Andrew Kingsley, Clinical Manager Infection Control & Tissue Liability

Report to Trust Board Date 22nd July 2008 Agenda Item Title Sponsor Prepared by Presented by P2 Intravascular Device Policy Carolyn Mills, Director of Nursing Andrew Kingsley, Clinical Manager Infection Control & Tissue Liability Andrew Kingsley, Clinical Manager Infection Control & Tissue Liability 1 Purpose and Key Issues To present latest update to the Intravascular Device Policy. Implementation of the policy will ensure that: The Trust is compliant with the saving Lives national guideline Staff are given clear statements about the infection control elements of intravascular device insertion and management to enable them to achieve competency. 2 Equality and Diversity Implications The changes made to the document will continue to support the organisation s delivery of the equality and diversity agenda. There are no adverse or positive impacts. 3 Legal Implications The legal implications have been considered and none have been identified. 4 Patient, Public and Staff Involvement This is a policy update which has been undertaken by the authors A. Kingsley and K. Wedgeworth taking into account latest guidance. As it is an update rather than a new policy and changes have been minor further involvement by other groups was not considered necessary. 5 Controls and Assurances Policy audit will be undertaken by Infection Control on an annual basis. Aspects of this policy relating to best clinical practice are audited on a monthly basis by Infection Control Link practitioners as part of the High Impact Intervention audits of the Saving Lives initiative. The policy was given initial approval at the May 2008 Infection Prevention and Control Committee. The policy was given final approval at the June 2008 Clinical Services Executive Committee. Best Care, Highest Standards, Right Place

6 Cost Implications Institution of new antiseptic skin cleaning agents to match best practice guidance have already been agreed and implemented so there are no additional cost implications expected. 7 Potential risk to the organisation Clinical practice that follows this policy will reduce risk of healthcare acquired infection and contribute to lowering the MRSA bacteraemia rate 8 Recommendations The Trust Board is asked to RATIFY the Intravascular Device Policy. Infection Control Page 2 of 25

Strategic Objectives Ten strategic objectives were agreed by the Trust Board in May 2007 to support the Trust s mission statement Best Care, Highest Standards, Right Place. The strategic objectives have been developed to ensure there is a shared understanding and common purpose throughout the organisation about the Trust s strategic direction and what needs to be delivered. x Patient Safety High Quality Services Efficient & Effective Listening and responding to the needs of patients Deliver Care in the most appropriate setting Integrate Health and Social Care Strategic Partnerships Modern and Effective Infrastructure Public Health Robust and Sustainable Standards for Better Health The Core and Developmental Standards for Better Health have been developed by the Healthcare Commission. Compliance with the Standards throughout the year form a part of the Trust s Annual Health Check. C1a Incident Reporting C7e Equality & Diversity C16 Patient Information C1b Safety Alerts C8a Whistle blowing C17 Patient & Public Involvement C2 Child Protection C8b Personal Development Access to Services C18 Programmes Equality & Choice C3 NICE Interventional Access to Services C9 Records Management C19 procedures Emergency care x C4a Infection Control C10a Employment Checks C20a Security and Health & Safety C4b Medical Devices C10b Professional Codes of Patient Privacy & C20b Conduct Confidentiality C4c Decontamination C11a Recruitment C21 Hospital Cleanliness C4d Medicine Management C11b Mandatory Training C22a C4e Waste Management C11c C5a C5b C5c NICE Technology appraisals Clinical Supervision & Leadership Clinical Professional Development C5d Clinical Audit C13c C6 Healthcare bodies cooperating together Professional Development C22b C12 Research & Development C22c C13a Dignity & Respect C23 C13b Consent to treatment C24 Use of Confidential Information D1 C14a Complaints - Information D2a C7a Corporate Governance C14b Complaints Nondiscrimination C7b Finance & Probity C14c Complaints Service improvements C7c Clinical Governance C15a Patient Food Standards C7d Performance C15b Patient dietary requirements D13a D13b Public Health Health inequalities Public Health D of PH report Public Health - Working with partners Public Health Health promotion Major Incident Planning Patient Safety Risk reduction Clinical Effectiveness Best practice Public Health Health inequalities Public Health National guidance Infection Control Page 3 of 25

