.9% FLUSHES Portacath Implant venous systems: - The manufacturer recommends that Portacath Implants, for venous systems, require sodium chloride 0.9% flushes of 10ml, prior to administration of heparin locks Sitimplant venous systems: - The manufacturer recommends that Sitimplant Ports, for venous systems require sodium chloride flushes of 5ml, prior to administration of heparin locks HEPARINISED SALINE Portacath Implant venous systems: - The manufacturer recommends that Portacath Implants, for venous systems, when not in regular use, require a locking solution of heparinised saline every four weeks to maintain patency, using 5ml of heparinised saline 10 to 100 units per ml. Sitimplant venous systems: - The manufacturer recommends that Sitimplant Ports, for venous systems in adults, when not in regular use, require a locking solution of heparinised saline every four weeks, to maintain patency using 3 to 5ml of heparinised saline 500 units per ml. This is the strength of heparinised saline recommended for adults use only. This strength of heparinised saline is not manufactured and a dilution is therefore required. TO PREPARE HEPARINISED SALINE 500 UNITS PER ML Dilute 1.5mls of heparin 1000 units per ml with 1.5ml 0.9% sodium chloride to give 3ml of heparinised saline 500 units per ml. This is a high risk procedure. There is a potential risk of medication error. Please refer to risk assessment for Sitimplant Ports in Adults Only. SAFETY CHECKS PRIOR TO CONDUCTING PROCEDURE Prior to carrying out this procedure you must assess whether the patient has experienced any symptoms that may warn of catheter fragmentation and/or catheter embolism since the system was last accessed; for example, episodes of shortness of breath, chest pain, or palpitations. If any of these symptoms are reported, an x-ray is recommended to determine if there are problems with the catheter. The patient should be referred back to the hospital who inserted the Portacath or Sitimplant. 6/13

PROCEDURE FOR THE FLUSHING OF A TOTALLY IMPLANTED VENOUS ACCESS DEVICE FOR ADULTS (TIVAD) E.G. PORTACATH OR SITIMPLANT PORTS Activity Confirm patient s identity by asking for full name and date of birth, clarify with family/carer if patient unable to do so Staff members to introduce themselves and explain and discuss the procedure with the patient and relevant family members/carers. Establish patient has no known allergies, check in patient s records and also ask patient/family of any known allergies Obtain valid and informed consent and document in the nursing record. Ensure patient is comfortable and in a private area Check Patient Medicine Administration Chart (PMAC) is up to date and clearly written, stating the prescribed flushes. Gather all equipment prior to procedure Decontaminate hands Open sterile dressing pack onto a clean area and place all sterile single use equipment required within sterile field Rationale To ensure correct patient and avoid error in patient identification To ensure understanding of the procedure and allow time for patient to ask questions To reduce allergic reactions To gain patient consent for the procedure To comply with Trust polices To maintain privacy and dignity Effective medicines management To prepare for procedure To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To prevent contamination of key parts Apply single use disposable apron To protect clothing or uniform from contamination and potential transfer of micro-organisms Check expiry dates and packaging Patient safety Place 0.9% Sodium Chloride and Sodium heparin ampoule near to the working area but not on sterile field Decontaminate hands prior to procedure Apply single use disposable sterile gloves in a manner which prevents the outer surface of the sterile glove being touched by a non sterile item Use aseptic non touch technique principle to ensure that only sterile single use items are used to keep exposure of susceptible site to a minimum Connect filter needle to syringe with a piece of sterile gauge pick up the 0.9% sodium chloride ampoule and draw up the recommended volume dependant on the manufacturer s instructions for flushing using a 10ml syringe. Dispose of sharps directly into sharps container. Place the filled syringe on the sterile field Only one unlabelled medicine must be handled at one time To maintain sterile field To reduce the risk of transfer of transient micro-organisms on the healthcare workers hands To maintain asepsis, reduce the of microbial contamination and prevent the spread of infection To prevent contamination of a susceptible site by organisms that could cause infection 10ml syringes should always be used; smaller syringe sizes may damage the catheter. To reduce the risk of needle stick injury, To avoid administration errors 7/13

