Central Venous Access Devices (CVADs) Hickman/Broviac and PICC Care Management Policy

Central Venous Access Devices (CVADs) Hickman/Broviac and PICC Care Management Policy (Note: See Separate Policy for Port-a-Cath Care and Management) DOCUMENT CONTROL: Version: v2 Ratified by: Quality and Safety Sub Committee Date ratified: 6 December 2017 Name of originator/author: Community Practice Teachers Name of responsible Clinical Policy Review Group committee/individual: Date issued: 6 March 2018 Review date: December 2020 Target Audience Doncaster Care Group Children s Care Group

SECTION CONTENTS PAGE NO 1. INTRODUCTION 3 2. PURPOSE 3 3. SCOPE 3 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 3 4.1 Doncaster Care Group Director/Children s Care Group Director 3 4.2 Clinical Leads / Ward Department Managers 3 4.3 Clinical staff 4 5. PROCEDURE/IMPLEMENTATION 4 5.1 Dressing change and CVAD Care 4 5.1.1 Preparation 4 5.1.2 Essential Equipment 5 5.1.3 Pre-procedure 5 5.1.4 Procedure 6 5.1.5 Post-procedure 6 5.2 Accessing the Devices (CVADs) 6 5.2.1 Equipment 6 5.2.2 Pre-procedure 7 5.2.3 Procedure 7 5.2.4 Post-procedure 9 5.3 Risks and Complications - Problem-solving table 9 5.4 Contra-indication: Taking blood sample from a central venous access device 11 5.6 General Principles 11 6. TRAINING IMPLICATIONS 11 7. MONITORING ARRANGEMENTS 12 8. EQUALITY IMPACT ASSESMENT SCREENING 12 8.1 Privacy, Dignity and Respect 12 8.2 Mental Capacity Act 13 9. LINKS TO ANY ASSOCIATED DOCUMENTS 13 10. REFERENCES 14 11. APPENDICES - None Page 2 of 15

1. INTRODUCTION Central Venous Access Devices (CVADS) are used for short and long-term care. The most common factor for contributing to Blood Stream Infections (BSI) is the presence of an intravenous device. In the UK there are approximately 6000 patients per year who acquire a BSI. BSIs result in prolonged hospitalisation, increased cost of care, and worsening severity of the patients underlying ill health (Epic 2 2007).One third of these infections are associated with a CVAD (EPIC 2 2007). Patients with CVADs are commonly managed by Community Nursing Services which prevents the need to access secondary care. 2. PURPOSE The Policy is based on national guidelines for the management of CVAD, and sound infection prevention and control principles. The purpose of this guidance is to promote the appropriate and, safe use of CVADs throughout the Trust, and provide guidance for staff to: 1. Safely access the line when required. 2. Identify a line replacement strategy when/if required. 3. Choose a relevant dressing and renew when appropriate. 4. Document the intervention. 3. SCOPE The policy applies to all clinical staff within Doncaster Care Group and Children s Care Group whose duties will include delivering care to patients with CVAD. 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 4.1 Doncaster Care Group Director Children s Care Group Director It is the responsibility of the Care Group Directors to have policies in place that meet any legislation, national and local requirements and promote best practice. 4.2 Clinical Leads and Ward Department Managers It is the responsibility of the Clinical Leads to facilitate: All new staff whose role will involve CVAD s should attend the clinical skills simulation training session and complete the clinical skills training package. Page 3 of 15