Document Control Report Title Intravascular Device Policy Author Infection Control Team and CNS Intravascular Fluid Management Version Date Status Comment Issued March 2007 1.0 May 2008 Revision Approved at IP&CC. Revised into new format 1.0 June 2008 Final Review Approved at Clinical Services Executive Committee 1.1 June Revision Amends for corporate identity requirements 2008 Main Contacts Kathleen Wedgeworth CNS Intravascular Fluid Management Andrew Kingsley Clinical Manager Infection Control and Tissue Viability Lead Director Director of Nursing Document Class Policy Distribution List Senior Management Superseded Documents Intravascular Device Policy March 2007 Issue Date June 2008 Tel: Direct Dial 01271 322440 (KW) 01271 311601 (AK) Tel: Internal 2440 (KW) 3601 (AK) Fax: 01271 311756 (AK) Email: kathleen.wedgeworth@ndevon.swest.nhs.uk andrew.kingsley@ndevon.swest.nhs.uk Target Audience All clinical staff Non-executives Distribution Method TarkaNet Review Date June 2009 Archive Reference Infection Control Path Infection Control/IC Manual - Policies/Intravascular Device Filename Intravascular Device Policy Jun 08 v1.1 Infection Control Page 4 of 25

Section Contents 1 Introduction 5 2 Purpose 5 3 Definitions 5 3.1 Intravascular devices 5 3.2 Central venous catheters 5 3.3 Epidural catheters 5 3.4 Midline PIC 5 3.5 Peripheral arterial devices 5 3.6 Peripheral intravenous devices 5 3.7 PICC 5 3.8 Subcutaneous cannula 6 3.9 TIC 6 3.10 Tunnelled central venous catheters 5 3.11 Infection 5 3.12 Phlebitis 5 3.13 Erythema 5 3.14 TPN 6 3.15 VIP score 6 4 Responsibilities 6 4.1 Role of the Infection Control Team and CNS Intravascular Fluid Management 4.2 Ward/ Dept Manager 6 4.3 Clinical Staff 7 5 Infection Control Team 7 6 Intravascular Device Policy 7 6.1 General principles 7 6.2 Insertion 7 6.3 Device selection 8 6.4 Central line replacement 8 6.5 Ongoing care of lines 8 6.6 Documentation 9 Page 6 Infection Control Page 5 of 25

Section Page 6.7 Education and training 10 6.8 Policy monitoring 10 6.9 Audit 11 7 Development of the Policy 11 7.1 Prioritisation of work 11 7.2 Document development process 11 7.3 Equality impact assessment 11 8 Consultation, Approval and Ratification Process 11 8.1 Consultation process 11 8.2 Policy approval process 11 8.3 Ratification process 12 9 Review and Revision Arrangements including Document Control 12 9.1 Process for reviewing the policy 12 9.2 Process for revising the policy 12 9.3 Document control 12 10 Dissemination and Implementation 12 10.1 Dissemination of the policy 12 10.2 Implementation of the policy 12 11 Document Control including Archiving Arrangements 13 12 11.1 Library of procedural documents 13 11.2 Archiving arrangements 13 11.3 Process for retrieving archived policy 13 Monitoring Compliance With and the Effectiveness of Procedural Documents 12.1 Process for monitoring compliance and effectiveness 13 12.2 Standards/ Key Performance Indicators 13 13 References 13 14 Associated Documentation 14 Appendices A Quick Reference Guide 15 13 B Checklist for the Review and Approval of Procedural Document (if required) 16 Infection Control Page 6 of 25

Section Page C Plan for Dissemination and Implementation of Procedural 18 D Algorithm for Venous Access Device Selection 20 E Equality Impact Assessment Screening Form 21 Infection Control Page 7 of 25

1 Introduction This document sets out s system for good practice by health care workers involved in the insertion, management and removal of intravascular devices. 2 Purpose The purpose of this document is to lessen the likelihood of a patient acquiring a health care associated infection from an intravascular device and assist the delivery of safe patient care. This is part of the Trust's commitment to the Department of Health's "Saving Lives" programme for the reduction of health care associated infection. (Department of Health, 2007). This policy applies to all Trust clinical staff. Implementation of this policy will ensure that: 3 Definitions The Trust is compliant with the Saving Lives national guideline Staff are given clear statements about the infection control elements of intravascular device insertion and management to enable them to achieve competency 3.1 Intravascular devices A term used to encompass devices that provide access to veins and arteries. The policy also gives guidance on epidural and subcutaneous access devices. 3.2 Central venous catheters Catheters inserted into the jugular or subclavian veins. Includes parenteral feeding lines and central lines used for fluid replacement, monitoring and administration of drugs or blood products. 3.3 Epidural catheters Catheters inserted into the epidural space used for the administration of analgesia. 3.4 Midline PIC These are Peripherally Inserted Cannulae. 3.5 Peripheral arterial devices Arterial lines used for arterial access or monitoring. 3.6 Peripheral intravenous devices Cannulae inserted into peripheral veins for fluid replacement. Also used for the administration of drugs or blood products. 3.7 PICC Infection Control Page 8 of 25

