Department Policy. Code: D:PC Entity: Fairview Pharmacy Services. Department: Fairview Home Infusion. Manual: Policy and Procedure Manual

Transcription

1 Entity: Fairview Pharmacy Services Department: Fairview Home Infusion Manual: Policy and Procedure Manual Category: Home Infusion Subject: Midline (Extended Dwell Peripheral) Catheter Care and Management Purpose: Fairview Home Infusion qualified staff will follow Infusion Nurses Society Policies and Procedures for maintenance of Midline catheters. For midline insertion see policy. Definitions A midline (ML) catheter is not a central line catheter. It is considered a long-dwell peripheral vascular access device that typically shouldn t be in place for longer than 30 days. Only therapies formulated for administration via a peripheral vascular access device may be infused. These catheters are not appropriate for the administration of irritants or vesicants. The tip of the catheter typically does not extend beyond the axilla; catheter length is generally 8-10 centimeters. Points of Information: I. General guidelines for protection of venous access device includes: A. Never use scissors near the catheter B. Routine clamping of an open ended device is necessary when not in use C. A needleless system shall be utilized in administering all intravenous therapies D. All connections in the intravenous system (catheter and tubing) shall be luer lock Rev 5/17 Page 1 of 12

2 II. There are specific catheters manufactured as midlines. At times, catheters manufactured as PICCs are trimmed or manipulated to be used as midlines. A. Clinicians should document catheter type and tip placement. Policy: I. The nurse shall be competent in midline catheter use and maintenance, including identification of potential complications and appropriate nursing intervention, including patient and caregiver education. Care and management of the midline catheter use shall be documented on the plan of care and include: A. Midline catheters may be used for drawing blood. II. For additional information related to possible complications and management of complications review the following policies: A. Complications With Intravenous Catheters FHI B. Central Line Protocol Management of Site Complications C. Intravenous Catheter Complications Procedure: Site Care and Dressing Change Dressings shall be changed at established intervals immediately upon suspected contamination or when integrity of dressing is compromised. Gauze dressings shall be changed every 48 hours on peripheral and central catheters. Transparent semi-permeable membrane dressings shall be changed every seven (7) days. Site Care and Dressing Change I. Perform hand Hygiene II. Verify the patient s identity using 2 independent identifiers. III. Explain procedure to patient. IV. Gather Supplies. A. Central Line Dressing Kit B. Alcohol pad Rev 5/17 Page 2 of 12

3 C. Needleless connector/extension set D. Preservative-free 0.9% sodium chloride (USP) prefilled syringe E. Heparin (see weight based dosing midline chart) F. Chlorhexidine-impregnated disc (CHG disc) if clinically indicated G. Alternative sterile dressing * if a patient is unable to use dressing provided in the kit V. Apply nonsterile gloves. VI. VII. IX. Prime extension set/needleless connector with 0.9% preservative free normal saline. Don surgical mask Remove dressing from VAD insertion site. Inspect site and catheter. X. Remove gloves and perform hand hygiene XI. XII. Don sterile gloves Cleanse midline catheter exit site with antiseptic solution; allow to dry completely. (If complications occur, see VAD complication policy). A. Chlorhexidine solution (preferred): apply using a back-andforth motion for at least 30 seconds. B. Povidone-iodine: apply using concentric circles or a backand-forth motion and allow to remain on the skin for 2 minutes or longer until dry. C. Allowing the antiseptic solution to dry completely provides antisepsis and decreases the potential for skin irritation. XIII. XIV. XV. XVI. Secure wings of catheter in PICC stabilization device if needed. Position Chlorhexidine-impregnated disc (CHG disc) around insertion site per manufacturer s instructions. Position sterile dressing over insertion site. Apply dressing according to manufacturer s labeled use and directions. Transparent dressing should be changed every 7 days. If using a non-transparent dressing it is changed every 48 hours. Dressings are changed anytime they become wet, loose, or soiled. Remove old extension set/needleless connector Rev 5/17 Page 3 of 12

