Intravascular Device Policy

Policy No: OP92 Version: 1.0 Name of Policy: Intravascular Device Policy Effective From: 27/06/2017 Date Ratified 12/04/2017 Ratified SafeCare Council Review Date 01/04/2019 Sponsor Director of Nursing, Midwifery and Quality Expiry Date 11/04/2020 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues Intravascular Device Policy v1

Version Control Ratified Version Release Author/Reviewer by/authorised by 1.0 27/06/2017 Helen Marr SafeCare Council Changes Date (Please identify page no.) 12/04/2017 New Policy Intravascular Device Policy v1 2

Contents Section Page 1 Introduction... 4 2. Policy scope... 4 3. Aim of policy... 5 4. Duties (Roles and responsibilities)... 5 5. Definitions... 6 6. Principles of Care... 6 6.1 Patient Asessment... 6 6.2 Device Selection... 7 6.3 Insertion Setting... 7 6.4 Infection Prevention... 7 6.5 Use of Ultrasound... 8 6.6 Needlefree Devices... 8 6.7 Total Perenteral Nutrition... 8 6.8 Lumens not in use... 8 6.9 Documentation... 9 6.10 Types of Devices... 9 6.11 Insertion Sites... 9 6.11.1 Peripherally inserted devices... 9 6.11.2 Midline inserted devices... 10 6.11.3 Centrally Inserted devices... 10 6.12 Care of insertion sites... 10 7. Training... 11 8. Diversity and inclusion... 12 9. Monitoring compliance with the policy... 12 10. Consultation and review... 12 11. Implementation of policy (including raising awareness... 13 12. References... 13 13. Associated documentation (policies)... 13 Appendices Appendix 1... 14 Appendix 2... 15 Appendix 3... 16 Appendix 4... 17 Appendix 5... 18 Appendix 6... 19-24 Appendix 7... 25-26 Appendix 8... 27-32 Appendix 9... 33-34 Appendix 10... 35-43 Appendix 11... 44-50 Appendix 12... 51-54 Intravascular Device Policy v1 3

Intravascular Device Policy 1 Introduction Many patients in hospital or community care will require venous access for the purpose of administrating intravenous fluids and drugs or for diagnostic purposes. Venous access can be either peripherally or centrally inserted and the use of these devices can result in many complications for the patient including phlebitis, thrombus, vessel damage and infection. Blood stream infections associated with vascular access devices are potentially among the most dangerous complications associated with healthcare (Loveday et al., 2014). Devices used within Gateshead Health NHS Foundation Trust are peripherally inserted venous cannulas, peripherally inserted midline cannulas, centrally inserted venous catheters (non tunnelled or tunnelled) and Continuous Veno Venous Heamofiltration (CVVH ) catheters these are used exclusively within critical care. NICE have provided guidance on the methods used for placement of CVC. Their subsequent management has been mentioned in government documents such as Winning Ways and Saving Lives and is also been the subject of a review by EPIC. CVC s are sited in a number of clinical areas within the Trust by clinicians from various specialties. This policy aims to aid all professionals in applying best practice within the setting of Gateshead Health NHS Foundation Trust. Acute lines should be inserted using custom made insertion packs stored in CCD. This pack comes with documentation covering line insertion, guide-wire removal, care of line and removal of line. Peripherally inserted cannulas are inserted by staff who has received appropriate training and completed appropriate competency based assessment. Peripherally inserted midline cannulas are inserted by clinicians in anaesthetics, and critical care, nursing staff in ambulatory care, acute response team nurse practitioners,community nurses and chemotherapy day unit nurses who have received the appropriate training and competency based assessment. Paediatric practice is beyond the scope of this policy,please refer to Consultant Paediatrician at RVI 2 Policy scope This policy is applicable to all health care professionals caring for adult patients with Venous Access Devices.Clinical staff must comply with relevant local policy and guidelines and must be used in conjunction with:- IC 4 Hand Hygiene Policy IC 2 Personal Protection Clothing in Clinical Practice Policy IC 9 Waste Disposal and Recycling Policy Intravascular Device Policy v1 4

IC07 Sharps Policy IC18 MRSA Policy 3 Aim of policy This policy aims to aid all professionals in applying best practice for care of Venous Access devices within Gateshead Health Foundation Trust to ensure that : Health care professionals undertaking any aspect of care relating to a VAD will have the most up to date and appropriate knowledge and skill and be competent in practice The most appropriate type of VAD is used for the patients needs Risks associated with VAD insertion are recognised and minimised On-going care is provided to minimise risk of complications VADs are removed at the earliest opportunity 4 Duties (roles and responsibilities) The Chief Executive has responsibility for ensuring the Trust has robust and effective Infection and Prevention Control Policies. Trust Board has a responsibility to ensure that the risk of infection to patients, staff and visitors is minimised to its lowest potential and therefore supports the full implementation of this policy. The Directors of Infection Prevention and Control have executive responsibility for Infection Prevention Control and oversee Infection and Prevention Control activity via the Infection and Prevention Control Committee. Consultant Microbiologist - will give advice against this policy and follow up all positive blood cultures with clinical staff. Head of Infection Prevention and Control - will give advice against this policy and Ensure that all staff have access to this policy via the Trust Intranet. The Acute Response Team will give advice and support on management and policy interpretation, and ensure that it is updated every two years or in line with current national guidance. The Infection Prevention and Control Committee - is responsible for the ratification of Trust wide infection prevention and control policies, procedures, and guidance, providing advice and support on the implementation of policies and monitoring the progress of the annual infection control programme. Heads of Department - Must ensure that appropriate training is available and that staff understand and comply with the Intravascular Device policy. Managers will ensure that all staff are aware of and follow this policy and are aware of their own roles and responsibilities to ensure safe practice. Intravascular Device Policy v1 5