Peripherally Inserted Central Venous Catheter used for fluid replacement, the administration of drugs or blood products. 3.8 Subcutaneous cannula A cannula inserted subcutaneously and used for the replacement of fluids or drugs. 3.9 TIC A totally implanted central venous catheter tunnelled beneath the skin with a subcutaneous port and accessed by a needle. 3.10 Tunnelled central venous catheters (including Hickman lines) These are inserted on occasions where the expected duration of a line is expected to exceed 30 days. 3.11 Infection Heat, inflammation, pain, cellulitis at site, pyrexia, presence of pus at site. 3.12 Phlebitis Warmth, tenderness, erythema, swelling, induration (hard swelling at insertion site), palpable venous cord. 3.13 Erythema Inflammation showing as redness on the skin suggestive of infection at insertion. 3.14 TPN Total parenteral nutrition which is usually given via dedicated central venous lines. 3.15 VIP Score Visual Infusion Phlebitis Score - a scoring system for assessing the severity of phlebitis. 4 Responsibilities 4.1 Infection Control Team & CNS Intravascular Fluid Management The Infection Control Team and Clinical Nurse Specialist in Intravascular Fluid Management undertake to provide education and clarification to support the utilisation of this policy when requested to do so by the Senior Nurse (usually Ward Sister or Departmental Manager in Charge of the areas to which these statements apply). 4.2 Ward/ Dept Manager The Ward/ Department manager is responsible for ensuring that their staff are trained and competent in the safe insertion and care of intravascular lines as required for the Infection Control Page 9 of 25

functioning of the ward/ department. He/ she is also responsible for ensuring that this policy is adhered to. 4.3 Clinical Staff Clinical staff who insert or manipulate intravascular lines are accountable for ensuring they are adequately trained and competent in carrying out these procedures. They are also responsible for adhering to this policy. 5 Infection Control Team and CNS Intravascular Fluid Management The Infection Control Team can be contacted in working hours on 01271 322680 (North Devon District Hospital internal extension 2680), via bleep 011 or out of hours by contacting the on-call Medical Microbiologist via the NDDH switchboard. The CNS Intravascular Fluid Management can be contacted on 01271 322440 (internal extension 2440) or bleep 280. 6 Intravascular Device Policy 6.1 General Principles The policy statements and guidelines must be followed unless a valid clinical reason for an individual case overrides them. Reasons for providing care different to that specified in this policy must be clearly documented in the patient's notes. 6.2 Insertion Insertion of central venous catheters should take place in a specialist area that can provide relevant expertise and safe conditions for patients. (See Appendix A Quick Reference Guidelines). If the patient can not be moved to the preferred location, the maximum aseptic technique possible needs to be observed in the general ward area. Staff hands must be decontaminated prior to insertion of any intravascular device (see Standard Precautions Policy - Hand Hygiene section in the Infection Control Manual). The intended insertion site should be clear of clothing and/ or miscellaneous items. Appropriate personal protective equipment (gloves minimum) must be worn during the procedure to protect against the risk of splashes of blood. See Gloves Policy and Prevention of Inoculation Injury Policy, both in the Infection Control Manual, and the Quick Reference Guide (Appendix A). An aseptic non-touch technique using clean, non-sterile gloves must be maintained during insertion of peripheral intravascular devices (see Aseptic and Clean Technique Policy 2008). The insertion of epidurals and central venous catheters (including all tunnelled devices, TPN lines, PICC, TIC) must take place under aseptic technique (see Aseptic and Clean Technique Policy 2008) including the use of a sterile gown, sterile gloves and sterile drapes (Department of Health 2001). Infection Control Page 10 of 25