4 XVII. XIX. XX. XXI. XXII. Disinfect catheter hub with alcohol pad using friction and a scrubbing motion for approximately 15 seconds; allow to dry completely. Replace with new extension set. Label dressing with initials and date. Discard used supplies. Remove gloves. Perform hand hygiene. General Flushing Information I. Flushing is performed to ensure and maintain patency of the catheter and to prevent mixing of medications and solutions that are incompatible. II. III. IV. Anticoagulant citrate may be used to maintain catheter patency for patients allergic to heparin. The volume or amount of the anticoagulant citrate will be equal to the amount of heparin used to flush the vascular access device. Routine flushing shall be performed with the following: Lab Draw V. Administration of medications or solutions VI. Or at minimum every 12 hours Flushing Procedure Medication Administration I. Perform hand hygiene II. III. IV. Verify the patients identify using 2 independent identifiers Explain procedure to patient Gather supplies A. Nonsterile gloves B. Alcohol pads C. Preservative free 0.9% sodium chloride (USP) prefilled syringe(s) D. heparin see weight based dosing midline chart or other anticoagulant, if applicable V. Don nonsterile gloves Rev 5/17 Page 4 of 12

5 VI. VII. IX. Disinfect needleless connector with alcohol pad using friction and a scrubbing motion for approximately 15 seconds; allow to dry completely Attach syringe of preservative-free 0.9% sodium chloride (USP) to needleless connector. Open clamp on catheter. Slowly inject preservative-free 0.9% sodium chloride (USP) (see weight based dosing midline chart) using a pulse flush technique into the device noting any resistance or sluggishness of flow. X. Never inject against resistance XI. VAD will require further evaluation if unable to flush freely. XII. XIII. XIV. XV. XVI. XVII. XIX. XX. Disinfect needleless connector for approximately 15 seconds with alcohol wipe using friction and a scrubbing motion; allow to dry completely Administer prescribed medication. Disinfect needleless connector with alcohol pad using friction and a scrubbing motion; allow to dry completely Slowly inject preservative-free 0.9% sodium chloride (USP) (see weight based dosing midline chart) using a pulse flush technique into the device. If ordered, administer anticoagulant. Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion for approximately 15 seconds; allow to dry completely Attach syringe of anticoagulant solution to the needleless connector. Slowly inject solution into the catheter using a pulse flush technique. Close clamp on catheter. Remove gloves and perform hand hygiene. Document procedure in patient s permanent medical record. Flushing Procedure - Maintenance Flushing I. Perform hand hygiene II. Verify the patients identify using 2 independent identifiers III. Explain procedure to patient Rev 5/17 Page 5 of 12

6 IV. Gather supplies A. Nonsterile gloves B. Alcohol pads C. Preservative free 0.9% sodium chloride (USP) prefilled syringe(s) D. Heparin - see weight based dosing midline chart or other anticoagulant, if applicable V. Don nonsterile gloves VI. VII. IX. Disinfect needleless connector with alcohol pad using friction and a scrubbing motion for approximately 15 seconds; allow to dry completely Attach syringe of preservative-free 0.9% sodium chloride (USP) to needleless connector. Open clamp on catheter. Slowly inject preservative-free 0.9% sodium chloride (USP) (see weight based dosing midline chart) using a pulse flush technique, into the device, noting any resistance or sluggishness of flow. X. Never inject against resistance XI. VAD will require further evaluation if unable to flush freely. XII. XIII. XIV. XV. XVI. Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion for approximately 15 seconds; allow to dry completely Attach syringe of anticoagulant solution to the needleless connector. Slowly inject solution into the catheter using a pulse flush technique. Close clamp on catheter. Remove gloves and perform hand hygiene Document procedure in patient s permanent medical record. Cap Change I. Needleless connectors are changed if there is blood or debris visible within the needleless connector, upon contamination, prior to drawing a blood culture through a catheter, after drawing blood sample and routinely every 7 days Rev 5/17 Page 6 of 12

