PROCEDURE FOR THE CARE AND MAINTENANCE OF CENTRAL INTRAVENOUS ACCESS DEVICES

Transcription

1 PROCEDURE FOR THE CARE AND MAINTENANCE OF CENTRAL INTRAVENOUS ACCESS DEVICES First Issued Issue Version Purpose of Issue/Description of Change Planned Review Date One To ensure a safe and effective procedure for the care and maintenance of central intravenous access devices by community nursing staff Named Responsible Officer:- Approved by Date Medicines Governance Pharmacist Quality and Governance Service Risk and Governance Group February 2012 Section: - Medicines Management MMSOP20 Target Audience Community Nursing UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

2 CONTROL RECORD Title Procedure for the care and maintenance of central intravenous access devices Purpose To ensure a safe and effective procedure for the care and maintenance of central intravenous access devices by community nursing staff. Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Annie Baker/Lisa Knight Document Librarian QGS Groups consulted with :- Medicines Management Group Infection Control Approved 08/08/2011 Date formally approved by 1 st Dec 2011 Risk and Governance Group Method of distribution Intranet Archived Date: February 2012 Location: S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 TC/R Updated procedure with added definitions of the different central catheters being used Status New / Revised / Trust Change 2/19

3 PROCEDURE FOR THE CARE AND MAINTENANCE OF CENTRAL INTRAVENOUS ACCESS DEVICES CONTENTS PAGE Introduction 4 Definitions 4 Target group 5 Training 5 Competency 5 Related policies 5 1. Procedure for exit dressing for skin tunnelled 5-7 catheters 2. Procedure for care of skin tunnelled catheters 7-10 that require saline flush and if prescribed heparin saline lock 3. Procedure for exit dressing changes for Peripherally Inserted Central Catheter 4. Peripherally Inserted Central Catheters That require Sodium Chloride Flush Trouble Shooting for Intravenous Central Access Devices Were to get advice from 17 Clinical Incident reporting 17 Vulnerable adults 17 Referrals 17 Equipment 17 Equality Assessment 17 References 18 Appendix 1 Highlighted Alert MDA/2008/ /19

4 PROCEDURE FOR THE MAINTENANCE OF CENTRAL INTRAVENOUS ACCESS DEVICES INTRODUCTION Patients requiring long term intravenous therapy may require a central intravenous access device. A central venous access device is a device where the tip lies within the lower third of the vena cava (superior and inferior) or the right atrium (Dougherty, 2006). This procedure refers to the care of skin tunnelled catheters (formally known as Hickman lines) and Peripherally Inserted Central Catheters (PICC). For the care and maintenance of peripheral intravenous access devices, please refer to the Trust s procedure for cannulation. For flushing totally implanted intravenous access devices, please refer to the Procedure for Flushing Totally Implanted Intravenous Access Devices for Adults. For all other central intravenous access devices, discuss with your line manger or on call manager if out of hours. DEFINITIONS A PICC catheter: is inserted via a peripheral vein and advanced along the upper arm to have the tip located in the lower third of the superior vena cava. A skin tunnelled catheter: is a catheter that is inserted into the skin usually on the chest wall, between the nipple and the clavicle, and the catheter is advanced via a subcutaneous tunnel and inserted along a large central vein until its tip lies in the vena cava or right atrium. Non-tunnelled catheter: is a catheter that is inserted directly into a vein with its tip usually located in the vena cava or right atrium. This type of catheter is not used in the community setting, if requested to care for this type of catheter, discuss with your line manger or on call manager if out of hours. Totally Implanted Intravenous Access Devices: is an implanted port that is implanted beneath the skin that comprises of a portal body and a catheter. For care of totally implanted intravenous access device ports refer to the Procedure for Totally Implanted Intravenous Access Device Ports for Adults There are two main types of tip endings for all catheters: Open-ended: an open ended catheter can be of two designs. One type opens directly out at the end of the catheter and can be cut to adjust the length of the catheter. The other has a staggered opening to allow for a more flexible and less traumatic tip endings but cannot be cut. The main disadvantage of an open-ended catheter is the risk of blood reflux if it is not flushed effectively. 4/19