Permanent staff whose duties include CVAD must attend the clinical skills training day and attend up-dates annually All clinical staff whose duties involve CVAD care can demonstrate compliance and competence in relation to the policy 4.3 Clinical staff The individual registered practitioner is accountable for their practice under the guidance of the Nursing and Midwifery Council Code of Professional Conduct (2015). Therefore, under no circumstances should a nurse undertake the management or care of CVAD s unless s/he has the appropriate knowledge, attended the Study Day and have completed the CVAD Clinical Skills Training Package (NPSA, 2007 RCN 2016). NOTE - It is the responsibility of the individual nurse to inform his or her manager if they do not have the appropriate training. All staff are required to ensure accurate records are maintained at all times in accordance with the Trust s Record Keeping Policy. 5. PROCEDURE/IMPLEMENTATION 5.1 DRESSING CHANGE AND CVAD CARE For: PICC (Peripherally- Inserted Central Catheter) Line Hickman/ Broviac Line 5.1.1 Essential Equipment (check these are present before starting procedure) Sterile Dressing pack including gloves and apron Non sterile gloves Sterile unopened wound care tegaderm dressing and stat-lock dressing 2% Chlorhexidine gluconate in 70% Isopropyl Alcohol wipes in individual packaging. Alcohol hand rub Access to liquid soap and water or foaming hand wipes. Appropriate waste collection Open-weave bandage if needed (eg class 1 k-band (for retention), class 2 k-lite (for support). The aim of a dressing is to minimise the contamination of the insertion site and provide stability of the device. To be changed every 7 days minimum but sooner if clinically indicated, soiled, if the dressing is no longer intact or moisture collects under it. Changing of a dressing requires an aseptic technique. Page 4 of 15

5.1.2 Pre-procedure Action Check patient ID and gain consent (explain procedure). Check site before continuing -refer to problem solving guidance. Hand hygiene. Open sterile dressing pack to make sterile field (check expiry dates). Decant equipment onto sterile field including opening dressing. Decontaminate hands with alcohol hand rub and apply non-sterile gloves remove soiled dressing pull dressing towards the insertion site. Check stat lock (remove if soiled) and dispose of in appropriate waste stream Check integrity of line and inspect the site. During inspection measure and document the length of the line from insertion site to the anchorage point, check against discharge information Remove non-sterile gloves, repeat hand hygiene. Apply apron and gloves from dressing pack. To ensure that the patient understands the procedure and gives his/her valid consent. If a patient is deemed not to have capacity to consent to treatment refer to Consent to Care and Treatment and Mental Capacity Act policies. To maintain asepsis and reduce contamination of equipment. To reduce risk of cross-contamination. To maintain asepsis and reduce contamination of equipment. To reduce risk of dislodgement. To reduce risk of infection. Observe site for any signs of infection. Checking line integrity and help detect if line has dislodged. To maintain asepsis and to reduce risk of cross-contamination. To maintain asepsis. 5.1.3 Procedure Action Place sterile field from dressing pack under CVAD. With Chlorhexadine and Alcohol wipe clean site from entry point outwards for a minimum of 15 secs and allow to air dry. Apply dressing as per instructions - replace stat-lock if required. If required apply sterile gauze as protection for the lumen and cover with loose bandage if patient chooses. To ensure a sterile field. To reduce risk of infection/contamination. To keep area clean and dry and maintain skin integrity. Stat lock supports stability of the line. To protect exit site. Page 5 of 15

5.1.4 Post-procedure Action Dispose of all waste in appropriate waste stream, including gloves and apron. Hand hygiene. Check patient is comfortable and answer any questions. Document procedure in line with Clinical Record Keeping Policy. Reduce risk of contamination. Reassurance for patient. To record intervention and action required. 5.2 Accessing the Devices (CVADs) Guidance/technique may vary as different Secondary Care Policies may need to be used. Accessing a CVAD should be performed using aseptic technique and also with reference to the following Patient group Directions (PGDs): Administration of Heparin Sodium To Line Lock a Vascular Access Device Administration of Sodium Chloride Injection as a Flush 5.2.1 Equipment (check these are present before starting procedure) Sterile Dressing Pack 3 x 10 mls syringes for aspirating and flushing (needles for drawing up if required) When using glass vials the solutions must be drawn up using a blunt filter needle or filter medical straw. (When using plastic vials a blunt needle or medical straw must be used) 0.9% Sodium Chloride for pre and post flushing Heparinised Saline (10units/ml) 5ml ampoule Medication prescribed and appropriate syringe size not less than a 10ml syringe to avoid internal pressure damage (for medication administration) 2% Chlorhexidine in 70% isopropyl alcohol wipes in individual packaging. Alcohol hand rub Liquid soap and paper towels/soapy hand wipes Sharps bin Appropriate waste stream Page 6 of 15

