INTERPROFESSIONAL PROTOCOL - MUHC Medication included No Medication included THIS IS NOT A MEDICAL ORDER Title: Classification number: Care of Central Venous Access Device (CVAD) in the Pediatric and Adult Population: Accessing connections and injection ports. Reserved Section This interprofessional protocol is attached to: 1. PURPOSE To standardize the access of CVAD injection ports in order to decrease the risk of infection. 2. PROFESSIONALS AND PATIENT POPULATION Professionals: All nurses, respiratory therapists working in anaesthesia, radiology technicians and physicians. Patient population: All patients with a CVAD 3. ELEMENTS OF CLINICAL ACTIVITY Professionals are responsible to know the limits and extent of their practice as related to the particular protocol. Equipment needed: One (1) pair of non sterile gloves (if contact with blood is possible at the time of accessing connection). 2 swabs of Chlorhexidine Gluconate (CHG) + Isopropyl alcohol 70% (IPA) Medication or flush solution, as per pt s condition Procedure: Health care providers will follow principles of aseptic non-touch technique when accessing or manipulating a CVAD: Always wash hands as per MUHC hand hygiene policy Aseptic non-touch technique (ANTT) is used to protect critical parts (catheter material, hub, septum or injection cap, connectors, syringe cannula, needle and luer) from beginning to end of procedure. ANTT aims to prevent micro-organisms on hands, surfaces or equipment from being introduced to a susceptible site. The overriding and basic principle is that the susceptible site should not come into contact with any item that is not sterile. Care of Central Venous Access Device (CVAD) in the Pediatric and Adult Population: Accessing connections and injection ports Updated June 30 2016 1
A. Line disconnection Procedure Wash hands as per MUHC hand hygiene policy. Don non sterile gloves (if contact with blood/body fluids is possible at the time of accessing connection). Maintain aseptic technique throughout procedure. Ensure catheter is clamped distally (if non valved CVAD). If not, proceed with clamping. Firmly hold tubing near (not on) connection. Ensure line is not broken, cracked or contaminated with blood or residue. If any are noted, replace without delay. Rationale Use non sterile gloves if any of the following: 1. Removing injection cap 2. Disconnecting IV tubing 3. Administering Blood/blood products In compliance with routine practices. To avoid air embolism. Valved CVAD do not have a clamp. The valve prevents air from entering into the blood stream. Tear open antiseptic swab and remove from packaging holding by corner. Ensure pad is wet. If antiseptic swab is dry, discard. Wrap swab around connection covering entire surface. Vigorously scrub the connection X 15 seconds. Include creases. If rotating collar is movable, move up and scrub connection under it. Allow to dry completely (10-15 seconds). 15 seconds are necessary to eliminate microorganisms and biofilm from the connection. Disconnect tubing ensuring not to touch connection. Protocol CVAD Access connection revised 2016-6-29.docRevision 2016-6-29 2
Tear open second antiseptic swab and remove from packaging holding by corner. Ensure pad is wet. If antiseptic cap is dry, discard Wrap swab around female end of tubing or catheter DO NOT COVER OPEN END. To prevent infection from particles, visible or not (blood, dry solution, bacteria ), that can be found on that end of the tubing or catheter. To prevent disconnection problems such as incapacity to undo connection and possible breakage. The air drying effect allows the alcohol to penetrate and kill the micro-organisms (time required to denature the protein in the cell wall of the bacteria). Vigorously scrub the connection X 15 seconds. Include creases. Allow to dry completely (10-15 seconds). Do not fan or blow on the connections to accelerate the drying process. Maintain aseptic technique while connecting ends, new tubing, cap or syringe. Do not fill gap with solution. Luer lock in position. Do not over tighten. To avoid accumulation of solution in the threads when connecting male end. To reduce risk of contamination of the hub and breakage on the next manipulation. Protocol CVAD Access connection revised 2016-6-29.docRevision 2016-6-29 3
B. Accessing injection port Wash hands as per MUHC hand hygiene policy. Don non sterile gloves (if contact with blood/body fluids is possible at the time of accessing connection). Maintain aseptic technique throughout procedure. Use non-sterile gloves if administering blood/blood products. In compliance with routine practices. Firmly hold the base of the injection port. Ensure line is not broken, cracked or contaminated with blood or residues. If any are noted, replace without delay. Tear open antiseptic swab and remove from packaging holding by corner. Ensure pad is wet. Cover entire surface of injection port with swab. Vigorously scrub the hub X 15 seconds. Include sides and creases. Scrub the hub describes cleaning the surface of the injection port as if juicing an orange (push on top and squeeze all around). 15 seconds are necessary to eliminate microorganisms and biofilm from the injection surface. Allow to dry completely (10-15 seconds). Do not fan or blow on the connections to accelerate the drying process. Maintain aseptic technique while injecting medication/fluid or connecting infusion set. Wash hands as per MUHC hand hygiene policy. Medications (if necessary): No medication Protocol CVAD Access connection revised 2016-6-29.docRevision 2016-6-29 4
