Policy for Peripheral Cannulation

Transcription

1 Policy Number 102 This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form. Part A Information about this Document Policy Name Policy for Peripheral Cannulation Policy Type Board Approved (Trust-wide) Trust-wide Divisional / Team / Locality Action Approval No Minor Major New Change Change Change Policy No Longer Needed As Mersey Care s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and d) has been updated to reflect any local contractual requirements Date: Signature: Part B Changes in Terminology (used with Minor Change, Major Changes & New Policy only) Terminology used in this Document New terminology when reading this Document Liverpool Community Health Mersey Care NHS Trust Part C Additional Information Added (to be used with Major Changes only) Section / Paragraph No Page 5 Version 3 Page 11 Outline of the information that has been added to this document especially where it may change what staff need to do Introduction of Posiflush Device N.Saline 0.9% 10ml device Page 15/16/ Updated RCN & DH Guidelines (2017/2018 Pages 18/19/21/23 Added appendix6 picture of Posiflush Part D Rationale (to be used with New Policy & Policy No Longer Required only) Please explain why this new document needs to be adopted or why this document is no longer required Part E Oversight Arrangements (to be used with New Policy only) Accountable Director Recommending Committee Approving Committee Next Review Date December 2020 Policy on Peripheral Cannulation v3 Page 1 of 31

2 LCH Policy Alignment Process Form 1 Policy on Peripheral Cannulation v3 Page 2 of 31

3 SUPPORTING STATEMENTS This document should be read in conjunction with the following statements: SAFEGUARDING IS EVERYBODY S BUSINESS All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult; knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your role); ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation; ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session EQUALITY AND HUMAN RIGHTS Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership. The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices. Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act. Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy Policy on Peripheral Cannulation v3 Page 3 of 31

4 Policy on Peripheral Cannulation v3 Page 4 of 31

5 Title Policy reference number Policy for Peripheral Cannulation Reference Number: 102 Aim and purpose of the policy To provide guidance to Mersey Care Community Health staff undertaking peripheral Cannulation Author Community Intravenous Therapy Team Type New document Reviewed document Review Date December 2020 Person/group accountable for review Intravenous Therapy Team Lead Type of evidence base used C: Evidence includes published and/or unpublished studies and expert opinion Issue date March 2011 Authorised by Clinical Policies Group Impact Assessment Undertaken Authorised via delegated authority Yes No Evidence collated Policy on Peripheral Cannulation v3 Page 5 of 31

6 Version Control Version Number: Ratified by: Date of Approval: V3 Clinical Policies & Procedures Group December 2018 Name of originator/author: Approving Body / Committee: IV Team Clinical Policies & Procedures Group Date issued: March 2011 Review date: December 2020 Target audience: Trained nurses in IV Team and nurses with special interest Name of Lead Director / Managing Director: Changes / Alterations Made To Previous Version: Jenny Hurst Added version control, removed midline and central venous VIIAD Included Key individuals involved in developing the document Name A.Smith/C.Roberts Designation IV Team leaders This document was circulated to the following individuals for consultation Name Alison Thompson Lisa Hammond/ Hilary Smith Designation Senior Infection Control Nurse In patient matron/pharmacist This document should be read in conjunction with the Policy on Peripheral Cannulation v3 Page 6 of 31

7 following documents: Mersey Care NHS Infection and Prevention Control Manual Mersey Care NHS Instant Reporting Policy Mersey Care NHS Hydration Policy Mersey Care NHS Transfusion Policy Mersey Care NHS Cold Chain Policy Policy on Peripheral Cannulation v3 Page 7 of 31

8 Contents 1. Introduction General Policies Statement Definitions Legal & Statutory Duties and Responsibilities 6 5. Process Training Requirements Implementation, Monitoring and Review Impact Assessment Linked Areas/ Associated Documents Relevant Legislation/Statutory Requirements Appendices list References 23 Policy on Peripheral Cannulation v3 Page 8 of 31