5.2.2 Pre-procedure Action Check patient ID and gain consent (explain procedure) Check site before continuing -refer to problem solving guidance. Hand hygiene. Open sterile dressing pack to make sterile field (check expiry dates). Decant equipment onto sterile field including prepared medication Ensure used needles and syringes are disposed of immediately into appropriate sharps container. Do not leave any sharps on opened sterile pack. Check integrity of line and inspect the site. Observe for any leakage when flushing. Hand hygiene and apply apron and gloves from dressing pack. To prepare patient, gain consent and to ensure that it is safe to carry out procedure. If the patient does not have capacity please refer to the Consent-tocare-and treatment policy and MCA guidance http://www.rdash.nhs.uk/wp- content/uploads/2014/04/consent-to- Care-and-Treatment-Policy-v8.pdf http://www.rdash.nhs.uk/wp- content/uploads/2015/01/mca1-mental- Capacity-Assessment.pdf To maintain asepsis and reduce contamination of equipment. To reduce risk of cross-contamination. To maintain asepsis and reduce contamination of equipment. To reduce the risk of needle stick injury and to prevent contamination of pack. Observe site for any signs of infection. Checking line integrity and checking for dislodgement. To maintain asepsis. 5.2.3 Procedure Action Place sterile field from dressing pack under CVAD. With Chlorhexadine and Alcohol wipe clean each lumen with a separate wipe and each bung with a separate wipe for a minimum of 15secs and allow to air dry. Check the patient s referral letter as some hospitals also clean the clamp as this will be touched. If available, refer to the referring To ensure a sterile field. To reduce risk of infection/contamination. Check patency of line. Page 7 of 15

Action hospital s guidance which may/may not instruct the following: Aspirate blood (amount according to guidance) with an empty 10ml syringe. Dispose of syringe including blood in sharps bin. Attach syringe containing the 10mls 0.9% sodium chloride flush always check prescription this may vary. Open the clamp (devices may vary - be confident in use of device). Whichever device is in-situ, gently inject 0.9% sodium chloride flush using push/pause technique. Close clamp. Remove empty syringe from flush immediately attach the syringe with prescribed and prepared drug. Open the clamp at the start of the procedure and close the clamp at the end. Inject the drug at the specified rate, recommended by the manufacturer, see instruction. If in doubt check the Injectable Medicines Administration Guide available in basepoints Consult the patient during the injection about any discomfort or pain. If more than one drug is to be administered, flush with 10mls 0.9% sodium chloride between administrations by changing syringes, always check prescription this may vary. At the end of the injection, flush with 0.9% sodium chloride, usually 10mls. Always check the prescription. Line-lock with Heparin Sodium if prescribed on the patient s referral instruction to administer medication proforma. Administer the flushing solution using push/pause and ending with positive pressure. Clamp off in the last 1-2mls of flush maintain a positive pressure. To flush the access device prior to giving medication to ensure patency. To confirm patency of the vein. To maintain patency of device and reduce the occurrence of a thrombus. Monitor for resistance and pain. For a seamless procedure. Observe the patient and the injection site whilst administering. To prevent excessive pressure within the vein. To prevent speed shock. To detect early signs of an allergic reaction and complications around the insertion site. To detect any complications at an early stage, and ensure patient comfort. To prevent drug interactions. To flush any remaining irritant solution away from the device site. To maintain patency of CVAD. Page 8 of 15

Action Observe the insertion site carefully. Check patient comfort and answer any questions. To detect any complications at an early stage. Extra pressure within the vein caused by both fluid flow and injection of the drug may cause rupture of the vessel. Reassurance for patient. 5.2.4 Post-procedure Action Dispose of waste immediately after use, into appropriate waste streams, including gloves and apron. Repeat hand hygiene. Record the flush in patient s Record and any medication administration on medication chart or transcription cards. Complete patients in-house paper record (where appropriate) and complete record keeping on system used with full details including batch codes and expiry dates, in line with Clinical Record Keeping Policy. Communicate outcome of visit with team for next handover. To avoid needle stick injury and reduce risk of infection. To maintain accurate records, provide a point of reference in the event of any queries and prevent any duplication of treatment. Continuity of care. 5.3 If only accessing CVAD for flush follow above procedure but only flush once. Risks and Complications - Problem-solving table Nursing care must be recorded in the patients nursing record and evaluated at each visit. This must include insertion/exit site and condition of dressing. Problem Cause Action Bruising Infection Swelling to or around site of insertion Due to trauma of procedure or accidental Local infection of the skin or from within the bloodstream Blood Clot Thrombosis Infection Will usually settle within a few days. If continues refer back to ward. Refer back to original referrer/ward Refer to ward where discharged. Page 9 of 15