Main Authors (original version 2011): France Paquet, Practice consultant (Transition support Office), MUHC Chantal-Mignonne Mailloux,Vascular Access Coordinator, MUHC, Pediatric Mission Consultants: Lyne Saint-Martin, CIC Infection Prevention and Control Manager, MUCH, Pediatric Mission Lorette You (Vascular Access Coordinator, MCH), Chantal Perpête (Infection Control Practitionner, MCH), Connie Patterson (Infection Control Practitioner, RVH), Liz O Hagan (ANM, RVH), Caroline Laberge (EIDM expert, MUHC), Colleen Rooney (NPDE, MGH), Astride Bazile (NPDE, RVH), Aparna Bhattacharjee (NPDE, RVH), Caroline Beauchamp (Pharmacist, RVH) Revision (2016) France Paquet, Nursing Practice consultant (Clinical Professional Staff Development dept.), MUHC Protocol CVAD Access connection revised 2016-6-29.docRevision 2016-6-29 5
4. APPROVAL PROCESS Departmental / Service mandate Department / Service Professional leader (Print) Signature Date Infection Control MUHC Charles Frenette 2011-03-10 Institutional and professional approval Committees Pharmacy and Therapeutics Pediatrics (if applicable) Adult Pharmacy and Therapeutics (if applicable) MUHC Adult Site Medication Administration Policy (MASMAP) (if applicable) MUHC Pediatric Medication Administration Policy (PMAP) (if applicable) Date Nursing Clinical Practice Review Committee (if applicable) 2011-04-04 Multidisciplinary Clinical Practice Review Committee (if applicable) Nursing Executive Committee and Council of Nurses (NEC and CN) (if applicable) Multidisciplinary Council (if applicable) MUHC Central Executive Committee of Council of Physicians Dentists and Pharmacists Committee (ECPDP) (Obligatory if attached to a collective order) Final approval Signature of Chairperson: 5. REVIEW DATE To be updated in maximum of 4 years or sooner if presence of new evidence or need for practice change. Protocol CVAD Access connection revised 2016-6-29.docRevision 2016-6-29 6
6. REFERENCES Björkman, L., Ohlin, A., (2014) Scrubbing the hub of intravenous catheters with an alcohol wipe for 15 sec reduced neonatal sepsis, Acta Paediatrica, 104, 232-236 Blake M., Update:catheter-related bloodstream injection rates in relation to clinical practice and needleless device type. Canadian Journal of Infection Control. 2008; 23(3):156-160, 162 Frasca, D., Cahyot-Fizeller, C., Mimoz, O. (2010) Prevention of central venous catheter-related infection in the intensive care unit. Critical Care, 14, 212. Kaler. W., Chinn, R., (2007) Successful Disinfection of Needleless Access Ports: A Matter of Time and Friction, Journal of the Association for Vascular Access, 12,3,p.140-142 Hong, H., Forbes Morrow, D., Sandora, T.J., Priebe, G.P. (2013) Disinfection of needleless connectors with Chlorhexidine-alcohol provides long-lasting residual disinfectant activity, American Journal of Infection Control, 41, e77-e79 Infusion Nurses Society. (2016) Infusion Therapy Standards of Practice, Journal of Infusion Nursing, 39 1S, S68-S69. Institute for Healthcare Improvement and Safer health care now! Quebec Campaign, (2009) Prevent Central Line Infection How-to-Guide. Available at: http://www.saferhealthcarenow.ca/en/interventions/cli/pages/default.aspx Lockman, J.L., Heitmiller, E.S., Ascenzi, J.A., Berkowitz, I. (2011) Scrub the Hub! Catheter Needleless Port Decontamination, Anaesthesiology, 114, 4, 958 McGolrick, M. and the Joint Commision s Home Care National Patient Safety Goals (2009). Preventing Central-Line Associated Bloodstream Infections, 27(4) accessed on March 10, 2011 at http://www.nursingcenter.com/pdf.asp?aid=858014 Menyhay, S.Z., Maki, D.G. (2006) Disinfection of Needleless Catheter Connectors and Access Ports With Alcohol may Not prevent icrobial Entry: The promise of a Novel Antiseptic-Barrier Cap, Infection Control and Hospital Epidemiology, 27,1 Moureau, N.L., Flynn, J. (2015) Disinfection of Needleless Connector Hubs : Clinical Evidence Systematic Review, Nursing Research and Practice, 2015, Article ID 796762, http://dx.doi.org/10.1155/2015/796762 Rupp, M.E., Yu, S., Huerta, T., Cavalieri, R.J., Alter, R., Fey, P.D., Van Schooneveld, T., Anderson, J.R., Adequate Disinfection of a Split-Septum Needleless Intravascular Connector with a 5-Second Alcohol Scrub, Infection Control and Hospital Epidemiology, 33, 7 (July 2012), pp. 661-665 Smith, J.S., Irwin, G., Viney, M., Watkins, L., Pinno Morris, S., Kirksey, K.M., Brown, A., Optimal (2012) Disinfection Times for Needleless Intravenous Connectors, Journal of the Association for Vascular Access,17, 3, p. 137-143, http://dx.doi.org/10.1016/j.java.2012.07.008 Simon, S., Bryson, C., Porter, S., (2011) «Scrub the Hub» Cleaning Duration and Reduction in Bacterial Load on Central Venous Catheters, Critical Care Nursing Quaterly, 34, 1, 31-35 Soothill, J., Braver, K. Ho. A, et al. A fall in bloodstream infections followed a change to 2% CHG in 70% ipa for catheter connection antisepsis: a pediatric single center before/after study on hematopoeitic stem cell transplant ward. American Journal of Infection Control, 2009;37(8):626-630. The Rotherham NHS Foundation Trust (2009) Saving lives, available at : http://www.ivteam.com/saving%20iv%20campaign%20-%20champion%20support%20material2.pdf, accessed on Sept. 1, 2010 Protocol CVAD Access connection revised 2016-6-29.docRevision 2016-6-29 7