All Trust staff - have a responsibility to adhere to Trust policy and ensure that appropriate measures are taken to reduce risks associated with infection. All Trust staff have a responsibility to ensure they attend Central Line training, annual training in infection Prevention and Control and attend Central Line training updates thereafter. 5 Definitions Venous access device - is any device that is inserted into the venous system for either diagnostic,central venous pressure monitoring or therapeutic purposes. Peripheral Venous Cannula (PVC) - A peripheral cannula is a short, hollow, flexible tube placed in a peripheral venous blood vessel for the administration of fluid or drug therapy. Midline Venous Catheter (MVC) A midline is a peripherally inserted catheter inserted into a larger vein without entering the central venous circulation, the tip terminates at or below the level of the axilla. Central Venous Catheter (CVC) - A CVC is a catheter placed within the superior or inferior vena cava or other large central vein. Exceptions to this are with CVCs that are placed in the femoral vein Central Venous Catheters may be short term, peripherally inserted central catheters (PICC ) long term tunnelled lines with cuff (Groshong lines,hickman Lines ). ART Acute Response Team IPCN Infection Prevention and Control Nurse TPN Total Parenteral Nutrition Bionector Trade name of Vygon needle-free injection cap 6 Principles of Care Care standards 25 a,b,c,and d explain the principles of care for specific lines in detail (appendicies 3-6) 6.1 Patient Assessment It is essential to choose the most appropriate device for the intended use and duration of therapy and tools to assist with the assessment of veins and type of device should be used as guidance but not replace the individual professionals clinoical assessment Guidance on selection of the appropriate venous device (see appendix 1) Guidance on selection of vein (See appendix 2 ) Patient assessment should include: Length and frequency of intended use Requirements/proposed therapy Frequency of therapy Intravascular Device Policy v1 6

Previous surgery, radiotherapy, VAD, fractured clavicle which may affect access to vein Venous access history Future requirement for venous access for dialysis Haematology profile, including full blood count (FBC) and clotting (INR) (for centrally inserted devices) Patient preference and life style Allergy status The professional inserting the device is responsible for ensuring that any contraindications have been addressed. 6.2 Device Selection Regardless of the type of device used, the principles of care for the device remain the same. To prevent infection. To maintain a closed' intravenous system with minimal connections to reduce the risk of contamination To prevent damage to the device and associated intravenous equipment. To maintain a patent and correctly positioned device. The procedure should be explained to the patient and consent gained 6.3 Insertion Setting Peripherally Inserted venous cannulas and midline inserted catheters may be inserted in practice areas and community settings Planned centrally inserted catheters should be sited in theatre or radiology environment Open areas of critical practice such as CCD, ED, EAU and CCU are acceptable for the insertion of short term CVC due to the nature of the patients treated. The urgency of placement and the stability of the patient should be assessed when deciding on the most suitable environment Groshong or Hickman lines for long-term access and CVAD s for TPN should be sited and removed in a theatre environment. 6.4 Infection Prevention Centrally Inserted Devices With reference to IC policy 18 MRSA policy, all in-patients should have MRSA screening of nose and throat unless access is femoral when screening would be indicated nose, throat and groin, and thereafter on a once weekly basis for as long as the CVAD in situ. Any plan for CVAD insertion, renewal or removal (where MRSA status positive) necessitates discussion with the microbiologist and IPCN review to ensure appropriate antimicrobials given prior. Octenisan body wash is indicated for all in patients. This is irrespective of their MRSA status. All vascular devices Intravascular Device Policy v1 7

Patients with devices should have the area and site of insertion assessed and recored 3 x daily using VIP tool 6.5 Use of ultrasound guidance Training in the use of ultrasound guidance is now routine in anaesthetic practice. NICE published guidance on this in 2002 and reviewed it in 2014 with minimal change to guidance from 2002. http://www.nice.org.uk/guidance/ta49 The grade and training of the clinician inserting CVADs or MVC will vary between areas depending upon the level of expertise available. Anyone undertaking insertion should be competent to do so either as demonstrated by their training documents or experience. 6.6 Needle Free Devices Peripherally inserted venous cannulas should have needle free extension sets in place Peripherally Inserted Midline Catheters should have TKO bionector in place and replaced every 7 days All lumens on CVADS should have bionectors in place with the exception of patients within the Critical Care environment.bionectors should be replaced every 7 days Patients discharged from Critical Care with a CVAD in situ must have all other needle free devices removed (3 way taps )or similar from the CVAD and replaced with bionectors prior to discharge from CCD.Advice may be sourced from the Acute Response Team TPN should be administered using a dedicated lumen (EPIC3 Section 4.5) with a dedicated bionector in place. Decontaminate the bionector before and after use with PDI Sani Cloth CHD 2% (Chlorhexidine/alcohol) 6.7 Total Parenteral Nutrition If TPN is being administered prior to surgery, following a risk assessment a double lumen CVAD may be used. This has to be in conjunction with a risk assessment for a named patient only and not as routine practice. Consideration must be given to patients with non-tunnelled devices that require treatment for duration greater than seven days. A tunnelled device may be indicated and planned for by contacting radiology or the on call vascular team. The lumen dedicated to TPN use should ideally be the smallest lumen on the device. It should be capped with a needle-free cap and identified as the TPN lumen. Once TPN has been commenced the line should not be used for any other purpose. Three way taps are not acceptable for TPN, nor should 3 way taps be used outside of CCD or theatres. 6.8 Lumens not in use Please note the guidance differs depending on the type of device see below. For Non-tunnelled devices, CVADs lumens not requiring daily access should have a bionector in place, flushed daily, and consideration given for removal. Intravascular Device Policy v1 8