All intravascular devices must be checked for sterility, intact packaging and that they are within their 'use by' date prior to commencement of the procedure. The intended insertion site must be decontaminated according to the device being inserted (see Quick Reference Guide in Appendix A) by wiping the intended site for a minimum of 5 seconds, normally with 2% chlorhexidine gluconate in 70%, and allowing the skin to dry completely (20-30 seconds) before inserting the device. Palpation of the site following skin preparation must be avoided unless done so with a sterile gloved hand. Dressings used to secure intravascular devices must be a sterile transparent film and render the device secure. In addition, dressings used for central venous catheters, tunnelled and arterial devices must also have a high moisture/ vapour transmission rate. An aseptic non-touch technique using non-sterile gloves must be maintained during connection of intravenous administration sets, connectors and caps to catheter ports. Single-lumen central venous catheters must be used unless multiple ports are essential for the management of the patient. 6.3 Device selection For device selection, please refer to Appendix E - Algorithm for Venous Access Device Selection. 6.4 Central line replacement Replacement of central intravascular devices due to infection must not take place using a guide wire. A different insertion site must be used. 6.5 Ongoing care of lines Thorough hand decontamination must occur before manipulation of intravascular devices or lines. Non-sterile latex gloves must be worn during use or care of the device/ line, unless a staff or patient allergy is identified, in which case a suitable alternative should be available for use. A clean technique using non-sterile gloves must be maintained when interrupting the integrity of the line or dressing for any reason (e.g. during dressing/ line change, during administration of drugs via the device). Intravenous device insertion sites must be observed each time the device is accessed (e.g. when changing intravenous fluids or giving intravenous medication) for signs of infection/ phlebitis, leakage, bleeding or damage to dressing, during the inpatient period. Documentation of the above observations must be made, noting any of the above, and action taken if required. All intravascular devices should be removed if not required. Infection Control Page 11 of 25

Subcutaneous devices must be removed if not infusing fluids and be changed at least every 24 hours. Peripheral intravenous devices inserted in an emergency setting must be replaced as soon as it is safe to do so or within 48 hours, whichever is sooner. Peripheral intravenous devices inserted must be replaced on first signs of infection/ phlebitis or once 72 hours has elapsed, whichever is sooner. Devices that are clinically required to be left in situ but that are not in constant use must be flushed regularly. See Appendix A for minimum guidelines. All intravenous fluids and blood products must be checked for sterility, the absence of foreign bodies and that they are within their 'use by' date prior to infusion. Intravenous administration giving sets used for the infusion of clear fluids via central or peripheral lines need not be replaced more frequently than at 72 hour intervals unless they become disconnected or the device is changed. Intravenous administration sets used for the infusion of blood and blood products must be changed after 2 units have been infused, and on completion of the infusion. Individual bags of clear intravenous fluids, TPN or lipid solutions must not be allowed to hang for longer than 24 hours. Individual bags of red blood cells must be transfused within 4 hours of removal from storage, platelets within 30 minutes, fresh frozen plasma and cryoprecipitate within 1 hour. Needle-less intravascular or safer needle devices must be used for the administration of additional solutions, drugs or flushes where they are available. All ports and access points in intravascular lines prior to access must be wiped with a 2% chlorhexidine gluconate in 70% isopropyl swab and allowed to dry prior to use. Caps or bungs removed must be discarded and replaced with sterile ones. Additional connections and lines (e.g. 3-way taps, supplementary lines) must only be used when necessary and not routinely. They must be removed when no longer in use. Unnecessary breaks in the intravascular system must be avoided. The dressing securing the device must be changed if it becomes damp, loosened, soiled, or has remained in place for the period mandated in the Quick Reference Guidelines (Appendix A). Skin cleansing at dressing change for all intravascular catheters will follow the guidance in the Quick Reference Guide at Appendix A which is normally 2% chlorhexidine gluconate in 70%, unless contraindicated by the manufacturer s instructions Infection Control Page 12 of 25

6.6 Documentation Documentation relating to intravascular device insertion and care must be made in line with the Trust's and professional bodies' standards for documentation. The following details must be documented in the patient's case notes on insertion of the device: Type and gauge of device Date and time of device insertion Site of insertion Name of person inserting the device The following must be observed each time the device is accessed as part of its routine inspection. Any problems identified from the following must be documented. Patency Leakage Bleeding Signs of infection Damage to dressing Assessment of need for the device to remain in situ The VIP score for each device must be documented at access and at least twice daily for intravascular devices on the drug chart. A saline flush label should be inserted into the patient s drug chart for intravenous devices (available from Pharmacy) and flushes recorded. The following information must be documented in the patient's case notes on removal of the device either on the IV Cannula Insertion Record label or directly into the case notes. Date and time of removal Name of person removing the device Reason for removal (e.g. changed to oral therapy) VIP (phlebitis score) score at time of device removal 6.7 Education and training All healthcare workers providing care of intravascular devices must: Have received appropriate education and training and be able to perform to their identified competencies. Ensure their knowledge and skills are kept up to date by obtaining on-going education. Promote best practice at all times within the multi-disciplinary team. Convey concerns regarding their own or others' practice to a relevant authority (usually their line manager). Infection Control Page 13 of 25