5 Valve catheters or closed end catheters: There are two types of valved catheters: one with a valve in the tip (known as a Groshong Valve) and the other has a valve in the hub, this is known as a pressure activated sensory valve (PASV) catheter. Valved catheters work by ensuring that that there is no blood reflux when the valve is not in use. Both work on a pressure activated valve which opens with infusate (positive), and aspiration (negative), but remains closed in the absence of any pressure and eliminates the need for any clamps attached. TARGET GROUP All registered nurses employed by the Trust who are required to carry out this procedure as part of their role. TRAINING All clinical staff need to undertake training in Care of Central Venous Access Devices. COMPETENCY All clinical staff must complete the Care and Maintenance of Intravenous Central Access Devices competency framework. The competency will need to be updated every two years, if staff are continuing to care for patients requiring this intervention. The competence will be available on the Trust s intranet site. In addition, the Quality and Governance Team will hold a supply of models for staff to update their skills as required, as it is appreciated that there may be months between caring for patients requiring this procedure. Staff may need to attend the discharging hospital, if additional clinical information is needed to care for the patient prior to patient being admitted onto the caseload. RELATED POLICIES Please refer to relevant Trust policies and procedures PROCEDURE FOR EXIT DRESSING CHANGES FOR SKIN TUNNELLED CATHETERS EQUIPMENT REQUIRED: Single use disposable sterile dressing pack Single use disposable non -sterile gloves Chlorhexidine gluconate 2% in 70% Isopropyl alcohol impregnated sterile swab/applicator is generally recommended. (An aqueous solution of chlorhexidine gluconate is recommended, if the manufacturer s instructions prohibit the use of alcohol with their product. For selection of the appropriate aqueous chlorhexidine product, seek advice from referring hospital) If patient is sensitive to chlorhexidine use aqueous povidone-iodine (For selection of the appropriate product, seek advice from referring hospital) Semi-permeable transparent Intravenous (IV) dressing Liquid soap and paper towels or alcohol hand rub or gel 5/19

6 PROCEDURE Verbally check patient s identity with patient by asking full name and date of birth. Check with carer/family if not able to confirm Staff members to introduce themselves Explain and discuss the procedure with the patient and relevant family members/carer Explain procedure and obtain informed and valid consent, and document in patient s nursing care plan Establish patient has no known allergies, check in patient s records and also ask patient/family of any known history and document in the patient s records. Decontaminate hands Ensure all equipment is gathered before commencing procedure Nurses should ensure that catheter site care is compatible with catheter materials (tubing, hubs, injection ports, luer lock connectors and extensions) and carefully check compatibility with manufacturer s recommendations Open sterile dressing pack onto a clean area and place all sterile single use equipment required within the sterile field and check all packaging is intact and in date Use an aseptic non-touch technique Decontaminate hands Apply single use disposable apron Apply non sterile gloves. Using a non touch technique stabilise the insertion device and loosen and remove exit site dressing, working from the edges to the exit site. Dispose of old dressing in waste disposal bag Inspect the catheter exit site for signs of skin discolouration or infection for example erythema and/or swelling. Refer to phlebitis score for indications of infection on the Trust intranet. Remove gloves and decontaminate hands. If infection suspected contact referring hospital team who inserted the catheter for advice, document all necessary actions to be taken in patient s notes. Apply single use disposable sterile gloves in a manner RATIONALE To check the correct identity of the patient To promote mutual respect To ensure understanding of the procedure and allow time for patient to ask questions To comply with Trust Consent Policy To allow the patient/client to make an informed and valid decision and gain co-operation (NICE 2003). To reduce allergic reactions, e.g. to heparin, chlorhexidine To reduce the risk of transfer of transient organisms on the healthcare workers hands To prevent infection and catheter contamination (Pratt et al 2007). Ensure compatibility and maintain safety (NICE 2003 Brittan 2008) Refer to MDA/2007/051. To prevent contamination of key parts To reduce the risk of transfer of transient organisms on the healthcare workers hands To protect clothing or uniform from contamination and potential transfer of microorganisms To prevent contamination of key parts and key site To prevent accidental removal of the catheter and friction or trauma to skin surface To identify early signs of infection and to treat appropriately. (DH 2007). To prevent cross infection and environmental contamination To maintain asepsis, reduce the risk of 6/19