For Tunnelled devices, lumens not requiring daily access should have a bionector in place, lumens should be flushed and bionectors replaced on a weekly basis. For Peripherally inserted Midline catheters not requiring daily access a bionector TKO should be in place,the line should be flushed and bionector changed on a weekly basis. For peripherally inserted cannulas a bionector should be in place It is advised that flushes should be 0.9% Normal Saline unless the devices is a Hickman CVAD (please refere to policy for care and flushing of this device appendix 7 ) 6.9 Documentation The procedure should be documented in the patient s case notes. This will include the date, time and name,signature, grade and contact number of professional performing insertion, plus type of line and rationale for choice of inserted device. Care standard 25a, 25b 25c or 25d should be used Monitoring of the site x 3 times per day and VIP scores should be recorded recorded,any signs of erythema should be reported which should include referral to the link IPCN and /or microbiologist for CVAD devices. All care documented and actioned. Any swabs taken from insertion sites site must be documented in the Care Standard evaluation. 6.10 Types of Devices Within Gateshead Health NHS foundation Trust Devices are normally : Peripherally Inserted Venous Cannula size 14-24 gauge the device selected should be the smallest gauge which will accommodate the prescribed therapy as large bore PVC obstruct blood flow in the vessel and are more likely to lead to phlebitis.where there is a clinical need for a larger gauge cannula the rationale for doing so should be recorded on the VIP record. Midline venous catheter size 8 cm 22 gauge for or 20cm 22 gauge (for patients on chemotherapy day unit only ) Centrally Inserted Non-tunnelled short term use/multi lumen (Acutely ill patients) Tunnelled, long term use (Groshong/Hickman) Please ensure you are aware of the type of line inserted prior to any care being given to the line. 6.11 Insertion Sites 6.11.1 Peripherally inserted devices The site at which a PVC is inserted may influence the risk of associated complications including and the risks are greatly reduced when inserted in upper compared to the lower limbs( EPIC3 IVAD 12 ) Intravascular Device Policy v1 9

Damage to vessels caused by previous cannula should be considered when selecting a subsequent site and should be proximal to a previous cannula site ( INS 2011). Areas of flexion should be avoided except in emergency situations when the antecubital fossa is recommended Selection of vein Use distal veins first Subsequent cannulation should be made proximal to the previously cannulated site Use veins that feel soft and resilient Use large veins where possible Use a straight vein suited to the length of cannula Use veins on patient s non-dominant limb The following should be avoided: Arm of a patient who has undergone mastectomy and/or axillary node dissection /radiotherapy. Limbs with fistulae or awaiting fistula formation Limbs with fractures Small, visible but impalpable veins Veins on the palm side of hands Median cubital veins Limbs affected by lymph node dissection or radiotherapy Veins that feel hard and sclerosed Areas of joint flexion Veins in close proximity to arteries/arterial lines Veins in lower limbs Previously cannulated veins 6.11.2 Midline Inserted Catheters The ideal choice of vein for a midline inserted catheter should be either basillic or cephalic veins of the arm 6.11.3 Centrally Inserted Neck (internal jugular vein), chest (subclavian vein), or groin (femoral vein). Tunnelled lines are Inserted in the internal jugular or subclavian vein with the line being tunnelled under the skin and exiting on the chest 6.12 Care of the Insertion Site All VADs must be securely fixed to stabilise the device to minimise movement of the device to prevent trauma to the exit site and the vessel trauma to the vessel and to prevent micro- organisms to. The site should be visable and be protected from extrinsic micro -organisms For PVC Should be covered with a transparent semi permeable dressing (e.g IV 3000 frame ) to secure and stabilise the device to ensure that the site of cannulation Intravascular Device Policy v1 10

7 Training is visible and is protected from extrinsic micro-organisms and to prevent trauma to the vessel. The dressing should be kept dry clean and intact and changed when they become soiled damp loose or the site of insertion in not visible. MVC Midline Catheters should be secured with a dedicated securement device which should be changed every 7 days (or earlier if indicated) using aseptic technique. The site must be cleaned at every dressing change to reduce microbial colonisation using 2% chlorhexidine gluconate in 70% alcohol. the dressing and TKO change will usually be undertaken weekly as a single procedure; however, there may be circumstances when either will need to be done as a stand-alone intervention Centrally Inserted Catheters Clean with 2% Chlorhexidine / 70% isopropyl alcohol (EPIC3 IVAD 20), dress with transparent semi-permeable dressing (EPIC3 IVAD 17) renewed every 7 days, or more often if necessary (EPIC3 IVAD 18). A sterile gauze dressing may be indicated if there is bleeding from the insertion site or profuse perspiration this will need changing if it becomes damp, soiled or displaced, or to inspect the site, and should be substituted with a transparent semi permeable dressing as soon as appropriate (EPIC3 IVAD 19). Condition of the insertion site should be observed and documented daily by nursing staff, and medical staff informed of any inflammation or discharge at site. CVCs placed in neck or chest veins should have their position confirmed by x-ray prior to use also to exclude pneumothorax caused during insertion. Line manipulation must be kept to a minimum and flushed when not in use. The flush should be recorded in the nursing record. PVC insertion This is a ward based learning clinical skill and requires competency based assessment (appendix 8) MVC insertion All staff must attend dedicated training and complete a specific competency based assessment which includes supervised practice.(appendix 9) Are inserted by appropriately trained and competency assessed staff only Centrally Inserted Catheter care and maintenance All staff must attend dedicated training accessed through OD and training and complete competency based assessment to be able to use and care for all CVC devises (appendix 10) Intravascular Device Policy v1 11