Complete Trust Incident Forms for any adverse incidents and near misses relating the intravascular devices insertion and ongoing care. 6.8. Policy monitoring The Ward/ Departmental Manager is responsible for monitoring the implementation of these arrangements, supported by the Infection Control Team when required. 6.9 Audit The Infection Control Team will review this policy annually. If new guidance is received or circumstances change, this policy will be reviewed accordingly. 7 The Development of the Policy 7.1 Prioritisation of Work Following vertical integration of the community services from the North Devon Primary Care Trust with the acute services, a requirement was identified to harmonise the two organisations policies for consistency of advice, education and practice. 7.2 Document Development Process As the authors, the Infection Control Team and CNS Intravascular Fluid Management are responsible for developing the policy and for ensuring stakeholders were consulted with. Draft copies were circulated for comment before approval was sought from the relevant committees. 7.3 Equality Impact Assessment The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. An Equality Impact Assessment Screening has been undertaken and there are no adverse or positive impacts (Appendix D). 8 Consultation, Approval and Ratification Process a. Consultation Process The author consulted widely with stakeholders, including: CNS Intravascular Fluid Management Infection Prevention & Control Committee CNS Chemotherapy Consultation took the form of a request for comments and feedback via email. Hard copies were available on request. b. Policy Approval Process Infection Control Page 14 of 25

Initial approval of the policy was sought from the Infection Prevention & Control Committee on 30 May 2008. Final approval was sought from the Clinical Services Executive Committee in June 2008. c. Ratification Process The policy will be ratified by the Board July 2008. 9 Review and Revision Arrangements including Document Control 9.1 Process for Reviewing the Policy The policy will be reviewed annually. The author will be sent a reminder by the Tarkanet Support Officer four months before the due review date. The author will be responsible for ensuring the policy is reviewed in a timely manner and that the reviewed policy is initially approved by the Infection Prevention & Control Committee and then given final approval by the Clinical Services Executive Committee and ratified by the Trust Board. All reviews will be recorded by the author in the Document Control Report. 9.2 Process for Revising the Policy In order to ensure the policy is up-to-date, the author may be required to make a number of revisions, e.g. committee changes or amendments to individuals responsibilities. Where the revisions are minor and do not change the overall policy, the author will present the revised version to the Infection Prevention & Control Committee for approval. Significant revisions will require final approval by the Clinical Services Executive Committee and ratification by the Board. All revisions will be recorded by the author in the Document Control Report. 9.3 Document Control The author will comply with the Trust s agreed version control process, as described in the organisation-wide Guidance for Document Control. 10 Dissemination and Implementation 10.1 Dissemination of the Policy After ratification by the Trust Board, the author will provide a copy of the policy to the Tarkanet Support Officer to have it placed on the Trust s intranet. The policy will be referenced on the home page as a latest news release. Information will also be included in the weekly Chief Executive s Bulletin which is circulated electronically to all staff. An email will be sent to senior management to make them aware of the policy and they will be responsible for cascading the information to their staff. In addition, staff will be informed that this policy replaces any previous versions. Infection Control Page 15 of 25

10.2 Implementation of the Policy Line managers are responsible for ensuring this policy is implemented across their area of work. Support for the implementation of this policy will be provided by the Infection Control Team and the CNS Intravascular Fluid Management. 11 Document Control including Archiving Arrangements 11.1 Library of Procedural Documents The author is responsible for recording, storing and controlling this policy. Once the final version has been ratified, the author will provide a copy of the current policy to the Tarkanet Support Officer so that it can be placed on Tarkanet. Any future revised copies will be provided to ensure the most up-to-date version is available on Tarkanet. 11.2 Archiving Arrangements All versions of this policy will be archived in electronic format within the Infection Control Team policy archive. Archiving will take place by the Infection Control Team Administrator once the final version of the policy has been issued. Revisions to the final document will be recorded on the document control report. Revised versions will be added to the policy archive held by Infection Control Team. 11.3 Process for Retrieving Archived Policy To obtain a copy of the archived policy, contact should be made with the Infection Control Team. 12 Monitoring Compliance With and the Effectiveness of the Policy 12.1 Process for Monitoring Compliance and Effectiveness Monitoring compliance with this policy will be the responsibility of the Infection Control Team and CNS Intravascular Fluid Management. This will be undertaken by High Impact Intervention audits. Where non-compliance is identified, support and advice will be provided to improve practice. 12.2 Standards/ Key Performance Indicators Key performance indicators comprise: 100% compliance in all areas with High Impact Intervention audit results of peripheral and central intravenous cannulae MRSA bacteraemias at or below annually set target 13 References British Committee for Standards in Haematology (2006) Guidelines on the Insertion and Management of Central Venous Access Devices. Department of Health, Chief Executive Bulletin (2001) 49: 12th - 18th January, Infection Control Page 16 of 25

