SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY

PS1006 SARASOTA MEMORIAL HEALTH CARE SYSTEM CORPORATE POLICY TITLE: INFECTION PREVENTION FOR INTRAVASCULAR Job Title of Responsible Owner: Executive Director, Quality POLICY #: EFFECTIVE DATE: REVIEWED/REVISED DATE: POLICY TYPE: 03/08/02 07/11/12 Clinical 1 of 12 Non-Clinical PURPOSE: POLICY: STATEMENT: To outline practices for reducing the risk and prevention of infections related to intravascular lines. It is the policy of Sarasota Memorial Health Care System (SMHCS) to adhere to current standards of care in order to minimize the risk of infection or cross-contamination related to intravascular lines. Related procedures include: Procedure Title Management of Vascular Access Complications Parenteral Nutrition Peripheral IV Care, Maintenance, Insertion & DC Implanted Port, Care, Maintenance, Insertion & DC Central Line Care, Maintenance & DC PICC & Midline Care, Maintenance, Insertion & DC Hickman and Groshong Care & Maintenance Chemotherapy Extravasation Intraosseous Needles Procedure Number Cen05 Inv11 Inv02 Vad01 Cen01 Pic00 Hic01 Onc10 Inv08 EXCEPTIONS: Procedures used when placing an intravascular line during an emergent situation may deviate from these standards. DEFINITIONS: 1. Central Venous Catheter (CVC) Line: A vascular access device in which the tip of the catheter will rest optimally in the superior vena cava at the junction of the right atrium. Access points may include the internal jugular, external jugular, subclavian, or the femoral vein. Other types of central lines include those accessed in the arm (PICC), implanted ports, and Tunneled (Groshong) catheters. 2. Chorhexidine Impregnated Sponge (BioPatch): A sponge patch impregnated with Chlorhexidine that is applied print side up around the central line or PICCs. 3. Dialysis Catheters & Quintin Catheters: A type of vascular access catheter used in hemodialysis. 4. IV: Abbreviation for intravenous therapy

2 OF 12 5. Midline IV Catheter (MLC): An indwelling catheter that is inserted via the proximal basilic or cephalic veins of the arm with the tip terminating at or near the axillary vein level but below the shoulder joint. It is approximately 20 cms long and is classified as a peripheral line. 6. Peripheral Venous Catheter (PIV): An indwelling catheter that is usually inserted in veins of the forearm or hand. Less than three inches in length. Risk of phlebitis with prolonged use, rarely associated with bloodstream infection. 7. Peripheral Arterial Catheter: An indwelling catheter usually inserted in a radial artery or femoral artery. Less than three inches in length; may be associated with bloodstream infection. 8. Peripherally Inserted Central Venous Catheter (PICC): An indwelling catheter inserted into basilic, cephalic or brachial veins of the arm with the tip terminating in the superior vena cava. Usually between 40-60 cm in length depending on the size of the patient. Has a lower rate of infection than other central venous catheters. 9. Pulmonary Artery Catheter (PA): Inserted through an introducer in a central vein (subclavian, internal jugular or femoral). Usually greater than thirty cm depending on the size of the patient. Similar rate of bloodstream infection as central venous catheters. The subclavian site is preferred to reduce the risk of infection. 10. Skin prep: Patient s skin should be assessed to determine sensitivity to skin prep solution. If sensitivities are identified, the alternate prep should be selected. a. Single Skin Prep: The site will be thoroughly cleansed with 2% chlorhexdine skin prep. Use repeated back-and-forth strokes of the applicator for approximately 30 seconds. Completely wet the treatment area with antiseptic. Allow the area to air dry for approximately 30 seconds. Do not blot or wipe away. b. Double skin prep: The site will be thoroughly cleansed with 70% isopropyl alcohol, followed by application of povidoneiodine solution. This will be allowed to air dry for a minimum of two minutes. 11. Totally Implantable Subcutaneous Port: (Examples Life Port, Pass Port). A subcutaneous port that is tunneled beneath the skin, accessed with a non- coring needle. Usually implanted in a subclavian or internal jugular vein. Greater than eight cm depending on the patient size. Lowest risk for central line