48 Diversity and inclusion The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010). 9 Monitoring compliance with the policy Surveillance of CVAD devices will be carried out on a continual basis by the IPC nurses and ART. Any CVAD practice will be monitored and supported. Any variance from best practice will be addressed with individual practitioners. This will be in conjunction with the practice development team and ART. Escalation to line managers will be initiated where additional education and support does not resolve poor practice issues. Standard/Process/Issue Monitoring and audit Method By Committee Frequency VIP assessment of device insertion sites IPC Committee Bi-monthly Indwelling vascular device infection reporting Dashboard Submission of weekly audits Divisional Safecare Report Ward Manager Designated Nurse Matron IPC Committee Bi-monthly Centrally Inserted line blood culture contamination Compliance with MRSA screening IPCN Monitoring Data reports IPCN follow up IPCN MRSA Lead With IPCT Admin Support IPC surveillance meetings IPC Committee IPC Surveillance meetings IPCC Committee Quaterly Quaterly Compliance with standard of practice for insertion of CVC and midline devices Audit of insertion documentation ART Intravascular Device Group Yearly 10 Consultation and Review This policy has been developed in consultation with IPCC, PDT, Consultant anaesthetist and they will be involved with review of this policy. Intravascular Device Policy v1 12

11 Implementation of policy (including raising awareness) Following ratification of the policy it will become available to all clinical staff via the Trust Intranet. All members of staff will be informed via email and individual team meetings when due for review. 12 References Department of Health (2007). Saving lives: reducing infection, delivering clean and safe care. DoH, 2007. http://antibiotic-action.com/wp-content/uploads/2011/07/dh-cleansafe-care-v2007.pdf The Royal Marsden Hospital Manual of Clinical Nursing Procedures Ninth Edition 2015 Epic 3: National Evidence Based Guidelines for Preventing Healthcare Associate Infections in NHS Hospitals in England. Hallam C et al (2016) Development of the UK Vessel Health and Preservation (VHP) framework: a multi-organisational collaborative. Journal of Infection Prevention; 17: 2, 65-72. High Impact Intervention Central Venous Catheter Care Bundle Infusion nursing standards of practice Journal of Infusion Nursing, Supplement 34 (15), S1- S110) 13 Associated documentation The Saving Lives programme to reduce healthcare-associated infections includes guidance on taking blood cultures. This policy is based on that guidance and should be read and implemented in conjunction with the following infection, prevention and control policies: IC 02 Personal Protective Equipment IC 04 Hand Hygiene IC 06 Isolation IC 07 Guidance for Clinical Healthcare Workers Sharps Policy IC 18 MRSA Intravascular Device Policy v1 13

Appendix 1 Peripheral Vein Assessment Tool Grade Vein Quality Definition of vein quality Insertion management 1 Excellent 2 Good 3 Fair 4 Poor 5 Non identifiable 4 5 palpable/visible veins suitable to cannulate 2 3 palpable/visible veins suitable to cannulate 1 2 palpable/visible veins suitable to cannulate (veins may be small, scarred or difficult to find and require heat packs to aid vasodilation) Veins not palpated/visible (requires ultra sound assistance or Infrared Viewer) No visible (naked eye or aids) or palpable veins Cannula may be inserted by trained/ authorised healthcare practitioner Cannula may be inserted by trained/ authorised healthcare practitioner Cannula may be inserted by trained/ authorised healthcare practitioner but may require Infrared Viewer or ultrasound Cannula may be inserted by an experienced practitioner in cannulation. Use Infrared Viewer, ultrasound, trans illumination or other aids Peripheral cannulation should not be performed Adapted from UK VHP framework Intravascular Device Policy v1 14

Right Line Decision Tool Appendix 2 Adapted from UK VHP framework Genuine Need for IV Yes No MUST therapy be administered centrally? Continue via alternate route Yes No Continue via alternate route Outpatient/Long Term Inpatient/Acute 1 Excellent <6 months Intermittent Therapy Peripheral Vein Assessment 2 Good <4 months Intermittent Therapy Less than 10 days therapy 3 Fair Ok for 4-6 weeks Intermittent Therapy 4 Poor One off Cannulation One off Cannulation 5 Non Identifiable Not Suitable for Cannulation If peripheral vein grade not compatible with intended treatment duration, consider other type of vascular device Duration of anticipated therapy? <10 Days >10 days <4 weeks >4 weeks <6 months >4 months <6 years Nontunnelled PICC/Tunnelled CVC CVC/PIC PICC/Midline Tunnelled or TIVAD C or Intravascular Midline Device Policy v1 15