7 II. Perform hand hygiene. II. Don nonsterile gloves. V. Remove existing needleless connector. V. Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion; allow to dry completely VI. Attach new sterile needleless connector. II. Discard used supplies. II. Remove gloves and perform hand hygiene. Lab Draw via Midline I. Obtain and review prescriber orders. II. Verify patient s identity using 2 independent identifiers. III. Explain procedure to patient. IV. Perform hand hygiene. V. Gather supplies: A. Gloves, nonsterile B. Blood collection tubes C. (3) 10 ml preservative-free 0.9% sodium chloride (USP) prefilled syringes (see weight based dosing midline chart). D. Anticoagulant flush as prescribed, if applicable E. Empty 10 ml sterile syringe(s), if applicable F. Vacutainer, if applicable G. Labels for tubes H. Transport containers I. Alcohol pads VI. Don nonsterile gloves. VII. Discontinue administration of all medications for a minimum of 2 minutes prior to obtaining blood samples. IX. Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion; allow to dry completely Flush midline with preservative-free 0.9% sodium chloride (USP) prefilled syringe (see weight based dosing midline chart). X. Obtain discard sample: XI. Attach empty 10mL syringe and withdraw 3-5mL of blood -or- XII. Attach blood-tube holder and advance blood collection tube to obtain 3-5mL of blood XIII. If unable to obtain blood return, have patient change position, Rev 5/17 Page 7 of 12

8 XIV. XV. cough, move arm above head or take a deep breath and hold Flush CVAD with preservative- free 0.9% sodium chloride (USP) Replace blood tube or attach a new empty sterile 10 ml syringe and withdraw 4-5 ml of blood XVI. Obtain blood samples as ordered. XVII. Transfer blood samples from syringe(s) to appropriate blood specimen tubes if applicable. X Change needleless connector (see cap change). XIX. Flush device with preservative-free sodium chloride (USP), anticoagulant (weight based) or resume infusion as ordered XX. Label blood samples before leaving the patient s side with the following: A. Patient name B. Patient date of birth C. Date and time of specimen collection D. Your initials E. Provider XXI. Place blood samples in a sealed container for transport. XXII. Identify container with BIOHAZARD label. XXIII. Certain specimens may need to be placed on ice during transport. Check with laboratory used by the organization. XXIV. Discard waste sample and vacutainer in sharps container. Discard all other used supplies in appropriate receptacles. XXV. Remove gloves and perform hand hygiene. XXVI. Document in patient s permanent medical record. Catheter Removal A vascular access device (VAD) will be removed when therapy is completed as ordered by a licensed independent practitioner (LIP), when contamination or complication is suspected or when tip location is no longer appropriate for the prescribed therapy. Follow manufacturer s labeled use and directions for catheter removal. A nurse educated and competent in the removal of nontunneled, noncuffed CVADs may do so per organizational policy. Catheter Removal I. Obtain and review prescriber orders. II. Verify patient s identity using 2 independent identifiers. III. Explain procedure to patient. IV. Perform hand hygiene Rev 5/17 Page 8 of 12

9 V. Gather supplies A. Gloves, non-sterile B. Suture removal set, as needed C. Gauze, sterile D. Petroleum based ointment, sterile E. Transparent semipermeable membrane dressing VI. VII. IX. Don gloves. Place patient in sitting or recumbent position. Use aseptic technique and observe Standard Precautions throughout procedure. Remove dressing from exit site. X. Remove stabilization device or sutures if present. XI. XII. XIII. Inspect catheter-skin junction. Disinfect catheter-skin junction. Apply gauze to insertion site. XIV. Place first two fingers of nondominant hand lightly above catheterskin junction site with gauze between fingers. XV. Pull catheter using straight, downward pressure. XVI. Apply pressure to site with gauze for a minimum of 30 seconds or until homeostasis is achieved. XVII. Apply petroleum-based ointment to exit site, cover with gauze and TSM dressing. X Patient should remain in sitting or recumbent position for 30 minutes post removal. XIX. Patient will be instructed to change dressing every 24 hours until exit site is healed. XX. Assess integrity of removed catheter. Compare length of catheter to original insertion length to ensure entire catheter is removed. If any discrepancy or concern, contact prescriber and enter icare. XXI. Discard used supplies. XXII. Remove gloves. XXIII. Perform hand hygiene. XXIV. Document in patient s permanent medical record. Documentation I. Appearance of device site Rev 5/17 Page 9 of 12