Department of Health. Department of Health (2001) Guidelines for Preventing Infection Associated with the Insertion and Maintenance of Central Venous Catheters. Journal of Hospital Infection, 47 (supplement 1) S47-67, http://www.doh.gov/hai Department of Health (2007) Saving Lives: a Delivery Programme to Reduce Healthcare Associated Infection including MRSA. Department of Health. London. Infection Control Nurses Association ICNA (2001) Guidelines for Preventing Intravascular Catheter-related Infection. ICNA/3M Healthcare, London. NICE (2003) Infection Control: Prevention of Healthcare Associated Infection in Primary and Community Care - Clinical Guideline 2. www.nice.org.uk O'Grady N, Alexander M, Healthcare Infection Control Practices Advisory Committee (HICPAC) et al (2001) Guidelines for the Prevention of Intravascular Catheterrelated Infections. American Journal of Infection Control volume 30: No 8: 476-489. Pratt R.J. et al (2006) National Evidence Based Guidelines for preventing Healthcare Associated Infections in NHS Hospitals in England (epic 2). Thames Valley University. South West PICC Initiative Document (1999) Supported by BD Medical Systems. 14 Associated Documentation Northern Devon Healthcare Trust (2007) Infection Control: Gloves Policy (available on Tarkanet). Northern Devon Healthcare Trust (2008) Infection Control: Prevention of Inoculation Injury Policy (available on Tarkanet). NDHT (2007) Medicines Policy (available on Tarkanet). NDHT (2008) Insertion of Peripheral Intravenous Cannula Policy. NDHT (2006) Assessment of Competency Intravenous cannulation. NDHT (2007) Assessment of Competency Management of patient controlled epidural analgesia. NDHT (2007) Assessment of Competency Management of intravenous patient controlled analgesia. NDHT (2006) Assessment of Competency Administration of blood products. NDHT (2006) Assessment of Competency Administers an infusion intravenously or subcutaneously. NDHT (2006) Assessment of Competency Administration of medications intravenously (Bolus). NDHT (2007) Assessment of Competency Deliver chemotherapy intravenously. NDHT (2004) Gloves Policy. NDHT (2003) Waste Policy. NDHT (2008) Aseptic and Clean Technique Policy. NDHT (2007) Blood Transfusion Protocol. Infection Control Page 17 of 25