Vascular Access Devices Type of Device Peripheral cannula Material Features Common Insertion Site (Veins) Teflon Vialon Winged Non-winged Non-ported Ported Cephalic Basilic Dorsal Venous network Appendix 3 Recommended Indwelling Life and Common Uses 48-96 hours for shortterm access Peripherally Inserted central catheter (PICC) Polyurethane Silicone Dual lumen Single lumen Valved Antecubital fossa Basilic Cephalic Brachial Used primarily for patients requiring several weeks or months of intravenous access Midline catheter Silicone Polyurethane Single lumen Dual lumen Basilic Median Cubital Cephalic Used for 1-6 weeks or longer for short-to intermediate-term access Skin- 16unneled Catheter Polyurethane Silicone Valved Antimicrobial/silver cuff Multiple lumen Jugular Axillary Subclavian Femoral Indefinite. Used for long-term intermittent, continuous or daily intravenous access. May be appropriate for short-term use if reliable access needed. Implanted ports Catheter Dual ports Antecubital fossa Indefinite. Used for ng-term access. Silicone Port Titanium Plastic Peripheral ports Valved Low profile CT compatible Subclavian Femoral Intermittent, continuous or daily intravenous access Intravascular Device Policy v1 16

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Appendix 9 Care Standard 25D MIDLINE PERIPHERAL VENOUS CANNULA Patients Name DOB NHS Number Unit No Ward 1. Explain the procedure to the patient and gain consent 2. Wash hands thoroughly and ensure aseptic technique with sterile gloves and equipment is used when handling the catheter, dressing changes, accessing the site and changing the administration set. 3. Check entry site and upper arm daily for inflammation or leakage and any signs of phlebitis. 4. Record VIP score at least three times in 24 hours and assess after each access. 5. The dressing and Grip-Lok device should be clean and intact and changed using ANTT every 7 days. 6. The dressing should be changed if damp, loose or contaminated. 7. Chloroprep should be used to clean the skin during dressing change. 8. TKO bionector to be changed every 7 days. 9. Administration sets should be changed every 24hours. 10. Ensure that the appropriate medications are used with the correct diluents. 11. The cannula should be flushed with at least 10mls of 0.9% normal saline prior to and following each infusion and weekly if not in use. 12. The cannula should be flushed using a positive pressure technique. 13. Advise the patient to inform staff of any pain or change of sensation around the site, which could indicate infection or that the cannula has come out of the vein. 14. Remove the cannula if VIP score = equals 2 and continue monitoring VIP score / site until back to zero. 15. For clear fluids change infusion set every 24 hours and document in daily care record that set has been changed. 16. Change the infusion set immediately following a blood transfusion. 17. Ensure that the clinical need for the Midline is reviewed and recorded daily 18. The Midline site has been assessed and removed if there are signs of inflammation or phlebitis at the site. 19. Medical staff have reviewed the need for intravenous therapy and antibiotics and switched to oral if possible today. 20. When removing midline cannula apply pressure to the area and continue this pressure until haemostasis achieved. Document that midline cannula has been removed. 21. Midline cannula is not to be used for blood sampling. This cannula is not to be used for TPN. Intravascular Device Policy v1 33

Please sign, print and date in the columns below. Patients Name DOB NHS Number Peripheral Right Line Decision Date of Time of Vein Tool used midline midline Assessment insertion insertion Tool Grade Ward Unit Number Position of midline Clinical indication for midline AM Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Dressing Change PM Night AM Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Dressing Change PM Night AM Day 15 Day 16 Day 17 Day 18 Day 19 Day 20 Day 21 Dressing Change PM Night AM Day 22 Day 23 Day 24 Day 25 Day 26 Day 27 Day 28 Dressing Change PM Night Intravascular Device Policy v1 34

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Gateshead Health NHS Foundation Trust Appendix 11 Guidelines for Nursing Staff on the Care and Management of Tunnelled Devices The following guidelines are a reference material to professionals caring for central venous access devices within Gateshead Health NHS Foundation Trust. However, any professional performing these cares must first have been assessed and deemed competent within the Trust/Organisation. All practitioners must ensure they are aware of and working within their personal and professional accountability. The term Central Venous Access Device (CVAD) or Central Venous Catheter (CVC) implies that the tip of the device is positioned in the lower third of the superior vena cava (SVC). For the purpose of this document CVC will include: Tunnelled catheters generally inserted via the jugular vein, with the other end being tunnelled under the skin and exiting on the chest. Peripherally inserted catheters (PICC s) which are inserted through an antecubital vein or upper arm vein and threaded up to the SVC. Groshong Catheters Groshong catheters can be single or double lumen. Double lumen Groshong lines have a red lumen for blood sampling and infusion of blood products, and a white lumen for infusion of other crystalloid products. They are soft, silicone tubes with radiopaque stripes and tips. They have winged connectors for injection cap placement. Groshong catheters have a valve. The Groshong valve remains closed at normal central venous pressure. The valve is designed to restrict blood backflow and air embolism when closed. The valve will remain closed between 7 and 80mm Hg. PICC lines have a Groshong valve. It is important to remember that only 10ml or larger syringes should be used for infusing with Groshong catheters. Infusion pressures should always be low, and not exceed 25psi. Intravascular Device Policy v1 44