Problem Cause Action Displacement of line Unable to aspirate Unable to flush Exudate at insertion site Catheter damage Blockage, displacement or a vacuum causing the tubing to stick to vein wall, kinky or pinching of the line. Displacement of device Thrombosis Pinching Poor infection prevention measure Cross contamination From insertion or when dressing change. Repeated clamping Accidental damage Use of wrong size syringe smaller than 10mls Visually check site and line, attempt to flush and try to aspirate again, if able to flush give medication and observe patient and site. Reposition or ask patient to move to reduce kinking etc. If unable to aspirate or flush, refer to ward where patient discharged. Refer to ward where patient discharge. Clean site, record and monitor on next visit, if symptoms persist at next visit swab and send to microbiology. You could not leave this until the next visit if the patient is only on weekly visits. They need an extra visit a couple of days later to reassess and monitor as indicated below Visit more frequently than weekly if necessary to monitor (eg monitor temperature for potential bacteremia pending microbiology results) Refer patient back to ward. Use a separate clamp to clamp above the fracture this clamp is usually organised/ provided by the original referrer/ward. Fluid leakage at insertion site Catheter rupture Fibrin sheath (a growth of cells around the catheter) Pinch off Infection Refer patient back to ward. Page 10 of 15

5.4 Contra-indication: Taking blood samples from a central venous access device Obtaining blood samples from a CVAD can lead to inaccurate results therefore is not routinely done within this Trust. Following trouble-shooting guidance, if any concerns refer patient back to the original referrer. 5.5 General Principles NERAL PRINCIPLES Prior to any procedure please ensure the appropriate consent is obtained in accordance with trust policy on Consent to Care and Treatment. Assess the risk for infection against the risk of mechanical complications (Refer to CVAD Clinical Skills Training Package available on the Intranet site in Clinical Skills Packages) 6. TRAINING IMPLICATIONS Staff will receive instruction and direction regarding CVAD procedures and information from a number of sources: Policies and Procedure available on the Trust Policies site Line Manager/ Community Practice Teachers Clinical Skills workshops - dates available on the RDaSH Learning and Development site via RED Centre. Clinical Skills Training Package Central Venous Access Devices (CVADs) Care and Management Policy Staff groups requiring training New starters and permanent staff relevant to role How often should this be undertaken On employment and yearly update assessment as per Clinical skills training package Length of training Half day Delivery method Simulation E-learning Demonstration Observation Assessment Training delivered by whom RED CENTRE Community Practice Educators Clinical Educators Competent confident trained staff up to date with relevant assessments Where are the records of attendanc e held? Electronic Staff Record system (ESR) Page 11 of 15

7. MONITORING ARRANGEMENTS Staff will receive instruction and direction regarding CVAD procedures and information from a number of sources: Policies and Procedures Line Manager/ Community Practice Teachers Clinical Skills workshops - dates available on the RDaSH Learning and Development site via RED Centre. Clinical Skills Training Package available on the intranet leaning and development site clinical skills packages. Infection Prevention and Control team for IPC information Area for Monitoring Training compliance and following up on those who fail to attend How Who by Reported to Frequency Follow up in writing with relevant trainers/ managers Line Mangers Community Practice Educator Managers Yearly Any Service User feedback, Complaints or Your Opinion Counts which relate to none compliance with the standards in this policy Investigation Feedback Review Matrons/Man ager Business Divisions Leadership and Quality Groups Ongoing as the need arises 8. EQUALITY IMPACT ASSESSMENT SCR EENING The completed Equality Impact Assessment for this Policy has been published on this policy s web page on the Trust policy website 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). Indicate how this will be met Care delivered within the scope of this policy will be within a community setting, in Community hospital setting and in patients own homes. Care will be organised taken the patients and families views and beliefs into consideration and all care will be delivered with consideration of the patients requirement of privacy. Page 12 of 15