Suitable for Appendix A INTRAVASCULAR POLICY QUICK REFERENCE GUIDELINES Peripheral IV Central IV Midline PIC TIC Epidurals Arterials Subcut PICC Dedicated TPN central line/lumen Tunnelled Hickman cuffed type Central IV Non cuffed type Clear fluids Blood Anaesthetics Antibiotics Drugs various TPN* Clear fluids Blood Chemo Drugs various TPN* TPN* Clear fluids Blood TPN Chemo Inotropes Drugs various Clear fluids Blood TPN Chemo Inotropes Drugs various As PICC Chemo Antibiotics Drugs various PCA Analgesia Blood pressure monitoring Blood gas sampling Clear fluids Analgesia Drugs various in palliative care Preferred insertion location Dressing Dressing frequency Observation frequency Skin cleaning pre insertion Skin cleaning at dressing change All clinical areas Sterile film (preferably high MVTR) Device life unless complications Record VIP score at access and at least twice daily 2% CHG in 70% 2% CHG in 70% Chemo unit Sterile film (high MVTR) As clinically indicated/7 days max Record VIP score at access and at least twice daily when at home at access and weekly 2% CHG in 70% 2%CHG in 70% Flush solution Normal saline Normal saline and heparinised saline Flush frequency Max. cannula dwell time Max duration giving set for clear fluids 12 hourly if no continuous infusion After access and weekly 72 hours Up to 52 weeks if no site infection/bsi/mech failure Theatre ICU Sterile film (high MVTR) As clinically indicated/7 days max Record VIP score at access and at least twice daily 2% CHG in 70% 2%CHG in 70% Normal saline and heparinised saline 12 hourly if no continuous infusion 7 days preferred unless tunnelled 72 hours 72 hours Every bag change (24 hours) Theatre Sterile film until healed (high MVTR) As clinically indicated/7 days max Record VIP score at access and at least twice daily when at home at access and weekly 2% CHG in 70% 2%CHG in 70% Normal saline and heparinised saline 12 hourly during inpatient stay then weekly No upper limit if no site infection/bsi/mech failure Theatre ICU/HDU CCU Sterile film (high MVTR) As clinically indicated/7 days max Record VIP score at access and at least twice daily 2% CHG in 70% 2%CHG in 70% All clinical areas Theatre Theatre ICU CDS Sterile film (preferably high MVTR) As clinically indicated/7 days max Record VIP score at access and at least twice daily 2% CHG in 70% 2%CHG in 70% Sterile film until healed (high MVTR when infusing) As clinically indicated/7 days max Record VIP score at access and at least twice daily when inpatient 2% CHG in 70% 2% CHG in 70% when dressing in place prior to healing of insertion wound Normal saline Normal saline Normal saline and heparinised saline 12 hourly if no continuous infusion No upper limit if no site infection/bsi/mech failure 12 hourly if no continuous infusion Up to 4 weeks if no site infection/bsi/mech failure At access and 4 weekly when not in use No upper limit if no site infection/bsi/mech failure 72 hours 72 hours 72 hours Duration of infusion (needle connector up to 2 weeks) Sterile film (preferably high MVTR) As clinically indicated/7 days max At least twice daily Preferably 2% CHG in 70% Preferably 2% CHG in 70% Theatre ICU/HDU CCU Sterile film (high MVTR) As clinically indicated/7 days max At least twice daily Preferably 2% CHG in 70% Preferably 2% CHG in 70% All clinical areas Sterile film (preferably high MVTR) Device life (i.e 24 hours) At least twice daily Preferably 2% CHG in 70% Not applicable because cannula removal at 24 hours max No routine flush Normal saline Not applicable No routine flush Continuous Not applicable 7 days No upper limit if no problems, 7 days preferred max Duration of infusion 24 hours 96 hours Duration of infusion only Gloves at Clean Sterile Sterile Sterile Sterile Sterile Sterile Sterile Sterile Clean insertion Gloves line care Clean Clean Clean Clean Clean Clean Clean Clean Clean Clean KEY: -drugs various = any drugs in compatible formulation for specific route of entry except inotropes, TPN, chemo. PCA = patient controlled analgesia PICC = peripherally inserted central catheter TIC totally implanted catheter e.g. Portacath High MVTR = High moisture vapour transpiration rate e.g. Opsite IV 3000 CHG = chlorhexidine gluconate bsi = blood stream infection mech failure = mechanical failure e.g. line blocking TPN*= different formulations for different lines Infection Control Page 18 of 25

Appendix B - Checklist for the Review and Approval of Procedural Document (if required) To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. /No/ Title of document being reviewed: Comments Unsure 1. Title Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or standard? 2. Rationale Are reasons for development of the document stated? 3. Development Process Is the method described in brief? It is an update of an existing policy Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 5. Evidence Base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are supporting documents referenced? 6. Approval Does the document identify which committee/group will approve it? If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? NA Infection Control Page 19 of 25

Title of document being reviewed: 7. Dissemination and Implementation Is there an outline/plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? 8. Document Control Does the document identify where it will be held? Have archiving arrangements for superseded documents been addressed? 9. Process to Monitor Compliance and Effectiveness Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance with the document? 10. Review Date Is the review date identified? Is the frequency of review identified? If so is it acceptable? 11. Overall Responsibility for the Document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the document? /No/ Unsure Comments HII audit schedule is monthly in 2008 Individual Approval If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval. Name Andrew Kingsley Date Designation Clinical manager Infection Control and Tissue Viability Committee Approval If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisation s database of approved documents. Name Date Designation Acknowledgement: Cambridgeshire and Peterborough Mental Health Partnership NHS Trust Infection Control Page 20 of 25

Appendix C - Plan for Dissemination and Implementation of Procedural Documents (if required) To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Acknowledgement: University Hospitals of Leicester NHS Trust. Title of document: Intravascular Devices Policy Date finalised: Previous document already being used? (Please delete as appropriate) Dissemination lead: Print name and contact details A. KINGSLEY ext 3159 If yes, in what format and where? Proposed action to retrieve out-of-date copies of the document: Electronic Tarkanet format preceding this format Remove and replace on Tarkanet To be disseminated to: How will it be disseminated, who will do it and when? Paper or Electronic Comments Dissemination Record - to be used once document is approved. Date put on register / library of procedural documents Date due to be reviewed Disseminated to: (either directly or via meetings, etc) Format (i.e. paper or electronic) Date Disseminated No. of Copies Sent Contact Details / Comments Infection Control Page 21 of 25