Prime the non-coring needle device including its tubing with sodium chloride 0.9% and clamp extension tube, remove syringe Locate the port and identify the septum clean the skin covering the TIVAD with Chloraprep (2% chlorhexidine in 70% alcohol, allow to dry) Remove gloves, decontaminate hands and reapply new pair of sterile gloves Remove needle cover from non-coring needle device. Holding the needle in the dominant hand, stabilise the port between forefinger and index finger of the non-dominant hand Do not introduce or allow air into the port Inform the patient that you are about to insert the needle Insert needle at 90 degree angle through the skin into the septum of the TIVAD until the needle comes into contact with the medal backing plate Attach syringe containing 0.9% sodium chloride, draw back on the syringe and check for blood return. Administer the 0.9% sodium chloride and observe the site for any swelling or pain: flush using a push pause action clamping as the last ml of the solution is instilled into the catheter. Remove the syringe and discard in sharps container Following successful 0.9% sodium chloride flush, repeat the flushing procedure using sodium heparin (strength and volume as recommended for specific port, see section on equipment) Maintain pressure on the plunger as syringe is disconnected from the injection cap If TIVAD was accessed for flushing purposes only remove the needle, press on either side of the portal of the implanted port with two fingers Withdraw the needle using a steady traction Discard needle in sharps container Apply pressure over the puncture site for a few minutes with sterile gauge until bleeding stops. No dressing is usually required but a small plaster or dressing may be applied Clear all equipment away disposing of clinical waste as per trust policy On completion of the procedure remove and dispose of Personal Protective Equipment (PPE) to comply with waste management policy Decontaminate hands following removal of PPE Document on the record of treatment and in the patient s health records all interventions and actions taken. To check patency of needle and extension set (Dougherty 2008) To stabilise port reduce risk of transfer of any transient micro-organisms from the resident microorganisms To prevent contamination of key parts To ensure the port is stabilised and will not move on insertion of the needle An air pocket may allow blood to pool and clot To prepare the patient for a pushing sensation To ensure the needle is well inserted into the portal system To check the needle is correctly placed, the port is patent and correct positioning. To administer medicines and carry out instructions as per prescription As per waste management policy To maintain patency over a longer period of time e.g. one month To prevent backflow of blood and possible clot formation To support the port whist removing the needle To prevent trauma to the skin and the risk of needle stick injury To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE Trust Health Records Policy Working in partnership with patient 8/13