8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1) Patients capacity to make decisions will be considered within the assessment of delivering care within the scope of this policy. Where possible, patients will be afforded the time and attention to make decisions for themselves wherever possible. 9. LINKS TO ANY ASSOCIATED DOCUMENTS Consent to Care and Treatment Policy Aseptic Non-Touch Technique Policy Hand Hygiene Procedure (within the Infection Prevention and Control Manual) Standard Precautions Procedure (within the Infection Prevention and Control Manual) Sharps; Safe Use and Disposal and Management of Contamination Injuries Procedure (within the Infection Prevention and Control Manual) Blood and Body Fluid Spillages Procedure (within the Infection Prevention and Control Manual) Minimum Standards for the Physical Assessment and Examination of Inpatients in Mental Health and Learning Disability Services Waste Policy Administration of Sodium Chloride Injection as a Flush Patient Group Direction http://www.rdash.nhs.uk/29741/administration-of-sodium-chloride-injectionas-a-flush-pgd/ Page 13 of 15

Administration of Heparin Sodium to Line Lock a Vascular Access Device Patient Group Directions NICE Clinical Guideline 139 Prevention and Control of healthcareassociated infection in primary and community care last accessed 20-11- 2017 http://publications.nice.org.uk/infection-cg139 National Institute for Health and Clinical Excellence (2012 updated 2017) Prevention of healthcare-associated infection in primary and community care. NICE.London EPIC 2 2007 accessed 16-7-14 http://www.hpa.org.uk/topics/infectiousdiseases/infectionsaz/hcai/guideli nesforprofessionalshcai/ 10. REFERENCES Bishop,L. Dougherty,L. Bodenham,A. Crowe,P. Kibbler,C et al (2006). BCSH Guidelines on the insertion and management of Central Venous Access Devices. Dougherty, L & Lamb, J (Eds.) (2008). 2ND Edition: Vascular access in the Acute Care setting: INTRAVENOUS THERAPY IN NURSING PRACTICE: Blackwell Publishing, Oxford.pp.271-320. Dougherty, L & Lister, S: (Eds.) (2011). 8th Edition: THE ROYAL MARSDENHOSPITAL MANUAL OF CLINICAL NURSING PROCEDURES: Blackwell Scientific Publ.: Oxford. EPIC 2: (2007). National Evidence-Based Guidelines for preventing Healthcare-Associated Infections in NHS Hospitals in England. JOURNAL OF HOSPITAL INFECTION: 65S,S1-S64 [on line at: http://www.epic.tvu.ac.uk/pdf%20files/epic2/epic2-final.pdf EPIC3: (2013): National Evidence-Based Guidelines for preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 (2014) S1 S70 Irving, V: (2001). Skin problems in the pre-term infant: avoiding ritualistic practice. PROFESSIONAL NURSE: Vol. 17: No.1: p63-663. Medicines & Healthcare products Regulatory Agency [MHRA] (2004). MEDICAL DEVICE ALERT: MDA/2004/01: January 2004: MHRA: London. Page 14 of 15

NICE [National Institute of Clinical Excellence] (2003). INFECTION CONTROL PREVENTION OF HEALTHCARE-ASSOCIATED INFECTION IN PRIMARYAND COMMUNITY CARE Clinical Guideline 2: June 2003: NICE: London. National Institute for Health and Clinical Excellence (2012 updated 2017) Prevention of healthcare-associated infection in primary and community care. NICE.London NMC (2015) The Code: Standards of Conduct, Performance and Ethics for Nurses and Midwives. London: Nursing and Midwifery Council. Available at: www.nmc uk.org NPSA (2007) Alert 20. Promoting the Safer Use of Injectable Medicines.: National Patient Safety Agency. London RCN (2016) Standards for Infusion Therapy, Fourth Edition.: Royal College of Nursing. London Woodrow, P (2002). Central venous catheters and central venous pressure. NURSING STANDARD: Vol.16: No.26: p.45-51. Page 15 of 15