This is an official Northern Trust policy and should not be edited in any way Catheters - Insertion and Ongoing Management of Central Venous Catheters Reference Number: NHSCT/11/466 Target audience: Medical, pharmacy and nursing staff charged with the insertion and on-going care of central venous lines. Sources of advice in relation to this document: Valerie Jackson, Director Acute Hospital Services Paul Johnston, Consultant Anaesthetist Paul Leyden, Consultant Anaesthetist Replaces (if appropriate): N/A Type of Document: Trust Wide Approved by: Policy, Standards and Guidelines Committee Date Approved: 17 November 2011 Date Issued by Policy Unit: 22 December 2011 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves
Insertion and Ongoing Management of Central Venous Catheters November 2011
Insertion and Ongoing Management of Central Venous Catheters Target Audience Medical, pharmacy and nursing staff charged with the insertion and on-going care of central venous lines. Legislative Compliance It should be noted that the Northern Trust has agreed to comply with CCaNNI guidelines on this matter and has a duty to comply with the Department of Health (DoH) directive Saving Lives which specifically aims to holistically reduce healthcare related infection. Therefore the guidelines herein will be drawn from and relate to these previous guidelines. Roles and responsibilities Chief Executive The Chief Executive has overall responsibility for ensuring infection prevention and control is a core part of the Trust s governance and patient safety programmes. Board The Board has collective responsibility for ensuring assurance that appropriate and effective policies are in place to minimise the risks of health care associated infections. Director of Infection Prevention & Control It is the responsibility of the Director of Infection Prevention & Control to oversee the development and implementation of infection prevention and control procedures. Infection Prevention & Control Team It is the responsibility of the Infection Prevention & Control Team to ensure this policy is reviewed and amended at the review date or prior to this, following new developments in Aseptic Non-Touch Technique. Service Managers It is the responsibility of managers to ensure that they oversee the development and implementation of this policy among ward staff. Education, training and assessment in the Aseptic Non-Touch Technique should be provided to all persons undertaking such procedures and audit should be undertaken to monitor compliance with Aseptic Technique (The Health Act 2006). 1
Insertion and Management of Central Venous Catheters 1. Introduction Central venous catheters (CVC) are inserted by a range of clinicians for a variety of indications including Parenteral nutrition and Dialysis. The majority of CVC lines are however inserted within the Theatre / ICU arena. Following the recent NCEPOD mixed bag report on Parenteral Nutrition it is recommended that a specific policy for CVC line insertion and management is in place within each Trust. As the Northern Trust has already accepted the CCaNNI guidelines which are generic we aim to produce a Trust specific policy that should be adhered to. http://www.ccanni.org.uk/images/documents/cvc%20april%2008.pdf Previous recommendation by the department of health to reduce the risk of line related infection is also applicable. (Saving Lives 2007) http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicati onspolicyandguidance/dh_078134 Healthcare associated infection (HCAI) is common and detrimental both to patient s health and the expenditure associated with prolonged hospitalisation and increased resource consumption required to treat such infections, EPIC 2007 1. These guidelines are drawn largely from those of the EPIC guidelines which were preceded by an expert review of evidence-based guidelines for preventing intravascular device related infections, developed at the Centres for Disease Control and Prevention (CDC) by the Healthcare Infection Control Practices Advisory Committee (HICPAC), updated in 2002 2. It is therefore correct that each trust should adopt policies which aim to reduce these infections, in this case catheter related blood stream infection associated with central venous lines. It is postulated that Catheter related blood stream infection is caused by: Skin micro-organisms contamination of catheter at insertion. Subsequent catheter contamination by skin commensal organisms Catheter contamination during intervention Direct introduction of micro-organisms via port site injection 2. Purpose To provide Northern Trust wide guidance in the management of CVC lines to help reduce HCAI and allow compliance with current guidelines and national recommendations, which are based upon best practice and the available evidence base. 2
3. Objectives To ensure patient safety at point of insertion To ensure appropriate continued line care post insertion To standardise policy within the trust To ensure that policy is applied in all cases with the possible exception of the emergency situation. To promote the use of Peripherally Inserted Central Catheters (PICC) within the Trust when clinically suitable. 4. Definition The term CVC refers to any intravenous catheter whose tip lies within one of the large central veins. These lines are primarily used for: Haemodynamic monitoring Drug and fluid administration Parenteral nutrition Haemodialysis Pacemaker wire placement 5. Policy Statements a. Assessment i. An assessment of the need for a CVC and the type of catheter should be recorded in the clinical notes by the referring team. ii. CVC lines should only be used for blood sampling on rare occasions at the request of a senior clinician. b. Consent In the unconscious patient CVC lines are often inserted in the patients best interests. In the conscious patient the referring team should document the discussion of indication with the patient. In addition the clinician responsible for insertion should gain fully informed procedure consent. If the procedure is part of a holistic anaesthetic management plan documentation of verbal consent is considered adequate. c. Insertion i. CVC lines should be inserted by suitably trained and/or supervised staff in a designated clean area. In the emergency situation a line inserted in less than ideal circumstances should be changed at the next available opportunity. ii. All practitioners who insert CVC lines unsupervised should have appropriate training to allow safe insertion and identification of potential complications. iii. Manipulation and removal of CVC should be undertaken by staff with the appropriate competencies. 3
