SH CP 138 Central Venous Access Devices (CVAD) Procedures (e.g. Peripherally Inserted Central Catheter ( PICC lines) and Skin Tunnelled Central lines) Version:2 Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: Registered Nurses Doctors Next Review Date: July 2020 Trust procedures for a Central Venous Access Device (CVAD) (e.g. skin tunnelled central venous catheter and Peripherally Inserted Central Catheter (PICC). Includes: Routine on going care: including observations, flush to maintain patency of Central Venous Access Device and dressing change. Taking of a blood sample for analysis from a Central Venous Access Device Administration of Intravenous Medicines via a Central Venous Access Device Intravenous therapy, IV, IV therapy devices, PICC, skin tunnelled, implanted port, cannulation, peripheral cannula, midline, insertion, maintenance, removal, flush, diluent, reconstitution, infiltration, extravasation, VIP score, vesicant, phlebitis, thrombosis, thrombophlebitis infusion, CVAD. Approved & Ratified by: Medicines Management Committee Date of meeting: 19/07/17 Date issued: Author: Sponsor: Sharon Guy, Clinical Educator & Mandy Lyons, Clinical Educator Julie Dawes, Director of Nursing & AHP. 1
Version Control Change Record Date Author Version Page Reason for Change August 2014 April 2017 Jane Byrnell 1 All Replace ANTT terminology with Aseptic Technique 2 All Title change SH CP 138: Administration of IV Medication (Including Flush) of a Central Venous Access Device (CVAD) Procedure & SH CP 143: Withdrawal of Blood from Central Venous Access Device for Blood Sampling Procedure have been combined in to one document for CVAD procedures. Reviewed in response to updated Royal College of Nursing Standards for Infusion Therapy and a Safeguard alert regarding NICE guidance on chlorhexidine allergy. Reviewers/contributors Name Position Version Reviewed & Date Theresa Lewis Head of Infection Prevention and Control 1 2 ( May 2017) David Jones Chief Pharmacist 1 Steve Menear Senior Clinical Pharmacist 1 Zoe Denyer Inwood Day unit Sister 1 Steve Coopey Practice Development Specialist Nurse 1 Claire Hollywell Clinical educator 2 2
Contents Section Title Page 1. Introduction 4 2. Routine ongoing care: including observations and flush to maintain patency of a central venous access device and dressing change. 3. Taking of a blood sample for analysis from a central venous access device 4. Administration of Intravenous Medicines via a Central Venous Access Device 5 7 10 3
1. Introduction Central Venous Access Device (CVAD) Procedures (e.g.: Peripherally Inserted Central Catheter (PICC Line) and Skin tunnelled central catheter eg: Hickman line) 1.1 These procedures should be read in conjunction with the following Southern Health policies for further information: SH CP 137: Intravenous Therapy and Peripheral cannulation SH CP 13: Aseptic Technique and Clean Technique procedure SH CP 1: Medicines Control, Administration and Prescribing Policy (MCAPP) 1.2 All Peripheral Cannulation and Intravenous (IV) Therapy administration via a Peripheral Intravenous Device, including flush, requires the use of an aseptic technique, observation of standard precautions and product sterility 1.3 Aseptic technique (AT) requires individual risk assessment to determine the use of sterile or non-sterile gloves. Sterile gloves are not always required for AT. If there is a likelihood of the Registered Nurse/ Clinician touching the key parts of the system then sterile gloves must be worn. If you can carry out the procedure without touching the key parts with your hands, in theory, clean non-sterile gloves may be worn. However, sterile gloves are recommended for accessing a Central Venous Access Device, and if any procedure is complex or the patient is immuno-compromised, sterile gloves must be worn. Well-fitting gloves should be worn to protect hands from contamination from blood, body fluids, secretions and excretions, and to reduce the risk of cross-contamination to both patient and staff (RCN Standards for Infusion Therapy, 2016.) 1.4 Aprons: Single-use disposable plastic aprons should be worn whilst carrying out ALL infusion procedures due to the risk of contact with blood/ bodily fluids or contamination of uniform/clothing (RCN Standards for Infusion Therapy 2016) 1.5 Checking for blood return to confirm patency of CVAD: The health care professional should aspirate central venous access devices to check blood return to confirm patency, assess catheter function and prevent complications prior to administration of medications and/or solutions ( RCN Standards for Infusion Therapy, 2016) 10 mls of blood must also be withdrawn and discarded if a blood sample is being taken for analysis. In the absence of blood return for CVAD s see Algorithm for persistent withdrawal occlusion (SH CP 137: Intravenous Therapy and Peripheral Cannulation Policy) 1.6 Thorough individual patient assessment should be carried out each time before administration of any IV medication and/or infusion, including routine flush This assessment should include: asking the patient if they have any pain, discomfort, swelling in the area of the CVAD or if they are experiencing any new/different symptoms asking the patient if they have pulled or caught the catheter measuring the length of the external portion of the catheter at each visit to ensure it remains the same, and documenting the length checking the exit site and surrounding area to ensure there is no visible swelling 4