10 II. Presence or absence of a blood return III. Date/time IV. Label the dressing with date dressing change was performed V. Medication/solution administration VI. Pain management interventions VII. Flush/lock solution and volume Patient education IX. Patient s response to the procedure X. After removal, length and integrity of catheter removed External Ref: Joint Commission applicable standards Policies and Procedures for Infusion Nursing; 4 th Edition, 2011 Infusion Nurses Society Infusion Nursing An Evidence-Based Approach, 3 rd Edition, 2010 Internal Ref: Source: FHI Clinical Managers, Quality Department Approved by: Director of Operations, Medical Director Date Effective: 7/2016 Date Revised: 4/2017 Date Reviewed: 4/ Rev 5/17 Page 10 of 12

11 Device/Catheter Routine Flush w/medication Administration Midline, Openended Chloride 10mL -Medication Chloride 10mL -Heparin 10 units/ml 5mL Midline, valved Chloride 10mL -Medication Chloride 10mL -Heparin 10 units/ml 5ml Flushing w/blood draws Chloride 10mL -Draw 5 ml blood discard prior to obtaining sample Chloride 20mL -Heparin 10 units/ml 5mL Chloride 10mL -Draw 5 ml blood discard prior to obtaining sample Chloride 20mL -Heparin 10 units/ml 5mL Weight Based Dosing Chart >10kg to adult Flushing w/no therapy -Heparin 10 units/ml5ml every 12 hours -Heparin 10 units/ml 5ml every 12 hours Dressing Change Chlorhexidineimpregnated disc (CHG disc) TSM-weekly and prn Gauze-every 48 hours Chlorhexidineimpregnated disc (CHG disc)-with each dressing change TSM-weekly and prn Gauze-every 48 hours Chlorhexidineimpregnated disc (CHG disc)-with each dressing change Device/Catheter Routine Flush w/medication Administration Flushing w/blood draws 10kg Flushing w/no therapy Dressing Change Chlorhexidineimpregnated disc (CHG disc) Rev 5/17 Page 11 of 12 Cap and/or Extension Set Chance Clamping vs Non-clamping Cap-weekly & after each blood draw Ext set-weekly Either-anytime the device is compromised -Use clamp to prevent reflux of blood Cap-weekly & after each blood draw Ext Set-weekly Either-anytime the device is compromised -Clamping is unnecessary due to distal end of catheter design *Clamp must always be available Cap and/or Extension Set Chance Clamping vs Non-clamping

12 Midline, Openended Chloride 5mL -Medication Chloride 5mL -Heparin 10 units/ml 3mL Chloride 5mL -Draw 3 ml blood discard prior to obtaining sample Chloride 10mL -Heparin 10 units/ml3ml every 12 hours TSM-weekly and prn Gauze-every 48 hours BioPatchChlorhexidineimpregnated disc (CHG disc)-with each dressing change -Heparin 10 units/ml 3mL Midline, valved Chloride 5ml -Medication Chloride 5ml -Heparin 10 units/ml 3mL Chloride 5mL -Draw 3 ml blood discard prior to obtaining sample Chloride 10 ml -Heparin 10 units/ml 3mL every 12 hours TSM-weekly and prn Gauze-every 48 hours Chlorhexidineimpregnated disc (CHG disc)-with each dressing change -Heparin 10 units/ml 3mL Rev 5/17 Page 12 of 12 Cap-weekly & after each blood draw Ext set-weekly Either-anytime the device is compromised -Use clamp to prevent reflux of blood Cap-weekly & after each blood draw Ext Set-weekly & after each blood draw Either-anytime the device is compromised -Clamping is unnecessary due to distal end of catheter design *Clamp must always be available