9 1. Introduction The term peripheral cannulation refers to the insertion of a cannula into a vein to allow administration of intravenous drugs and fluids. The most common way to cannulate a peripheral vein is a cannula over a needle, where the lumen of a plastic cannula contains a needle that allows insertion through the skin. Once introduced, the needle is removed leaving the cannula in the vein. 1.1 Status This is a clinical policy for use in Mersey Care NHS Trust. 1.2 Purpose of the policy Infusion therapy is provided for patients of Mersey Care NHS Trust by registered health care professionals. Standard techniques are required to prevent complications like catheter site and blood stream infection, misplacement at point of insertion and dysfunction and loss of patency during insertion. The purpose of this policy is to ensure a consistently high standard of practice across the trust with regards to peripheral cannulation. 1.3 Scope of Policy This policy applies to staff employed by Mersey Care NHS Trust undertaking cannulation. This procedure should only be carried out by professionally registered clinical staff. 2. General Policy Statement Mersey Care NHS Trust has developed this policy to ensure that staff are trained and equipped properly to effectively approach and improve cannulation technique, ultimately preventing needless cannulation on patients and needless line related infections. Policy on Peripheral Cannulation v3 Page 9 of 31

10 3. Definitions 1 Cannula Flexible tube/catheter containing a needle, which may be inserted into a blood vessel (Anderson and Anderson 1995) Peripheral catheter Midline catheter Peripheral intravenous central catheter (PICC) A catheter inserted through the skin A longer (approx 20 cm) catheter inserted peripherally into a vein on the arm. It is used for mid term infusion of fluids/nutrition A central venous catheter inserted peripherally into the arm. 5 Central Line A central venous catheter inserted into a large vein in the neck, chest or groin 6 7 Erythema Phlebitis Redness of skin along the vein track due to vascular irritation or capillary congestion of fluid; it may be a precursor to phlebitis (Perdue 2001). Inflammation of the intima of the vein (Perdue 2001) 8 Haematoma Uncontrolled bleeding at a venepuncture site usually creating a hard painful swelling filled with infiltrated blood (Perdue 2001) 9 Infiltration Inadvertent administration of solution into the surrounding tissue instead of into the intended vascular pathway (Perdue 2001) 10 Saline flush 0.9% sodium chloride for injection to flush the cannula NB It should be prescribed on the drug chart and given by a competent Policy on Peripheral Cannulation v3 Page 10 of 31

11 health practitioner 11 VIIAD Visual inspection infusion access device indicator 12 Ward Manager Nurse in charge of a ward in a hospital 13 Team Leader Service Manager Nurse in charge of a team, specifically outlined in this document a team in the community. Manager responsible for services and the staff that deliver them. This is specific to the Manager of the inpatient units and Intravenous Therapy Team Leader. 14 Health Care Professionals (HCP) Staff who work within the PCT who have received training in the insertion of peripheral cannula and saline flush 15 Secondary care The acute hospital setting. 4. Legal and Statutory Duties and Responsibilities The following general (statutory) duties apply: All Mersey Care NHS Trust staff are responsible for co- operating with the development of Mersey Care NHS Trust policies as part of their normal duties and responsibilities. All other personnel are expected to comply with the requirements of all relevant Mersey Care NHS Trust policies applicable to their area of operation. All potential adverse incidents should be reported in line with the Mersey Care NHS Trust Accident and Incident Reporting and Management Policy (including serious untoward incidents). Policy on Peripheral Cannulation v3 Page 11 of 31

12 5. Process In this document, the process for peripheral cannulation includes: Outline of the responsibilities of the accountable practitioners Patient selection method i.e. indication for use. Operative procedure of the cannulation, e.g. insertion, management etc. Monitoring and documentation method 5.1 Accountable Practitioners: Registered Health care professionals I. It is the responsibility of the registered health care professional to obtain consent from the patient prior to performing cannulation. II. It is the responsibility of the registered health care professional to be consistent with standard precautions to be used during cannulation for all patients. III. It is the responsibility of the registered health care professional to monitor for signs of vascular access device infection. IV. It is the responsibility of the registered health care professional, if any infection is detected, to manage this appropriately, including consulting with the infection control team and/or sending the cannula tip to the laboratory for culture. V. Where a peripheral cannula has been inserted in an emergency without an aseptic technique, it is the responsibility of the registered health care professional to replace this cannula within 24 hours Ward Manager/Team Leader I. It is the responsibility of the ward manager/ team leader to ensure that staff are aware of this policy and that working practice is in line with the policy described. II. It is the responsibility of the nurse manager/ team leader to ensure that nursing staff have the knowledge and the practical skills to deliver this care. III. It is the responsibility of the nurse manager/ team leader to ensure that the necessary equipment is available to carry out this procedure. Policy on Peripheral Cannulation v2 Page 10 of