CLINICAL INCIDENTS Any related incidents arising from carrying out this procedure which may involve a clinical error or near miss must be reported following Trust Incident Reporting Policy. TROUBLE SHOOTING PROBLEMS Do not initiate injection or infusion therapy until system integrity is confirmed If Huber needle is introduced with too much force through the port septum and hits the housing, damage to the septum and the needle can occur Aspirate for blood return Examine and palpate the portal pocket and catheter tract for erythema, swelling, tenderness or infection which might indicate fluid leaking from catheter Erythema at exit site, tenderness, swelling or purulence within 2cm of exit site may or may not have temperature Fluid leaking from catheter Ruptured catheter Fluid leaking from catheter hub exit site Cracked hub May hear catheter pop or rupture while flushing Burning pain with flush or infusion Swelling along catheter tract Do not use excessive force when flushing catheter, do not continue to flush the catheter if extreme resistance is encountered During the flush observe the portal pocket and catheter tract for swelling and inquire or observe whether the patient is experiencing burning pain, swelling along catheter site with infusion or discomfort at portal site. Most manufacturer s only recommend using a 10ml syringe or larger for flushing Do not rock or tilt the needle once the septum is punctured If any of the following symptoms are present then notify referring clinician or General Practitioner immediately; Chest pain Cyanosis Hypotension Tachycardia May have fainting and/or loss of consciousness POSSIBLE CAUSES/RATIONALE To ensure no system damage exists and prevent complications This can cause kinking of the needle shaft resulting in potential needle fracture on removal and/or the disruption of the septum Difficulty in withdrawing blood may indicate catheter blockage or improper needle position To determine if any problems with the catheter. Exit site infection, discuss with hospital or General Practitioner Damaged catheter may be hole or needle puncture, rupture from forced irrigation, pinch off syndrome. Notify referring hospital Damage due to excessive pressure may include but is not limited to, catheter rupture or fragmentation with possible embolisation or drug extravasations to the catheter if extreme pressure is exerted If any of these symptoms are noted and/or swelling of the portal pocket and catheter tract is observed, fluid extravasation into the portal pocket or catheter tract should be suspected, contact hospital who implanted the port The smaller the syringe, the higher the pressure exerted and this can cause disconnection between the portal body and catheter or cause catheter damage This may cause fluid leakage or damage to the septum. Possibly due to damaged or severed catheter, defective catheter or catheter damage during insertion. Arm or shoulder movements may interfere with infusion or blood withdrawal Assess patient for early signs of pinch off syndrome including the inability to flush or aspirate fluid when the patient is sitting, but able to aspirate and flush when the patient is lying down. 9/13

Arrhythmias Palpitations Dyspnoea Burning pain with flush or infusion Arm/shoulder movements may or may not interfere with infusion or blood withdrawal Cardiac arrest Unable to aspirate or flush catheter Arm swelling on the same side of the body as the catheter Neck pain or swelling Jugular vein distension Engorged peripheral veins in arm or chest wall Non-specific chest wall pain Shortness of breath Cough May or may not be able to aspirate/infuse May or may not have pain with infusion Cyanosis of face and upper extremities Jaw pain Ear ache Pinch off syndrome is the compression of the catheter between the clavicle and the first rib. Notify referring Hospital if pinch off syndrome suspected Inform hospital if any symptoms are reported Occlusion of catheter Occlusion of the vessel in which the catheter resides, notify referring hospital VULNERABLE ADULTS In any situation where staff may consider the patient to be a vulnerable adult, they need to follow Trust Vulnerable Adult Policy and discuss with their line manager and document outcomes. EQUALITY ASSESSMENT During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place. 10/13

REFERENCES Care of Sitimplant Manufacturer s Guidelines: VYGON UK Ltd http://www.vygon.com/en/contact-us/contact Collaborative Intravenous Nursing Service (2009) Intravenous Access Care and Maintenance for Adult Patients: In Hospital and at Home. Clinical Guidelines: Cheshire and Merseyside NHS North West. Dougherty, L. (2006) Central Venous Access devices: Care and Management. Blackwell publishing Ltd, Oxford. Dougherty L. & Lister S. (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 7th Edition. John Wiley and Sons Ltd, Oxford. National Patient Safety Alert (2008) Rapid Response Report: Risks with Intravenous Heparin Flush Solutions. NPSA/2008/RRR002, April 2008. http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=59892&p=3 PORT-A-CATH & PORT-A-CATH II (2005) Vascular Access Systems: Instructions for Use http://www.smiths- medical.com/upload/products/product_relateddocs/access/port-a-cath- Access-Systems/40-5091-24B.pdf Pratt. R. J. Pellowe. C. M. Wilson. J. A., et al (2007) EPIC 2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. The Journal of Hospital Infection, 655, 51-564. www.sciencedirect.com Royal College of Nursing (2005) Standards for infusion therapy. www.rcn.org.uk 11/13

Appendix 1 Stabilising and Accessing a Port (Adapted from Dougherty and Lister, 2008) 12/13

Appendix 2 Cross section of an implanted port accessed with a non-coring needle (Adapted from Dougherty, 2006) 13/13