taking regular physiological observations to observe for deterioration 1.7 Removal: Central Venous Catheters can only be removed by trained and competent staff in an appropriate setting. 2. Routine on going care: including observations, flush to maintain patency of Central Venous Access Device and dressing change. Dressing change is recommended weekly after performing the routine flush to maintain device patency, or as required if the dressing is soiled or damaged. Action Identify patient by surname, first name and date of birth using open questions checking against NHS/ hospital number. Explain the procedure to the patient; discuss the need for the intervention, obtaining informed consent for procedure, establishing whether patient has any known allergies. Refer to the Mental Capacity Act 2005 when appropriate and consider if intervention is in the patients best interests. Check whether the patient has experienced any new symptoms of pain, discomfort or swelling; whether the catheter has been pulled or caught since previous therapy; whether the exterior length of the line remains constant. Routine physiological observations should be documented on the Adult physiological observations chart. Decontaminate hands as per Hand Hygiene Procedure & put on disposable plastic apron & gloves Identify a working area (eg: clean, plastic, re-usable wipe-clean tray/ trolley) and clean with a Clinell Universal sanitising wipe, and ensure all equipment gathered before commencing procedure Open sterile pack allowing inner pack to fall onto cleaned working area. Open out sterile pack to create an aseptic field. Open remaining equipment onto aseptic field, ensuring no contamination occurs; include correct number of device and skin cleansing wipes single use 2% chlorhexidine gluconate in 70% Isopropyl alcohol e.g. Clinell Single Use device wipes( small green) and skin wipes ( Blue) or suitable alternative ( povidone iodine in alcohol if patient sensitive to chlorhexidine) Equipment for flush: 10 ml Luer lock syringe, 5 micron filter (safety) needle for drawing up & flush solution or pre- Rationale To ensure correct identification of the patient. To ensure patient is informed of procedure prior to giving consent. To ensure consent is obtained. To assess whether the catheter may be malpositioned or displaced. In these circumstances X-ray is required to confirm position of catheter tip. To observe for individual patient patterns and recognise potential early signs of any change or deterioration To prevent infection To reduce the risk of infection. To use for cleansing hub/port and vials 5
filled syringe if prescribed.) sterile 0.9% sodium chloride for injection is the recommended solution to flush and lock CVAD s that are accessed frequently) clean sterile dressing clean bung Connect needle to the syringe and draw up flush as prescribed. Dispose of the needle directly into sharps container as per Sharps Safety and Management Policy. Place the filled syringe on the aseptic field, cover and protect with sterile gauze swab. NB: There are pre-prepared 10mL syringes containing 0.9%sodium chloride for injection available (e.g. BD Posiflush) which remove the need to use needles to draw up the solution from an ampoule. Remove dirty dressing from CVAD site, remove gloves and dispose of correctly following Handling & Disposal of Healthcare Waste Policy. Inspect the catheter exit site for signs of skin discolouration or signs of infection using a Visual Infusions Phlebitis Score (VIPS) Measure length of external line Decontaminate and dry hands and put on clean sterile gloves Using recommended 2% chlorhexidine gluconate in 70% Isopropyl alcohol cleansing wipe ( or povidone in alcohol if patient sensitive to chlorhexidine)and aseptic technique thoroughly clean hub of CVAD, line and clamp for minimum 30 seconds to 1 minute, and place onto sterile paper towel to dry for 30 seconds. Check catheter position by withdrawing and discarding blood; if unable to withdraw ask patient to cough/raise arm/lean forward /turn head; if still unable to withdraw blood flush with 2mLs 0.9% sodium chloride (do not use force) then repeat attempt to aspirate from the catheter. If you are unable to withdraw blood or you have any cause for concern arising from the individual assessment, the patient will need further assessment/ investigation. Contact your local Hospital Specialist Nurse for advice or refer to the GP/Medical Clinician or Consultant s Team if shared care. To administer flush attach syringe with 0.9% sodium chloride for injection (or compatible alternative) to the hub/port of the Central venous Catheter, and flush with 10mls by intermittent push pause To prevent aspiration of particulates from glass ampoules. To prevent excessive pressure and promote safe connection to device. To prevent needle stick injury and reduce risk of cross infection. To prevent infection To assess for risk of infection being present. To check catheter position To prevent cross infection. To encourage movement of central venous catheter away from vein wall as this may be causing occlusion. To seek advice and plan intervention if unsure of correct placement. To create turbulent flow that will remove debris from the sides of the lumen and to create positive pressure. 6