3 OF 12 associated bloodstream infection; is associated with improved patient self-image. Surgery is required for catheter removal. 12. Tunneled Cuffed Catheters: (examples Hickman, Hickman Broviac) Inserted into the superior vena cava by creating a tunnel into the vessel. A Dacron cuff maintains placement of the catheter. 13. TPN: Total Parenteral Nutrition. 14. Umbilical Catheter: Inserted into either the umbilical vein or artery. Usually less than six cm depending on patient size. PROCEDURE: 1. Healthcare personnel shall be educated regarding the indications for intravascular catheter use, proper procedures for insertion and maintenance of intravascular catheters and appropriate infection control measures to prevent intravascular related infections upon hire and annually thereafter. 2. The type of catheter selected will be based on the intended purpose, duration of use and the condition of the patient s vascular and treatment needs. 3. Hand hygiene will be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained. 4. Skin Prep: A single or double skin prep should be performed prior to insertion and when changing dressing on any vascular line. 5. Gloves will be worn when in contact with blood, e.g., venipuncture, procedures involving the connection site and discontinuation of the line. Gloves will be worn when changing dressings on all IV catheters. 6. Aseptic technique will be maintained for the insertion and care of intravascular catheters. Sterile supplies will be used. All surfaces on which vascular access related equipment, tubing, dressings, etc. will be prepared, must be disinfected using a germicidal wipe. 7. Maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves and a sterile full body drape will be used for the insertion of CVCs, PICCs, guide wire exchange, or axillary/femoral artery catheter insertion.

4 OF 12 8. A sterile sleeve will be used to protect pulmonary artery catheters during insertion. 9. A securement device will be used on all PICCS, MLCs and any central line in which the weight of the line prevents the dressing from remaining intact. 10. All disposable sharps and biomedical waste will be discarded per SMHCS policy 00.IFC.12 Biomedical Waste and Sharps. 11. IV insertion and maintenance procedures will be documented in the patient medical record. 12. Each time that a patient s vascular line is accessed the needleless connector (access port) must be thoroughly scrubbed with alcohol for 15 seconds ( scrub the hub ) and allowed to air dry. Only sterile devices will be used to access the port. 13. Do not submerge the catheter or the catheter site in water. Showering is permitted if the catheter and connecting device are protected with an impermeable cover during the shower. 14. Encourage patients to report any changes in their catheter site or any new discomfort to their caregiver. 15. All vascular devices will be removed as soon as no longer clinically indicated. Proactive consultation with the physician is expected. 16. Administration Sets and Needleless Connectors: a. Tubing change, extension tubing, dial-a-flo and adapter change will be performed within 96 hours of prior tubing change or if contaminated.. b. Total Parenteral Nutrition (TPN) - TPN tubing will be changed within 24 hours of prior tubing change. c. Tubing used to administer blood and blood products will be changed within 4 hours of infusion regardless of the number of units administered. d. Tubing used to administer propofol will be changed every 12 hours, when the vial is changed, per the manufacturer s recommendation. e. Administration sets, add on devices and needless connectors will be changed upon contamination or when site locations are changed. f. Exception to 96 hours: IV solution with an expiration date/time less than 96 hours should be infused by the labeled expiration date/time (example: Nipride).

5 OF 12 g. All administration set ends will be covered with a red cap when not in use. If the red cap is not present, discard the administration set and obtain a new set. h. Needleless connectors will be changed by the primary nurse every 96 hours. i. Some units have designated days for tubing and needleless connector change days. 17. Dressing Regimens: a. Sterile gauze or sterile, transparent, semi-permeable dressing will be used to cover the catheter site. Sterile gauze will be used for those patient having oozing at the insertion site. The time and date of insertion or dressing change will be noted on the dressing. b. Place a chlorhexidine impregnated sponge on all central lines (except those that will be removed in 48 hours) and PICCs. c. Central lines & Midline transparent dressings are changed using sterile technique to include sterile gloves and mask every seven days or urgently if damp, loosened or visibly soiled. Gauze dressings are changed every 2 days,. d. Peripheral line dressings are changed every 96 hours (four days) with site rotation or sooner if damp, loosened or visibly soiled. e. Dressings on peripheral arterial lines, pulmonary artery lines, or intra-aortic balloon pressure lines are changed every 96 hours. or sooner if they become damp, loosened or visibly soiled. 18. Assessment: a. Each shift, all vascular devices will be inspected for erythema, tenderness, edema, leaks, infiltration, purulence, abscess, phlebitis or cellulitis and intact dressing. b. If purulent phlebitis, cellulitis or IV-related bacteremia is noted or strongly suspected, the entire administration set system, add on devices and needleless connectors will be changed immediately. Consult with the physician is necessary. c. All assessments and actions related to vascular access are to be documented in the electronic medical record and receiving nurses are to be notified of status. 19. Vascular Access Devices Inserted Emergently: a. Lines placed emergently will be assessed after the incident and relocated as soon as possible but not longer than 48 hours.