Implementation Plan Task Details Responsibility Implementation Training & Support Completed by: Name Designation Trust Date Infection Control Page 22 of 25

Appendix D - Vascular Access Device Selection Algorithm Osmolarity < 500 ph between 5-9 No Intimal Damage Peripheral Delivery Patient Requiring Intravenous Therapies Duration of therapy <3 days <4 weeks Cannula Midline Patient Assessment Therapy Related factors Cannula (Exchange every 48-72 hours) Midline >4 weeks Osmolarity >500 ph <5 or >9 Intimal Damage Central Delivery Duration of therapy <4 weeks PICC ACUTE CVC <4 weeks PICC Tunnelled CVC Implante d Port Patient Specific considerations A Midline or PICC may also be considered if any of the following are identified: History of difficult access Long term repeated treatments Administration of vesicants Needle phobia Presence of co-morbid factors i.e. Skin lesions, burns or infections close to site of device Previous surgery affecting lymph nodes or peripheral vascular system Thrombotic occlusions from previous devices Low platelets Clotting abnormalities Lymph oedema Contractures or weakness to a limb Radiotherapy Obesity Maintenance of veins is paramount Patients to receive intravenous therapies in a community setting Or where the healthcare professional deems it would be in the patients best interest References: RCN (2005) Standards for Infusion Therapy, London Bard (2007) Accessibility (www.accessabilitybybard.co.uk) Infection Control Page 23 of 25

Appendix E Equality Impact Assessment Screening Form Equality Impact Assessment Screening Form Title Author Directorate Team/ Dept. Intravascular Device Policy Infection Control Team and CNS Intravascular Fluid Management Nursing Infection Control and Tissue Liability Document Class Document Status Issue Date Review Date Policy Review May 2008 May 2009 1 What are the aims of the document? This document sets out s system for good practice by health care workers involved in the insertion, management and removal of intravascular devices. 2 What are the objectives of the document? The purpose of this document is to lessen the likelihood of a patient acquiring a health care associated infection from an intravascular device and assist the delivery of safe patient care. This is part of the Trust's commitment to the Department of Health's "Saving Lives" programme for the reduction of health care associated infection. (Department of Health, 2007). This policy applies to all Trust clinical staff. 3 How will the document be implemented? Release via Tarkanet, & inform staff via High Five Infection Control bulletin attached to Chief Executive bulletin. Inform Link practitioners via monthly meeting. Implementation of this policy will ensure that: The Trust is compliant with the Saving Lives national guideline Staff are given clear statements about the infection control elements of intravascular device insertion and management to enable them to achieve competency 4 How will the effectiveness of the document be monitored? Monitoring compliance with this policy will be the responsibility of the Infection Control Team and CNS Intravascular Fluid Management. This will be undertaken by High Impact Intervention audits. Where non-compliance is identified, support and advice will be provided to improve practice. 5 Who is the target audience of the document? All clinical staff and non executives 6 Is consultation required with stakeholders, e.g. Trust committees and equality groups? 7 Which stakeholders have been consulted with? CNS Intravascular Fluid Management Infection Prevention & Control Committee CNS Chemotherapy 8 Equality Impact Assessment Please complete the following table using a cross, i.e. X. Please refer to the document A Infection Control Page 24 of 25

Practical Guide to Equality Impact Assessment, Appendix 3, on Tarkanet for areas of possible impact. Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, cross the Positive impact box. Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, cross the Negative impact box. Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, cross the No impact box. Equality Group Positive Impact Negative Impact No Impact Comments Age Disability Gender Race / Ethnic Origins Religion or Belief Sexual Orientation X X X X X X If you have identified a negative discriminatory impact of this procedural document, ensure you detail the action taken to avoid/reduce this impact in the Comments column. If you have identified a high negative impact, you will need to do a Full Equality Impact Assessment, please refer to the document A Practical Guide to Equality Impact Assessments, Appendix 3, on Tarkanet. For advice in respect of answering the above questions, please contact the Equality and Diversity Lead. 9 If there is no evidence that the document promotes equality, equal opportunities or improved relations, could it be adapted so that it does? If so, how? No Completed by: Name Andrew Kingsley Designation Clinical Manager Infection Control & Tissue Liability Trust Date 27.03.08 Infection Control Page 25 of 25