technique, clamping whilst the last ml of solution is instilled into a non valved Central Venous Catheter. For a valved Central Venous Catheter, use an intermittent push pause flush technique, disconnecting by a twist action as the last ml of solution is instilled. Never force the solution into the catheter. Remove the syringe and discard into sharps container as per Sharps Safety and Management Procedure. Secure the central line in position by applying a fixation device eg: Statlock and apply new sterile, vapour permeable, transparent IV film dressing. Replace the bung (also known as hub/ access port) every 7 days, or if visibly contaminated. Ensure the patient is comfortable and the line secure. Remove dressing towel and discard. Remove gloves & apron & dispose of all waste correctly following Handling & Disposal of Healthcare Waste Policy. Decontaminate hands. Document all details of procedure, including observations, details of flush administered & any problems encountered and action taken in patient records. To create turbulent flow that will remove debris from the sides of the lumen and to create positive pressure. To prevent damage to the catheter. To reduce risk of infection and promote patency of the Central venous Catheter lumen. To improve patient experience and reduce risk of accidental misplacement To comply with Record Keeping Policy, promote continuity of care and patient safety. 3. Taking of a blood sample for analysis from a Central Venous Access Device Action Identify clinical need for intervention, and check all details on blood test request form Identify patient by surname, first name and date of birth using open questions checking against NHS number/ Hospital number. Explain the procedure to the patient; discuss the need for the intervention, obtaining informed consent for procedure, establishing whether patient has any known allergies. Refer to the Mental Capacity Act 2005 when appropriate and consider if intervention is in the patients best interests. Inspect the catheter exit site for signs of skin discolouration or signs of infection using a Visual Infusions Phlebitis Score (VIPS) and document accordingly. Ascertain whether the patient has experienced any new symptoms of pain, discomfort or swelling; whether the catheter has been pulled or caught since Rationale To prevent inappropriate intervention and exposure to associated risks. To ensure correct identification of the patient. To ensure patient is informed of procedure and the risk of allergic reaction is eradicated. To ensure consent for insertion is obtained, and that the insertion of the device is appropriate for the patient. To assess for risk of infection being present. To assess whether the catheter may be malpositioned or displaced. In these circumstances X-ray is required to confirm position of catheter tip. 7
previous therapy; whether the exterior length of the line remains constant. Identify a working area (eg: clean, plastic, re-usable wipe-clean tray) and clean with a Clinell Universal sanitising wipe. Ensure all equipment is gathered before commencing the procedure; this should include: Blood sample bottles Blood transfer device 10 ml luer lock syringes 2% chlorhexidine gluconate in 70% Isopropyl alcohol e.g. Clinell Single Use device wipes or suitable alternative ( povidone in alcohol if patient sensitive to chlorhexidine) Equipment to flush CVAD Decontaminate hands as per Southern Health Hand Hygiene Procedure. Open sterile pack allowing inner pack to fall onto cleaned working area. Open out sterile pack to create an aseptic field. Open remaining equipment, including the required number of 10ml Luer lock syringes onto aseptic field, ensuring no contamination occurs. Open onto aseptic field the correct number of device cleansing wipes -2% chlorhexidine gluconate in 70% Isopropyl alcohol e.g. Clinell Single Use Device wipes or suitable alternative ( povidone in alcohol if patient sensitive to chlorhexidine). Decontaminate and dry hands and put on gloves Using aforementioned cleansing agent/wipe, clean all blood bottles and ampoules as required using aseptic technique for 30 seconds to 1 minute, open and place on edge of aseptic field and allow to air dry. Using aforementioned cleansing agent/wipe, thoroughly clean hub of CVAD line and place onto sterile paper towel to dry. Remove gloves, decontaminate hands and put on sterile gloves. Draw up flush solution(s) as prescribed. Connect 5 micron safety filter needle Use 10mL Luer lock syringe or refer to Manufacturer recommendations. Dispose of the needle directly into sharps container as per Sharps Safety and Management Policy. Place the filled syringe on the edge of aseptic field and cover with sterile gauze. Labelling of syringes is recommended. Attach empty 10ml Luer Lock syringe into To reduce the risk of infection. To reduce the risk of infection. To use for cleansing hub/port and vials. To render aseptic. To prevent cross infection. Evidence has shown that hands can be contaminated on removal of gloves. To prevent aspiration of particulates from glass ampoules to the syringe(s). To prevent excessive pressure and promote safe connection to device. To prevent cross infection. To prevent error in administration. To prevent contamination from solutions 8