7 which prevents the outer surface of the sterile glove being touched by a non sterile item Using a non touch technique apply sterile dressing towel to patient as near as possible to skin tunnelled catheter. Clean around catheter and exit site with chlorhexidine gluconate 2% in 70% Isopropyl alcohol impregnated sterile swab/applicator or other recommended cleansing swab/applicator. The swab should be applied in a circular motion from exit site outwards using friction for up to one minute. Not too vigorous or the skin s natural defence maybe destroyed. It is advisable to seek advice from referring hospital/clinician and refer to manufacturer s guidelines if available. Allow to dry naturally and apply a sterile semipermeable IV transparent dressing to protect and secure skin tunnelled catheter. Dressing changes should be performed every seven days or sooner if dressing is no longer intact or moisture collects under the dressing. On completion of procedure remove and dispose of Personal Protective Equipment (PPE) to comply with waste management policy Decontaminate hands following removal of PPE Document all care in patient s nursing records, including the condition of the skin surrounding exit site (DH 2007) microbial contamination and prevent the spread of infection Some tunnelled silicone catheters are prone to fracture at connection point if excessive alcohol is used (CINS 2009). Chlorhexidine based solutions (in alcohol) are recommended for cleaning catheter exit site (DH 2007 Brittan 2008). Refer to manufacture s guidelines for appropriate chlorhexidine solution to be used with their central access device when providing exit site care (Pratt et al 2007). Allowing any cleaning solution to dry is vital for disinfection to be completed (Pratt et al 2007). Semi-permeable transparent IV dressings should be used to cover catheter insertion site, and permit continuous visual inspection of the site. As occlusive dressings can trap moisture on the skin, and provide an ideal environment for the rapid growth of local micro-flora. Dressings for insertion sites must be permeable to water vapour and impermeable to micro-organisms (Pratt et al 2007). To prevent cross infection and environmental contamination To remove any accumulated transient and resident skin flora that may have built up under the gloves and possible contamination following removal of PPE. To ensure adequate records and enable continued care of device and patient (Dougherty and Lister 2008) 7/19

8 PROCEDURE FOR CARE OF SKIN TUNNELLED CATHETERS THAT REQUIRE SODIUM CHLORIDE 0.9% FLUSH AND IF PRESCRIBED HEPARIN SODIUM FLUSH SOLUTION FOR HEPARIN LOCK This procedure requires two staff one of whom must be a registered nurse. Refer to appendix one regarding an alert on needle free intravascular connectors MDA/208/016 EQUIPMENT Patient Medicines Administration Chart, carefully checking the flush (s) prescribed Standard Operating Procedure for the Administration of Heparin Patient s health records/care plan to clarify the type of intravenous central catheter as types vary between closed and open. Some have an integrated valve, whilst others have an external clamp on the line. Two sterile dressing packs 10ml luer lock syringes x 2 0.9% sodium chloride 10ml is the usual dose Heparin sodium flush solution 10units/ml (50 units/5ml) 5ml is the usual dose Hypo allergenic tape Liquid soap and paper towels/alcohol hand rub Needle free I/V access connector Green needles/ Filter needles for glass ampoules Sharps container Ampoule breaker Chlorhexidine gluconate 2% in 70% Isopropyl alcohol impregnated sterile swab/applicator is generally recommended. (An aqueous solution of chlorhexidine gluconate is recommended, if the manufacturer s instructions prohibit the use of alcohol with their product. For selection of the appropriate aqueous chlorhexidine product, seek advice from referring hospital If patient is sensitive to chlorhexidine use aqueous povidone-iodine. For selection of the appropriate product, seek advice from referring hospital Phlebitis checklist (see web site for current version) PROCEDURE FOR CARE OF SKIN TUNNELLED CATHETERS THAT REQUIRES SODIUM CHLORIDE 0.9% FLUSH AND IF PRESCRIBED HEPARIN SODIUM FLUSH SOLUTION FOR HEPARIN LOCK PROCEDURE Verbally check patient s identity with patient by asking full name and date of birth. Check with carer/family if not able to confirm Staff members to introduce themselves Explain and discuss the procedure with the patient and relevant family members/carer RATIONALE To check the correct identity of the patient To promote mutual respect To ensure understanding of the procedure and allow time for patient to ask questions 8/19