iv. Platelet and coagulation blood results should be known and corrected if necessary prior to CVC line insertion, except in an emergency situation where delay may be unacceptable. v. Strict aseptic technique should be adhered to for line insertion. Cleaning of skin should be carried out using a solution of 2% chlorhexidine gluconate in 70% isopropyl alcohol and allowed to air dry. If there is a known patient sensitivity to chlorhexidine. In this circumstance alcoholic povidone-iodine solution should be used. vi. The use of antimicrobial impregnated lines should be considered if there is a high risk of infection and the line in expected to be required for between 1-3 weeks. vii. Site selection should be considered in respect to the risk of infection where the femoral site is considered highest risk. Lines should not be inserted through an area of suspected skin infection. viii. Routine antibiotic administration before or during insertion of CVC lines is not recommended. ix. Line position should be confirmed prior to use except where this is impracticable such as in the theatre environment. X ray confirmation should be obtained as soon as possible. Prior to commencement of TPN the prescriber should document adequate position of the CVC line in the clinical notes. This is considered to be in the lower third of the superior venae cavae. d. Documentation i. Full procedural description and clinical indication should be documented within the clinical notes ii. High impact intervention form No 1 should also be commenced and accompany the patient as part of their notation iii. The CVC dressing should have the relevant insertion information written clearly. iv. Date and time of removal should be recorded in the clinical notes and within the high impact intervention No 1 chart. e. Continued management i. Staff should adhere to the saving lives bundle of care and high impact intervention No 1 ii. Before any line intervention staff must decontaminate hands. iii. Prior to use of any injection port the cannulae hub should be decontaminated with a 2% chlorhexidine gluconate in 70% isopropyl alcohol and allow to dry. iv. 2% chlorhexidine gluconate in 70% isopropyl alcohol based solution should be used to clean catheter site when dressings are changed and allowed to air dry 4
v. A sterile transparent dressing should be applied to the catheter insertion site. vi. Transparent dressing should be routinely changed every seven days. Evidence of dressing breach or soiling should prompt earlier dressing change. f. Infection control Hand Hygiene i. Decontaminate hands before and after each patient contact. ii. Use correct 7 step technique. Aseptic Non Touch Technique i. Gown, gloves and drapes as indicated should be used for the insertion of the device. Personal Protective i. Gloves are single use items ands should be removed and discarded immediately after the care activity. ii. Eye/face protection is indicated if there is a risk of splashing with blob or body fluids. Daily considerations at ward level i. The insertion site should be inspected at least daily for signs of infection. Core temperature and white cell counts should also be taken regularly to screen for signs of a systemic inflammatory response. This may indicate line infection. ii. Consideration of line removal should be made on a daily basis. iii. In the event of purulent discharge a swab of skin site should be taken. iv. Catheter tips should not routinely be sent for culture unless there is a clinical suspicion of line related infection. v. Routine catheter replacement is not recommended and replacement should be based upon an assessment of infection risk amongst other factors. vi. Each clinical area should have a procedure for the management of CVC lines that show signs of local infection, tenderness at insertion site, phlebitis, unilateral distal oedema or other potential complications. If necessary referral of the patient to the inserting clinician or their team should be considered. vii. Use an aseptic technique for any catheter access and decontaminate ports or hubs with 2% chlorhexidine gluconate in 70% isopropyl alcohol and allow to dry prior to administering fluids or injections. 5
Sharps i. Sharps container should be available at point of use. Do not disassemble needle and syringe. g. Administration sets i. Administration sets used to infuse blood products must be replaced after every second unit, after transfusion episode or at 12 hours whichever is sooner. (EPIC 2007) ii. Parenteral nutrition sets should be changed every 24 hours except if the PN contains no lipid. In this case 72 hours is adequate iii. Fluid administration sets should be changed at 72 hours iv. CVC lines should be flushed after use normally with Sodium Chloride 0.9% h. TPN i. Parenteral nutrition should be administered via a dedicated lumen. This lumen should not be used for other purposes. A single lumen catheter should be considered for this purpose if PN is the only indication for a CVC line. ii. Administration sets should be changed according to previous guideline. ( g. ii ) Equality, Human Rights and DDA The policy is purely clinical/technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Alternative formats This document can be made available on request on disc, larger font, Braille, audio-cassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. References Department of Health UK. Epic 2: Guideline for preventing infections associated with the use of central venous access devices. Journal of Hospital Infection; 2007; 65 (Supplement):S33-S59. Centre for Disease Control Guidelines. Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections. American Journal of Infection Control 6
2002;30:476 489. ICNA. Audit tools for monitoring infection control standards 2004 Winning ways: working together to reduce healthcare associated infection in England 2003 www.clean-safe-care.nhs.uk 7