hub and aspirate 10mL of blood from the CVAD to discard. NB: If taking blood for an INR sample, at least 10-20mls of blood should be taken and syringe discarded into sharps container before taking the sample. If unable to withdraw blood, ask patient to cough/raise arm/lean forward /turn head; if necessary flush with 2mLs 0.9% sodium chloride for injection, (do not use force) then repeat attempt to aspirate from the catheter. If you are unable to withdraw blood, or you have any cause for concern arising from the individual assessment, the patient will need further assessment. Contact your local Hospital Specialist Nurse for advice or refer to the GP/Medical Clinician or Consultant s Team if shared care. Discard blood aspirated as per Handling and Disposal of Waste Policy into a sharps container. Using Aseptic Technique, attach an empty 10mL Luer Lock syringe to hub of the CVAD and gently aspirate volume of blood required for blood collection. Connect the syringe(s) holding the blood sample to a sterile Blood Transfer Device and attach to this device the blood collection bottles as required in the correct order. The blood will automatically be transferred from syringe to collection tubes.) Discard blood transfer device and connected syringe into sharps box as one unit. Needles must not be used to transfer blood from syringe to blood bottle Once procedure is complete ensure the patient is comfortable. Remove dressing towel and discard. Remove gloves & apron. Dispose of all waste correctly following Handling and Disposal of Healthcare Waste Policy. Decontaminate hands. Ensure immediate correct labelling of blood bottles at the patient s bedside/ next to patient, checking any spelling and ensuring this includes date, time and signature Document in patient s records samples taken, flush administered, any problems encountered and action taken. situated within the lumen. To move distal tip of implanted port away from the side of the vein as this may be occluding lumen. To ascertain whether a fibrin sheath is acting as a one way valve. To seek advice and plan intervention if unsure of correct placement. To prevent cross infection. To promote safety. To prevent cross infection To promote safety. To prevent needlestick injury To improve patient experience To prevent cross infection. To ensure blood samples are not mixed up with others. To ensure patient safety, continuity of care and adhere to Record keeping Standards. 9
4. Administration of Intravenous Medicines via a Central Venous Access Device (CVAD) Key Principles: The principles of administration of medication via a Central Venous Access Device are the same as that for Peripheral devices. However, the position of the tip of the CVAD must be checked prior to administration of medication, by aspiration and disposal of blood & if necessary an X-ray may be required to confirm placement. Procedure for administration of Intravenous Medicines via a CVAD Action Decontaminate hands as per Hands Hygiene Procedure and apply sterile gloves. Identify a working area (eg: clean, plastic, re-usable wipe-clean tray) and clean with a Clinell Universal sanitising wipe. Place the prepared syringe or infusion and the empty ampoule(s) /vials(s) in to the clean plastic tray with the prescription for taking to the patient for administration. Assemble everything you need including any flushing solution(s) and 10 ml Luer lock syringes for aspiration of blood prior to administration of medication. Identify patient by surname, first name and date of birth using open questions checking against NHS/ Hospital number. Explain the procedure to the patient obtaining informed consent for procedure, establishing whether patient has any known allergies. Refer to the Mental Capacity Act 2005 when appropriate and consider if intervention is in the patients best interests. Inspect the central catheter insertion site for signs of skin discolouration or infection using a Visual Infusions Phlebitis Score (VIPS) and document accordingly. Ascertain whether the patient has experienced any new symptoms of pain, discomfort or swelling; whether the catheter has been pulled or caught since previous therapy, whether the exterior length of the CVAD remains constant. Consider whether the prescribed medication to be administered is cytotoxic/ vesicant or hyperosmolar. If yes, catheter tip position MUST be confirmed by aspiration of blood from the catheter. Having checked that the CVAD is in position it is necessary to flush it immediately BEFORE and AFTER administration of a medicine, and Rationale To reduce the risk of infection. To ensure correct identification of the patient. To ensure patient is informed of procedure and the risk of allergic reaction/ anaphylaxis is reduced. To ensure consent for insertion is obtained, and that the insertion of the device is appropriate for the patient. To assess for risk of infection being present. To assess whether the central catheter may be malpositioned or displaced These types of medicine should not be administered without first checking that the catheter is correctly placed to reduce risk of extravasation. To reduce risk of adverse reaction and maintain patency of device 10
BETWEEN DOSES of different medicines administered consecutively, according to local policy ( see above for procedure for flushing) After administration advise the patient to report promptly any soreness at the catheter insertion site or discomfort of any sort. Re-check the administration site for signs of leakage, infection or inflammation and continue to monitor the patient. Discard the empty ampoules/vials from which the injection was prepared and any unused medicine. Ampoules or vials should never be used to prepare more than one injection unless specifically labelled by the manufacturer for multidose use. Make a detailed record of administration in the patient records. All documents and record keeping to be maintained as per Record Keeping Policies, Standards and Standard Operating Procedures. Report any adverse reactions to Prescriber, Medicine Management and Medicines and Medicine Health care Regulatory Agency MHRA via a Safeguard Incident Form. 11