9 Explain procedure and obtain informed and valid consent, and document in patient s nursing care plan Establish patient has no known allergies, check in patient s records and also ask patient/family of any known history and document in patient s records. Read patient s records, Patient Medicines Administration Chart and relevant regime/ protocol and identify any special instructions, investigations or issues for which you need to seek advice Check the Patient Medicines Administration Chart specifies the following information and confirms that the details relate to the patient to be treated:- Patient s full name Patient s date of birth (DOB) NHS Number (if available) Prescribers signature and date prescribed Name of flush e.g sodium chloride 0.9%, Volume and frequency of administration Route of administration The allergy status of the patient Ensure all equipment is gathered before commencing procedure. Decontaminate hands Open sterile dressing pack onto a clean area and place all sterile single use equipment required within sterile field. Use an aseptic non-touch technique Apply single use disposable apron Inspect the catheter exit for any signs of skin discolouration or signs of infection e.g. exudate from exit site. If infection is suspected, contact the hospital team who placed the catheter for advice. Place prescribed ampoule of sodium chloride 0.9% to be flushed near to the working area, but not on sterile field. Open ampoule, if glass use an ampoule breaker. Apply single use disposable sterile gloves in a manner which prevents the outer surface of the sterile glove being touched by a non sterile item Using a non touch technique connect needle to syringe. To comply with Trust Consent Policy To allow the patient/client to make an informed and valid decision and gain cooperation (NICE 2003). To reduce allergic reactions, e.g. to heparin, chlorhexidine Preparing and Administering heparin therapy (NPSA 2007). To ensure correct Patients Medicines Administration Chart and that all relevant information is recorded on the Patients Medicines Administration Chart. The date on the administration prescription chart must be checked to determine if it is legal and remains current for individual care plan. To reduce the risk of an allergic reaction to for e.g. heparin or chlorhexidine To reduce the risk of transfer of transient organisms on the healthcare workers hands To prevent contamination of key parts To protect clothing or uniform from contamination and potential transfer of micro-organisms To ensure the procedure can be carried out safely (CINS 2009) Clinical procedures should be carried out in a manner that maintains and promotes the principles of asepsis (DH 2008). To prevent injury to nurse from ampoule shattering To maintain asepsis, reduce the risk of microbial contamination and prevent the spread of infection To reduce the risk of transfer of transient organisms. 9/19

10 Using a piece of sterile gauge pick up sodium chloride ampoule and draw up 10mls for flushing. Dispose of needle directly into sharps container and place syringe on sterile field. Needle free access connector are changed weekly, refer to discharging hospital guidelines/manufacturer s guidelines. If needle free connector requires changing and the catheter has a clamp, ensure clamp is closed prior to changing needle free connector. 10ml syringes should always be used as smaller syringes may damage the catheter (RCN 2003). To prevent needle stick injury and dispose of needles safely. To comply with hospital guidelines/ manufacturer s instructions Needle free devices provide a closed system and reduce the risk of air entry (Dougherty and Lister 2008). Remove needle free connector and discard. Using chlorhexidine gluconate 2% in 70% isopropyl alcohol impregnated swab/applicator or other recommended cleansing swab/applicator, clean around the end of the catheter clockwise and anticlockwise for at least five times and allow to dry naturally. Connect new needle free connector to catheter securely. If needle free connector does not require changing then scrub the hub of the needle free system with 2% chlorhexidine gluconate in 70% isopropyl alcohol impregnated swab/applicator or other recommended cleansing swab/applicator. Rubbing from the top of the needle free connector to the sides, do this three times using different parts of the wipe/applicator over a period of thirty seconds. Allow to dry naturally Never Force the Solution into the Catheter. There is no requirement to routinely withdraw blood and discard prior to flushing (except prior to blood sampling) Using a non-touch technique attach syringe with 0.9% sodium chloride flush, open clamp and inject the flush using a push/pause action, clamping as the last ml of solution is instilled into the catheter. If no clamp is required, remove syringe whilst injecting the final ml of fluid. Remove the syringe and discard in sharps container. For open ended skin tunnelled catheter, repeat this procedure using a separate syringe containing sodium heparin 50 units/ 5ml using a 10ml syringe to lock catheter Decontaminate injection port or catheter hub after To reduce the risk of infection and avoid contamination (2009). Please see Medical Device Alert 18/03/08 reference MDA/208/016. Allowing any cleaning solution to dry is vital for disinfection to be completed (Pratt et al 2007). This can cause damage to the catheter (Pratt et al 2007). There is an increased risk of infection and occlusion when withdrawing blood via a central venous catheter (RCN 2005). The pulsated flush creates turbulence within the catheter lumen, removing debris from the internal catheter wall (RCN 2003). Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (RCN 2003). Dispose of equipment safely as per clinical waste policy. To maintain patency of intravenous access device using the correct technique (RCN 2003). Procedure in accordance with national guidelines (NPSA 2007) To reduce catheter associated infections 10/19