Maintaining Patency flushing the lumen of a Groshong line The catheter should be flushed every 7 days when not in use. It should also be flushed after administration of medications, fluid/blood transfusion, TPN, blood aspiration or if blood is observed in the line. Equipment required: Sterile pack containing sterile towel and gauze swabs A SD Sani-cloth (containing Chlorhexidine 2% in 70% alcohol) A 10ml syringe containing sterile 0.9% normal saline Procedure: ACTION 1 Explain and discuss the procedure with the patient. 2 Wash hands thoroughly or use an alcohol-based handrub. Apron and gloves should be worn 3 Open sterile pack and arrange equipment. 4 Clean the needleless injection cap using 2% chlorhexidine in 70% alcohol. Apply with friction, rubbing the cap in a clockwise and anticlockwise manner at least five times and allow to air dry 5 Attach the prepared syringe of 10ml saline to the needleless cap. 6 If lumen hasn t been used, aspirate line until blood can be seen in line. 7 Using a brisk push pause method, inject the contents of the syringe (inject 1 ml at a time). RATIONALE To gain the patient s co-operation and understanding as well as informed consent. To reduce the risk of contamination To gain access to equipment To minimize the risk of contamination at the connections To establish connection between cap and syringe To see that tip of lumen is inside vein. To create turbulence in order to flush the catheter thoroughly. 8 Maintain pressure on the plunger as the syringe is disconnected from the cap. 9 Remove syringe, wipe needleless cap with SD Sani-cloth and dispose of equipment safely To maintain positive pressure and prevent backflow of blood into the catheter, and possible clot formation To conclude care and prevent contamination of others 10 Record the procedure. To maintain accurate records Intravascular Device Policy v1 45

Blood sampling from a Groshong central venous catheter (single or double lumen) This procedure isn t recommended as first choice for single lumen catheters, and should be avoided if possible i.e. if the patient has an arterial line or bloods can be taken peripherally. Equipment required: Use equipment as for CVAD flush. Also include the additional items listed below. Vacutainer connector and 2 x 10ml syringes blood collection tubes Procedure: Follow the procedure for maintaining line patency through steps 1-10. Please note: When obtaining a blood sample from a double lumen line the sample should be taken from the RED lumen as outlined in the table below. The WHITE lumen just needs to be flushed as outlined above. The white lumen can be used for sampling if you are unable to use the red lumen. ACTION 1 With the lumen on a sterile surface, cleanse the hub with an SD Sani-cloth 2 Pull back on the syringe plunger 1-2ml and pause for 2 seconds. Aspirate 5ml blood and discard. 3 Attach either a vacutaner connector and then the blood containers or an empty 10ml syringe and aspirate the required amount of blood. 4 Remove the vacutaner/syringe and attach a sterile saline filled syringe. 5 Using a brisk push-pause method (inject 1ml at a time), inject the contents of the syringe, removing syringe when near empty. 6 Place blood in collection tubes and label correctly as per hospital policy. 7 Clean the CVAD needle-fee cap with a SD Sani-cloth. Allow to dry. RATIONALE Making sure to prevent contamination of CVAD To allow the valve to open. The saline in the blood may dilute the specimen and alter results. To obtain specimen. To establish a connection between the line and the sterile saline flush. To create turbulence in order to flush the catheter thoroughly. Doing this with positive pressure throughout so no blood will be drawn into lumen at syringe extraction. To ensure positive patient identification. To reduce the number of microbiological organisms. Intravascular Device Policy v1 46

Prevention of Infection Cares The exit site should be re-dressed every 7 days, or PRN, using a transparent occlusive dressing and skin area cleaned with Chloraprep solution. The dressing may need to be changed more regularly if loosened or if the patient is neutropenic. All patients should be prescribed Octenisan bodywash, and use this daily, and also have weekly MRSA screening performed. Replacing dressing of a Groshong or Hickman central venous catheter Equipment required: 1 dressing pack containing sterile gloves, towel and gauze Alcohol-based handrub Alcohol-based skin cleaning preparation (2% Chlorhexidine in 70% alcohol) 2 SD Sani-cloths CHG 2% for cleansing line 1 pair of non-sterile gloves 1 appropriate transparent occlusive dressing 1 apron Procedure: ACTION 1 Explain and discuss the procedure with the patient. 2 Perform the dressing replacement using aseptic technique. 3 Screen the bed. Assist the patient into a supine position, if possible. 4 Wash hands with bactericidal soap and water or bactericidal handrub. Apron and gloves should be worn 5 Place all equipment required for the dressing on the bottom shelf of a clean dressing trolley. 6 At the patient s bedside, open the sterile dressing pack onto the top of the trolley. 7 Attach an orange clinical waste bag to the side of the trolley below the level of the top shelf. RATIONALE To gain the patient s co-operation and understanding as well as informed consent. To reduce the potential for the spread of infection. To allow dust and airborne organisms to settle before the insertion site and the sterile field are exposed To reduce the risk of cross-infection To reduce the risk of cross-infection To minimize airborne contamination So that contaminated material is below the level of the sterile field Intravascular Device Policy v1 47