6 OF 12 b. The site will be marked with a bold E on the dressing. The emergently placed device will be verbally identified to the receiving nurse and documented as such in the electronic record. 20. Arrival at SMH with Vascular Access Device in Place: a. The vascular access site will be assessed for functionality to include blood return, signs and symptoms of thrombosis, potential infection or contamination and documented in the electronic record. The physician will be notified of any signs of phlebitis, cellulitis or infection. b. Peripheral IVs will be discontinued and restarted if phlebitis or infiltration is suspected, if the PIV has been in place 96 hours or longer or if the date of PIV start is unknown. c. PICCs, central lines and MLCs will be validated for patency by aspirating blood and ease of flushing. If no blood return is present or if ther is difficulty with flushing, consult the PICC team, Intervention RNs or supervisors for further guidance. d. A dressing and administration set change (including application of chlorohexidine impregnated sponge on central lines or PICCs) will be performed and documented in the electronic record. e. A nurse protocol flush order for normal saline and heparin should be entered in the electronic record. 21. Peripheral IV Lines (PIV): a. Site Selection: Determine if any condition exists that prohibits use of any extremity, example mastectomy or dialysis catheter: 1) Adults catheters should be inserted in upper extremity (arm or hand); non-dominant extremity is preferred. In the event that the antecubital vein needs to be used, the IV should be discontinued within 48 hours. 2) Pediatrics catheters may be inserted into the upper extremity, dorsum of the foot or scalp. 3) Clean gloves rather than sterile gloves are acceptable as long as the access site is not touched after the skin prep and prior to insertion. 4) If the vein needs to be palpated following skin prep, sterile gloves should be worn or the site should be reprepped with chlorhexidine. b. Site change will be performed within 96 hours of prior insertion except for neonatal and pediatric patients.

7 OF 12 22. Central IV Lines: a. Insertion will be performed by physicians. The subclavian rather than the jugular or femoral site should be used unless medically contraindicated. b. Site change, when necessary, will be performed by the physician. If a catheter-related infection is documented, guide wire assisted catheter exchange will not be done. c. Removal: Per nursing procedure Central Line Care, Maintenance & DC (cen01) found on the PULSE site. 23. Peripherally-inserted Central Catheters (PICCs) and Mid-Line Catheters (MLCs): a. A midline or PICC line may be considered if it is anticipated that duration of therapy may exceed six days, or osmolality of the solution is greater than 500 ml osmols/liter, or if the ph of the solution is less than 5 or greater than 9, or the patient has limited venous access. b. Specially trained qualified nurses of the PICC team department or interventional radiologic technologists or registered interventional radiologic technologists may perform insertion for adults and pediatrics. A specially trained NICU nurse will perform insertion for NICU patients. c. PICC team or NICU PICC RNs will monitor the site daily on all inpatients. The Day Treatment RN will monitor the site daily, based on when the patient arrives for therapy. d. A specially trained nurse will do dressing changes. e. Removal will be performed by a specially trained qualified nurse. 24. Pressure Monitoring Systems: Peripheral Arterial Catheters, Pulmonary Artery Catheters and Intra-Aortic Balloon Pressure Lines a. Sterile technique with cap, gown, mask, sterile gloves and sterile drapes will be used when inserting peripheral arterial lines. Maximal barrier precautions, including the use of a cap, mask sterile gown, sterile gloves, and a sterile full body drape, will be used for pulmonary artery catheters and intraaortic balloon pressure lines. b. Tubing and dressing change will be performed within 96 hours of prior change, or as necessary if wet or nonocclusive. A sterile occlusive dressing will be applied. The time and date of insertion will be noted on the dressing. c. The container of flush solution will be changed within 96 hours of hanging. d. The transducer, administration tubing and continuous flow device are disposable and will be replaced within 96 hours of prior tubing change.

8 OF 12 e. When zeroing the transducer for calibration, sterility of the occlusive cap will be maintained. f. Obtaining Specimens: The number of manipulations and entries into the system will be minimized. 1) Pressure-monitoring systems will be maintained as closed systems. Stopcocks, if used, will be covered with an occlusive cap or syringe and treated as a sterile field. 2) Pressure monitoring devices will not routinely be used to obtain blood cultures. 3) The timing of blood draws will be coordinated in order to minimize manipulation of the line. 4) Care will be taken to ensure that all specimens are obtained aseptically when the pressure monitoring system is accessed through a needleless port or stopcock. g. The transducer cable will be cleaned with a hospital germicide after each patient. h. Only normal saline or heparnized saline will be administered through the pressure monitoring circuit. Exception: NICU patients with an Umbilical Arterial Catheter. i. The nurse will monitor all pressure lines for erythema, tenderness, edema, oozing, diminished pulse distal to site and/or diminished blood return or dampened wave form every shift. Additionally, the respiratory therapist will monitor the peripheral arterial site. The physician will be notified if signs of infection or an occlusion are suspected. j. Intravascular pressure-monitoring systems will be removed when no longer medically indicated. They will be promptly discontinued or placed at another site if the initial site becomes infected or is suspected as the source of clinical sepsis or bacteremia. k. Pressure lines inserted outside of the facility will be assessed on admission. If the site exhibits erythema, tenderness, edema, leaks, infiltration, purulence, abscess, phlebitis or cellulitis the physician will be notified immediately and this will be documented in the patient's medical record. 25. Totally Implantable Subcutaneous Port: a. Insertion will be performed in Surgery/Radiology. b. Specially trained nurses may access the device using a non-coring needle. c. Sterile technique will be followed when accessing the device. The site will be thoroughly cleansed using a single or double skin prep and covered with a sterile transparent dressing. d. Re-access of the device will be initiated every seven days.