11 it has been used to access the system using chlorhexidine gluconate 2% in 70% isopropyl alcohol impregnated sterile swab/applicator or the recommended cleansing impregnated swab/applicator Ensure that the catheter is secure and comfortable for the patient using tape to secure catheter to skin. On completion of the procedure remove and dispose of all Personal Protective Equipment (PPE) Decontaminate hands following removal of PPE Document all care in patient s nursing records. (Pratt et al, 2007). Working in partnership with the patient To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE. In accordance with the Trust s Record Keeping Policy. PROCEDURE FOR EXIT DRESSING CHANGES FOR PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) EQUIPMENT Single use sterile dressing pack Single use non-sterile gloves Hypo allergenic tape Semi-permeable transparent Intravenous (IV) dressing Liquid soap and paper towels/alcohol hand rub/gel PICC catheters may require skin closure strips or skin fixation devices e.g. statlock. Chlorhexidine gluconate 2% in 70% isopropyl alcohol impregnated sterile applicator (An aqueous solution of chlorhexidine gluconate is recommended, if the manufacturer s instructions prohibit the use of alcohol with their product. For selection of the appropriate aqueous chlorhexidine product, seek advice from referring hospital.) If patient is sensitive to chlorhexidine use aqueous povidone-iodine. For selection of the appropriate product, seek advice from referring hospital Tunnelled silicone catheters are prone to fracture at connection point if excessive alcohol is used. Therefore, it is advisable to seek advice from referring hospital/clinician. An aqueous solution of chlorhexidine gluconate as an alternative is recommended if the manufacturer s recommendations prohibit the use of alcohol with their product. Check for allergies. PROCEDURE Verbally check patient s identity with patient by asking full name and date of birth. Check with carer/family if not able to confirm Staff members to introduce themselves Explain and discuss the procedure with the patient and relevant family members/carer Explain procedure and obtain informed and valid consent, and document in patient s nursing care plan RATIONALE To check the correct identity of the patient To promote mutual respect To ensure understanding of the procedure and allow time for patient to ask questions To comply with Trust Consent Policy To allow the patient/client to make an informed and valid decision and gain co- 11/19

12 Establish patient has no known allergies, check in patient s records and also ask patient/family of any known history and document in patient s records. Ensure all equipment is gathered before commencing procedure Nurses should ensure that catheter site care is compatible with catheter materials (tubing, hubs, injection ports, luer lock connectors and extensions) and carefully check compatibility with manufacturer s recommendations Decontaminate hands Open sterile dressing pack onto a clean area and place all sterile single use equipment required within the sterile field and check all packaging is intact and in date Use an aseptic non-touch technique Apply single use disposable apron Apply single use disposable non sterile gloves Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. erythema and/or swelling. Refer to phlebitis score for indications of infection e.g. exudate from exit site. If you suspect infection please contact the hospital team who placed the catheter for advice Using a non touch technique loosen exit site dressing. To loosen dressing lift lower end gently ease the dressing off from the skin. Dressing should be removed in the direction from hand to elbow to prevent accidental catheter removal. Be aware that the fixation device may come off with the dressing, dispose of old dressing in waste disposal bag. Remove gloves and decontaminate hands Apply single use disposable sterile gloves in a manner which prevents the outer surface of the sterile glove being touched by a non-sterile item operation (NICE 2003). To reduce allergic reactions, e.g. to heparin, chlorhexidine To prevent infection and catheter contamination (Pratt et al 2007). Ensure compatibility and maintain safety (NICE 2003 Brittan 2008) Refer to MDA/2007/051. To reduce the risk of transfer of transient micro-organisms on the healthcare worker s hands To prevent contamination of key parts To protect clothing or uniform from contamination and potential transfer of micro-organisms To protect hands from contamination with organic matter and transfer of microorganisms Exit site dressings are important in preventing trauma and the extrinsic contamination of the site of entry. To identify early signs of infection and to treat appropriately. (DH 2007). To reduce the risk of infection (Pratt et al 2007). To prevent accidental removal of the catheter and friction or trauma to the skin surface (CINS 2009). To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of personal protective equipment To maintain asepsis, reduce the risk of microbial contamination and prevention of the spread of infection 12/19