8 Open the other sterile packs, tipping their contents onto the centre of the sterile field and pour the sterile saline into the gallipot. 9 Wash hands with soap or bactericidal alcohol handrub. To reduce risk of contamination of contents Hands may have become contaminated by handling the outer packs 10 Place the sterile field under the patient's arm or on the chest and loosen the old dressing gently. 11 Put on clean gloves, remove the old dressing and discard it. 12 If the site is red or discharging, take a swab for bacteriological investigation. 13 Remove and dispose of gloves, clean hands and put on sterile gloves from pack. 14 Clean the wound with 2% Chlorhexidine in 70% alcohol, using back-and-forth strokes with friction. Allow area to dry prior to applying the dressing. 15 Apply appropriate dressing, moulding it into place so that there are no folds or creases. 16 Dispose of all equipment appropriately To create a clean working area. To remove old dressing without contaminating hands For identification of pathogens. To select appropriate treatment To minimize the risk of introducing infection To enable disinfection process to be completed. To ensure security of device and prevent dislodgement Completing care and disposing of waste safely 17 Document date and time on dressing To ensure the dressing is changed as required Above guide referenced from Marsden Manual of Clinical Nursing Procedures 9 th Edition 2015 Intravascular Device Policy v1 48

The following gives guidance on the management of possible line infections (intra/extra luminal or skin). All practitioners caring for these lines need to ensure they observe for any signs of infections and inform medical staff at each episode of care if concerned. If infection suspected, cultures to taken from CVAD and also peripherally at same time. BCSH Guidelines on the Management of CVAD Associated Infection Category of Infection Non-neutropenic Patient Exit site infection Remove catheter if no longer needed. Treat empirically with *flucloxacillin Neutropenic patient Remove catheter if no longer needed. Initial empirical therapy including glycopeptide Tunnel infection Presumed catheterrelated bloodstream infection Remove catheter if no longer needed Treat empirically with *flucloxacillin *Unless patient known or suspected to be MRSA positive. Remove catheter if no longer needed. Treat empirically with antibiotics targeted against isolates. *Unless patient known or suspected to be MRSA positive. Treat for 10-14 days or longer until infection resolved. Modify according to isolates Remove catheter if evidence of progression or if blood cultures are positive for Staph. aureus, Pseudomonas spp, Mycobacterium spp., or fungi Remove catheter if no longer needed. Initial empirical therapy including glycopeptide Treat for 10-14 days or longer until resolution of soft tissue infection. Modify according to isolates. If tracking continues to spread remove catheter. Remove catheter if no longer needed. Initial empirical antibiotic therapy. Modify according to isolates. Treat for at least 10-14 days Remove catheter if cultures remain positive after 48 hours of therapy or if proven catheter-related infection with Staph. aureus, Pseudomonas spp,, Mycobacterium spp., or fungi * Unless known to be colonised with MRSA, when a glycopeptide should be used. Intravascular Device Policy v1 49

Procedure for administrating medication via a CVAD ACTION RATIONALE 1 Explain procedure to patient and gain consent. 2 Assess exit site and area around for signs of infection or thrombosis 3 Staff should wear a clean apron and wash hands thoroughly. 4 An aseptic non-touch technique should be followed throughout. 5 Clean the needleless cap thoroughly with 2% Chlorhexidine in 70% isopropyl alcohol (SD Sani-cloth) for 30 seconds and let dry (EPIC3 IVAD30) 6 With a 10 ml syringe, aspirate the lumen to be used until 2-3 ml blood withdrawn. 7 Flush lumen with 10 ml of 0.9% normal saline using brisk push-pause technique (Royal Marsden 9 th Edition) 8 Administer the medication or commence the infusion as prescribed. 9 After use of the lumen: using a 10 ml syringe, flush and lock the line using 10 ml sterile 0.9% normal saline (EPIC3 IVAD 34) with brisk push-pause technique, withdrawing syringe before all the saline injected. NB If device has external clamps, these must be closed at all times when bung or needle-free cap is not in place on line Consent is required It must be safe to use To reduce the potential for the spread of infection. To reduce the potential for the spread of infection. To reduce the number of microbiological organisms that may be colonizing the injection bung. This confirms the patency of the lumen and ensures there are no clots or residual medication in the lumen. Clears the lumen of all indwelling blood with turbulance, which assists the lumen to remain patent. Prescription of medications or IV fluids is essential Maintains patency of CVAD whilst clearing lumen of all medication This action prevents either blood loss through line or air embolus from occurring, which is highly dangerous and can lead to great harm to patients Intravascular Device Policy v1 50

Appendix 12 Gateshead Health NHS Foundation Trust Guidelines for nursing staff on the care and management of Hickman Lines The following guidelines are a reference material to professionals caring for central venous access devices within Gateshead Health NHS Foundation Trust. However, any professional performing these cares must first have been assessed and deemed competent within the Trust/organisation. All practitioners must ensure they are aware of and working within their personal and professional accountability. The term Central Venous Access Device (CVAD) or Central Venous Catheter (CVC) implies that the tip of the device is positioned in the lower third of the superior vena cava (SVC). For the purpose of this document CVC will include: Tunnelled catheters generally inserted via the jugular vein, with the other end being tunnelled under the skin and exiting on the chest. Peripherally inserted catheters (PICC s) which are inserted through an antecubital vein or upper arm vein and threaded up to the SVC. Hickman Catheters A Hickman line is a narrow tube, made of silicone rubber or polyurethane. It can be single or double lumen. Double lumen Hickman lines have a red lumen for blood sampling and infusion of blood products, and a white lumen for infusion of other crystalloid products. These catheters have an open ended tip and therefore have a clamp on each lumen to prevent bleeding and air embolism. Intravascular Device Policy v1 51