9 OF 12 26. Culturing for suspected IV-related infections: a. If an invasive line is to be discontinued because of suspected purulent thrombophlebitis or bacteremia, the physician will be notified and the catheter tip will be cultured. Skin at the junction will be cleaned with either single or double skin prep and allowed to dry before cannula removal and the cannula will be cultured using a semi-quantitative technique. b. When a catheter related infection is suspected and if the catheter is removed, then: 1) Handle with sterile technique. 2) Cut at the proximal point, starting just below the skin. Submit a 5cm or 2-inch catheter segment using sterile scissors. 3) Place the catheter tip in any dry, sterile container immediately upon removal at the bedside. 4) Label and send specimen as soon as possible to the bacteriology laboratory. c. If fluid contamination is suspected as the source of bacteremia, the fluid will be cultured and the implicated bottle or bag will be saved by the laboratory. 1) If contamination of fluid is confirmed, the implicated bottle or bag and remaining bottles or bags of the implicated lot will be saved and the lot numbers of fluid and additives will be recorded. The Infection Control manager, the Pharmacy director and Risk Management director will be notified. 2) If intrinsic contamination (during manufacturing) is suspected, a sample of the remaining lot will be tested. If contamination is confirmed, the Infection Control manager, the Pharmacy director, Risk Management director, local health unit, CDC and the U.S. Food and Drug Administration (USFDA) will be notified immediately. RESPONSIBILITY: It is the responsibility of department directors and medical staff to assure that this policy is understood and adhered to by all. REFERENCE(S): 1. Intravenous Nurse Association Standards, 2011. 2. Centers for Disease Control & Prevention, (CDC) Guidelines for the Prevention of Intravascular Catheter Related Infections; 2011. 3. http://www.ihi.org/ihi/programs/campaign 4. APIC Elimination Guide, Guide to the Elimination of Catheter- Related Bloodstream Infections, 2009.

10 OF 12 5. Infect Control Hosp Epidemiology 2008;29:S22 S30 2008 by The Society for Healthcare Epidemiology of America 6. SMHCS Policy 00.IFC.12 Biomedical Waste and Sharps 7. SMHCS Policy 00.IFC.67 Hand Hygiene REVIEWING AUTHOR(S): ATTACHMENT(S): Sherry Wolabaugh, Manager, Infection Prevention and Control Karen Diffley, Nursing Standards Donetta Dangleis, Critical Care Respiratory Therapist Sue Drake, Infection Control Practitioner Yvonne Cales, Clinical Educator Nursing Resources Maribeth Desioncgo, Clinical Educator Appendix A : Administration Set Changes

11 OF 12 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy. Committees/Sections/Departments: Date Infection Control Committee Director/Responsible Owner: Vice President/Executive Director: Chief of Medical Operations: (if clinical policy or appropriate) Chief of Staff: (if clinical policy or appropriate) Manuel Gordillo, MD, chairman 5/18/12 Fred Jung, executive director, Quality 5/8/12 Jan Mauck, CNO 6/26/12 R. Stephen Taylor, MD 6/26/12 Medical Executive Committee: (if clinical and review requested by CMO and COS) John J. Collins, MD 6/25/12 Chief Executive Officer: Gwen MacKenzie, CEO 7/2/12

12 OF 12 Appendix A Administration Set Changes (INS 2011 Guidelines pg. 84- CDC 2011 Guidelines pg. 19). Administration Set Device Infusion Status Frequency of Administration Set & Needleless Connector Change Every time an access site is initially inserted, changed or moved and PRN diminished flow rates due to drug or blood precipitates, damage, and actual or suspected contamination Primary & Secondary Sets Continuous& Intermittent Every 96 hours Add on devices including Diala-flow, filters and all other add on devices Continuous or Intermittent With each device change or administration set change Type of Infusate Administration Set Frequency of Administration Set & Needleless Connector Change Blood & Blood Components Intermittent At the end of 4 hours (unless indicated otherwise) Parenteral Nutrition with or Continuous or Intermittent Every 24 hours without Intravenous Fat Emulsion Propofol Continuous Every 12 hours Vasoactive drugs Continuous Every 96 hours Ativan Continuous Every 96 hours