13 Apply sterile dressing towel to patient as near as possible to PICC catheter. Clean around catheter exit site with chlorhexidine gluconate 2% in 70% isopropyl alcohol impregnated swabs/applicator or other recommended impregnated swabs/applicator. The swab should be applied in a circular motion from the exit site outwards. The applicator should be applied with friction but should not be too vigorous or the skin s defence may be destroyed Allow to dry naturally and apply new skin closure strips or skin fixation device. A sterile semi-permeable IV transparent dressing should be used to reliably protect and secure PICC catheter. Dressing changes should be performed every seven days or sooner if dressing is no longer intact or moisture collects under the dressing. On completion of the procedure remove and dispose of Personal Protective Equipment (PPE) to comply with waste management policy Decontaminate hands following removal of PPE Document all care in patient s records Chlorhexidine based solutions (in alcohol) are recommended for cleansing catheter exit site (DH 2007 Brittan 2008). Alcoholic Chlorhexidine combines the benefits of rapid action and excellent residual activity (DH 2001) Allowing any cleaning solution to dry is vital for disinfection to be completed (Pratt et al 2007). Semi-permeable transparent IV dressings should be used to cover catheter insertion site, and permit continuous visual inspection of the site. As occlusive dressings can trap moisture on the skin, and provide an ideal environment for the rapid growth of local micro-flora. Dressings for insertion sites must be permeable to water vapour and impermeable to micro-organisms (Pratt et al 2007). To prevent cross infection and environmental contamination To remove any accumulated transient skin flora that may have built up under the gloves and possible contamination following removal of PPE. In accordance with Trust Record Keeping Policy PERIPHERALLY INSERTED CENTRAL CATHETER THAT REQUIRES SODIUM CHLORIDE 0.9% FLUSH INTRODUCTION Heparin Sodium flush solution 50 units in 5ml is not usually prescribed for flushing PICC catheters. However, if a heparin sodium flush solution 50 unit in 5ml has been prescribed, discuss with referring clinician the rationale for using heparin and document all instructions as outlined in the Standard Operating Procedure for the administration of heparin flushes via central intravenous access devices to check dosage. This procedure requires two staff one of whom must be a registered nurse. Standards for Medicine Management - Standard 20 (NMC 2010). 13/19

14 Refer to appendix one regarding an alert on needle free intravascular connectors MDA/208/016 EQUIPMENT Two sterile dressing packs 10ml luer lock syringes Patient s health records/care plan to clarify the type of intravenous central catheter as types vary between closed and open. Some have an integrated valve, whilst others have an external clamp on the line. Patient Medicines Administration Chart with prescribed flush Chlorhexidine gluconate 2% in 70% Isopropyl alcohol impregnated sterile swab/applicator is generally recommended. (An aqueous solution of chlorhexidine gluconate is recommended, if the manufacturer s instructions prohibit the use of alcohol with their product. For selection of the appropriate aqueous chlorhexidine product, seek advice from referring hospital) If patient is sensitive to chlorhexidine use aqueous povidone-iodine (For selection of the appropriate product, seek advice from referring hospital 0.9% sodium chloride 10ml is the usual dose Sodium heparin 10units/ml (50units/5ml) 5ml is the usual dose (if required) Liquid soap and paper towels/alcohol hand rub/gel Needle free I/V access connector Green needles / Filter needles if glass ampoules Sharps container Ampoule breaker PROCEDURE Verbally check patient s identity with patient by asking full name and date of birth. Check with carer/family if not able to confirm Staff members to introduce themselves Explain and discuss the procedure with the patient and relevant family members/carer Explain procedure and obtain informed and valid consent, and document in patient s nursing care plan Establish patient has no known allergies, check in patient s records and also ask patient/family of any known history. Read patient s records, Patient Medicines Administration Chart and relevant regime/ protocol and identify any special instructions, investigations or issues for which you need to seek advice Check the Patient Medicines Administration Chart specifies the following information and confirms that the details relate to the patient to be treated:- RATIONALE To check the correct identity of the patient To ensure understanding of the procedure and allow time for patient to ask questions To comply with Trust Consent Policy To allow the patient/client to make an informed and valid decision and gain cooperation (NICE 2003). To reduce allergic reactions, e.g. to heparin, chlorhexidine Preparing and Administering heparin therapy (NPSA 2007). To ensure correct Patients Medicines Administration Chart and that all relevant information is recorded on the Patients 14/19