Maintaining patency of a Hickman central venous catheter (single or double lumen) Equipment required: A clean trolley 10mls of sterile 0.9% saline per lumen. 1 apron 1 pair of non-sterile gloves 1 dressing pack containing sterile gloves 2 x 10ml luer-lock syringes (4 if double lumen) 1 SD Sani-cloth to cleanse line(2 needed if double lumen line) Possibly 1 needle-free injection cap (2 if double lumen) *Possibly 3mls heparin sodium solution 10units/ml (6mls if double lumen) for weekly flush Flushing procedure for Hickman line The patency of the device is a local agreement and according to Vygon (manufacturer). To maintain the patency of the Hickman device it is advised in action point 5 see below 1. Flush the catheter with 0.9% sodium chloride after each injection, infusion or blood sampling. If several drugs injections are needed, carry out a careful flushing with saline between each one to avoid any precipitation or drugs interactions. 2. *If the line is not being used regularly it needs to be flushed weekly with normal saline and locked after each flush with 3mls of 10units/ml Heparin (Heplock). This Heparin should be prescribed and ordered by pharmacy on a named patient basis. ACTION 1 Explain and discuss the procedure with the patient. 2 Wash hands thoroughly or use an alcohol-based handrub. Apron and gloves should be worn 3 For this aseptic procedure open sterile gauze pack and place gauze under lumen area. 4 Clean the needleless injection cap using 2% Chlorhexidine in 70% alcohol. Apply with friction, rubbing the cap in a clockwise and anticlockwise manner at least five times and allow to air dry 5 Ensure external lumen clamp is closed whenever bung or needle-free device is removed from line RATIONALE To gain the patient s co-operation and understanding as well as informed consent. To reduce the risk of contamination. To gain access to equipment To minimize the risk of contamination at the connections Prevents blood from leaking or room air entering circulation during times needleless bungs are removed. Intravascular Device Policy v1 52

6 NB. It may be necessary to aspirate the contents of the lumen before flush if so, connect an empty 10ml syringe to the cleaned lumen, open external clamp and aspirate 3-4mls from lumen. 7 Attach the prepared syringe of 10ml saline to the needle-less injection cap. 8 Using a brisk push pause method, inject the contents of the syringe (inject 1 ml at a time) until just before empty, then close clamp. 9 If lumen will not be regularly used, lock lumen with 3 mls of 10u/ml heparin solution (heplock) and replace bionector. 10 Use pressure on the plunger and close clamp before the syringe is disconnected from the needle-less cap. Removal of drugs/debris/heparin etc. from inside of the lumen, to avoid flushing it into patient. To establish connection between cap and syringe. To create turbulence in order to flush the catheter thoroughly. Maintenance of patency of rarely used lines. To maintain positive pressure and prevent backflow of blood into the catheter, and possible clot formation. 11 Dispose of equipment safely. To prevent contamination of others. 12 Record the procedure. To maintain accurate records Blood sampling from a Hickman central venous catheter (single or double lumen) Equipment required: Use equipment as for line flush. Also include the additional items listed below. Vacutaner connector or 2 x 10ml syringes (4 if double lumen) Blood collection tubes Procedure Follow the procedure for maintaining line flushing through steps 1-12. Please note: When obtaining a blood sample from a double lumen line the sample should be taken from the RED lumen as outlined in the table below. The WHITE lumen just needs to be flushed as outlined above. The white lumen can be used for sampling if you are unable to use the red lumen. Intravascular Device Policy v1 53

BLOOD SAMPLING ACTION 1 Ensure external lumen clamp is closed at all times when lumen not in use or when changing needle-free bung. 2 Pull back the syringe plunger whilst releasing the clamp. Aspirate 5ml of blood, re-apply the clamp and discard the syringe. 3 Attach a vacutaner connector with blood collection bottles, or an empty 10 or 20ml syringe (depending on samples required) and aspirate, whilst opening the clamp, required amount of blood. 4 Re-apply clamp, remove vacutaner or syringe and attach a pre-filled syringe of 0.9% sodium chloride solution. 5 Using a brisk push-pause method (inject 1ml at a time), inject the contents of the syringe. Apply the clamp, whilst pushing, when last 0.5 mls remain. 6 If lumen will not be regularly used, lock lumen with 3 mls of 10u/ml heparin solution (heplock) 7 Use pressure on the plunger and close clamp before the syringe is disconnected from the needle-less cap. 8 Label blood collection tubes correctly as per hospital policy. 9 Clean the CVAD needle-fee cap with a SD Sani-cloth. 10 Dispose of equipment safely and in accordance with Trust policy. Document procedure. RATIONALE Prevents blood from leaking or room air entering circulation during times needleless bungs are removed. The heparin solution in the blood may dilute the specimen and alter results. To obtain specimen. To establish a connection between the line and the syringe. To create turbulence in order to flush the catheter thoroughly. Applying the clamp whilst still injecting the flush helps to prevent blood from backing up into the catheter. Maintenance of patency of rarely used lines To maintain positive pressure and prevent backflow of blood into the catheter, and possible clot formation To ensure positive patient identification. To reduce the number of microbiological organisms. To prevent contamination of others and maintain safe practice. Occlusive dressing helps to prevent bacterial contamination. Above applied from guides in the Marsden Manual of Clinical Nursing Procedures 9 th Edition 2015 Intravascular Device Policy v1 54