15 Patient s full name Patient s date of birth (DOB) NHS Number if available Prescribers signature and date prescribed Name of flush e.g. sodium chloride 0.9%, volume and frequency of administration Route of administration The allergy status of the patient Ensure all equipment is gathered before commencing procedure. Decontaminate hands prior to procedure Open sterile dressing pack onto a clean area and place all sterile single use equipment required within sterile field. Use an aseptic non-touch technique Decontaminate hands Apply single use disposable apron Place sodium chloride 0.9% ampoule near to the working area but not on sterile field. Open ampoule, if glass ampoule use ampoule breaker Apply single use disposable sterile gloves in a manner which prevents the outer surface of the sterile glove being touched by a non sterile item Using a piece of sterile gauge, pick up sodium chloride 0.9% ampoule and draw up 10mls for flushing. Dispose of needle into sharps container and place syringes on sterile field. Place sterile towel as near as possible to catheter If needle free connector needs changing and catheter has a clamp, ensure clamp is closed prior to changing needle free connector. Remove needle free connector and discard. Using chlorhexidine gluconate 2% in 70% Isopropyl alcohol swab/applicator or recommended cleaning swab/applicator, clean around the end of the catheter clockwise and anti-clockwise up to five times and allow to dry naturally. Connect new needle free connector to catheter securely. Medicines Administration Chart. The date on the administration prescription chart must be checked to determine if it is legal and remains current for individual care plan. To reduce the risk of an allergic reaction to for e.g. heparin or chlorhexidine Reduce the risk of transfer of transient organisms on the healthcare workers hands To maintain asepsis, reduce the risk of microbial contamination and prevent the spread of infection. To reduce the risk of transfer of transient micro-organisms on the healthcare worker s hands To protect clothing or uniform from contamination and potential transfer of micro-organisms Reference Standard Operating Procedure for Administration of Heparin Flushes via Central Intravenous Access Devices. To prevent injury to the nurse from ampoule shattering To maintain asepsis, reduce the risk of microbial contamination and prevent the spread of infection 10ml syringes should always be used as smaller syringes may damage the catheter (RCN 2003). To prevent needle stick injury and dispose of needles safely. Needle free devices provide a closed system and reduce the risk of air entry (Dougherty and Lister 2008). To reduce the risk of infection and avoid contamination (CINS 2009). Please see Appendix One re infection alert MDA/208/ /19

16 Never Force the Solution into the Catheter Attach syringe with prescribed flush and inject sodium chloride 0.9% using a push/pause action, clamping as the last ml of solution is instilled into the catheter. If open ended PICC, repeat this procedure using sodium heparin lock Remove syringe and discard. Decontaminate injection port or catheter hub after it has been used to access the system using Chlorhexidine gluconate 2% in 70% Isopropyl alcohol impregnated sterile swab/applicator or the recommended cleansing impregnated swab/applicator Ensure that the catheter is secure and comfortable for the patient On completion of the procedure remove and dispose of Personal Protective Equipment (PPE) to comply with waste management policy Decontaminate hands following removal of Personal Protective Equipment (PPE) Document all care in patient s nursing records. This can cause damage the catheter (Pratt et al 2007). The pulsated flush creates turbulence within the catheter lumen, removing debris from the internal catheter wall (RCN 2003). Dispose of equipment safely. To reduce catheter associated infections (Pratt et al, 2007). Working in partnership with the patient To prevent cross infection and environmental contamination To prevent cross infection and environmental contamination In accordance with Trust Record Keeping Policy TROUBLE SHOOTING FOR INTRAVENOUS CENTRAL ACCESS DEVICES If patient experiences any of these symptoms contact referring hospital PROBLEM Air Embolism - This may occur if air enters through the catheter following removal, or via an open catheter or a faulty device. An air embolism can occur at anytime from insertion to a few days after removal and be fatal. Bleeding A small amount of bleeding is normal at the exit site for the first twenty four hours after catheter is inserted. Haemorrhage most often occurs in patients with prolonged or altered clotting profiles. Haemorrhage may occur as a result of the catheter or connections becoming dislodged, or damage caused to other vessels during insertion. Catheter breakage This can occur when there is too much twisting of the catheter when changing the connector, or too much kinking or too much force when flushing. Catheter thrombosis /Clotting A blood clot may block the flow of fluid through the catheter. Cardiac Tamponade SIGNS AND SYMPTOMS/CAUSE Dyspnoea, chest pain, tachypnoea (rapid shallow breath), cyanosis, raised central venous pressure (CVP), coma, cardiac arrest. If bleeding persists, or if the blood leaks through the dressing, apply firm pressure and contact the hospital for advice immediately. You may notice leakage of fluid and the dressing is wet. Loose connection in the system, check connections at each visit If you cannot flush any fluid into the catheter, Stop. Do not force the fluid, as this can rupture the catheter. The effusion of blood, air or pus into the 16/19

17 Cardiac tamponade occurs when a vein, right atrium or right ventricular wall is perforated as a result of erosion by the catheter tip. Infection Exit site infection/phlebitis may occur if the exit site is not kept clean and dry. Tunnel Infection Systemic infection Thrombosis in a major vessel may occur due to irritation/damage by foreign body (catheter). pericardial sac, putting pressure on the heart muscle and prevents normal beating. Check site for signs of infection redness, tenderness, or pain at site. As above with pain or induration along the track of the catheter. Pyrexia, tachycardia, rigors Signs of thrombosis are pain/oedema and tenderness of arm, neck, face and chest. Engorged peripheral veins or feelings of tightness. Adapted from (Green 2008). WERE TO GET ADVICE FROM If needed, seek advice from referring hospital or clinician INCIDENT REPORTING Clinical incidents or near misses must be reported and a Trust Incident Form must be completed SAFEGUARDING ADULTS In any situation where staff may consider the patient to be a vulnerable adult, they need to follow Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. REFERRALS Any referrals to health professionals, therapists or other specialist services must be followed up and all professional advice or guidance documented in the patient s health records. EQUALITY ASSESSMENT During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust incident form would need to be completed and an appropriate action plan put in place. 17/19

18 REFERENCES: Brittan. B, (2008) Health Care Associated Infection, Risk Management and Patient Safety Standards Bevan Brittan (Part of NHS Litigation Authority Standards). Cheshire and Merseyside NHS North West Clinical Guidelines: intravenous Access Care and Maintenance for Adult Patients in Hospital and at Home. Collaborative Intravenous Nursing Service (2009), Version 10. Department of Health (2008) The Health Act: Code of Practice for the Prevention and Control of Healthcare Associated Infections. Department of Health (2010) High Impact Intervention Central venous catheter care bundle Department of Health (2007) EPIC2: National Evidence-based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Dougherty, L. Lister, S (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Seventh Edition. Wiley-Blackwell Publications, Oxford. Green. J, (2008) Care and management of patients with skin-tunnelled catheters. Nursing Standard. June 25: vol 22, no. 42:2008. Jackson. A, (1998) Infection control: a battle in vein infusion phlebitis? Nursing Times, 94, (4), National Institute of Clinical Excellence (NICE) Infection control: prevention of health associated infection in primary and community care (Clinical guidelines 2. London: NICE (1). National Patient Safety Agency (2007). Patient Safety Alert Actions that can make anticoagulant therapy safer. Pratt. R. J., Pellowe C. M., Wilson J. A., Loveday, H. P., Harper, P. J., Jones S. R. L. A., McDougall C., Wilcox M. H. (2007) EPIC2: National Evidence-Based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England. Journal of Hospital Infections. 665, S1-S64. Royal College of Nursing (2010) Standards for infusion therapy. Third Edition. RCN, London. 18/19

19 APPENDIX ONE PROBLEM HIGHLIGHTED IN ALERT MDA/2008/016: There is a risk of infection if the top/septum of the connector remains recessed within its housing. Swabbing of the connector in this condition may lead to inadequate decontamination ACTION TO TAKE IF PROBLEM FOUND: 1. Follow manufacturer s instructions for use with regard to any warnings and recommendations relating to a recessed connector 2. If the top/septum remains recessed, replace the connector and report the incident, using the Trust incident form and report the incident to the Medicines Healthcare Products Regulatory Agency (MHRA). Full details are outlined in the PCT Medical Devices Policy 3. Ensure the faulty connector is kept secured to return to the MHRA REF: Needle free intravascular connectors MDA/208/016 19/19