13 IV. It is the responsibility of the team leaders and ward managers to ensure that patients, in receipt of peripheral cannulation from healthcare professionals employed by Mersey Care NHS Trust, work to the standard requirements for intravenous cannulation (CINS Guidelines, Epic 2 Guidelines, NICE Guidelines) In-Patient Service Manager/Intravenous Service Lead I. It is the responsibility of the service manager to ensure that regular audit is carried out to measure the compliance to the requirements to this guideline. This may be delegated to appropriate employees, e.g. Matron. II. It is the responsibility of the Intravenous Therapy Team Lead to review this document All Healthcare staff All potential adverse incidents should be reported in line Mersey Care NHS Trust Accident and Reporting and Management Policy. 5.2 Method of placing a peripheral cannula Patient selection: Short term administration of intravenous drugs (see table 1) Rehydration (see table 2). Transfusion of a blood component (see blood transfusion policy). Table 1 Intravenous antibiotic therapy should always be reviewed, stepped down and switched to oral as soon as possible. (BNF 2018) formulary-september aspx?gclid=eaiaiqobchmivtqdhiky3wivfp7vc h1nvgfbeaqyasabegjyp_d_bwe If longer venous access is required, patients should be referred to the community intravenous team for the most suitable venous access device. Policy on Peripheral Cannulation v2 Page 11 of

14 Table 2 NB Intravenous rehydration is not a substitute for nutrition. For patients who have been undernourished for more than 5 days, nutrition therapy must be considered. (BAPEN) Discuss nutrition with the pharmacy and nutrition team. Policy on Peripheral Cannulation v2 Page 12 of

15 5.2.2 Vein Selection (See appendix 1) Use dorsal hand veins first Use veins that feel soft and resilient Use large veins where possible Use straight veins suited to cannula length Use patient s non dominant limb, where possible Cannula Selection There are different types of cannula used for peripheral cannulation. Choice is determined by varying circumstances (see table 3) Table 3 Gauge (G) Flow rate ml/min Colour General uses Pink Blood transfusions, large volumes of fluids Blue Blood transfusions, most medications and fluids Yellow Medications, short term infusions, fragile veins, children Policy on Peripheral Cannulation v2 Page 10 of 31

16 5.2.4 Equipment Selection. 1. Clean tray/trolley 2. Sterile examination gloves 3 Clean tourniquet (disposable) 4 Cannula of the correct size 5 Dressing pack 6 Syringe (10ml) and Sodium Chloride 0.9% for flushing. * (Posiflush) 7 Spare gauze and tape 8 Sharps bin 9 Documentation :VIIAD charts (See appendices) 10 Prescription chart Policy on Peripheral Cannulation v2 Page 11 of 31

17 INSERTION PROCEDURE INSERTION PROCEDURE 1. Identify the patient as per Mersey Care NHS Trust policy. 2. Explain the procedure to the patient; ask for preference regarding site and obtain verbal consent and cooperation. 3. Discuss previous experiences and check need for local anaesthetic. 4. Prior to selection of equipment: Hand wash with soap and water. Select the correct cannula size choosing the smallest gauge that will accommodate the patient s infusion needs. 5. Decontaminate hands using alcohol hand rub or by hand washing with liquid soap as per Mersey Care NHS Trust Hand Hygiene Policy 6. Check integrity of packaging and expiry date before opening pack onto clean trolley/surface. 7. Wash and dry patients arm if visibly dirty. 8. Position the patient with arm supported by pillow or if required ensure assistance from a colleague. Place the drape under the patients arm. 9. Choose site according to patient condition and apply tourniquet at least 10cms above selected site. RATIONALE To ensure correct patient. To ensure patient understanding Link to consent policy. To establish venous history. To minimise risk of cross infection To reduce unnecessary trauma to the vein. To minimize risk of cross infection. To maintain asepsis. Clean skin required. To ensure patient comfort and safety. To dilate veins by obstructing venous return. 10. Find the PALPABLE vein. To reduce trauma to the vein. 11. Decontaminate hands using alcohol hand rub; To minimise risk of cross infection. Policy on Peripheral Cannulation v2 Page 12 of 31

18 INSERTION PROCEDURE 12. Disinfect site with chlorhexidine 2% in 70% alcohol for seconds. Allow to dry. Use an alcoholic povidine-iodine solution for patients with a history of chlorhexidine sensitivity. Allow the antiseptic to dry before inserting the catheter. Allow to air dry. Do not repalpate the vein or touch the skin. RATIONALE To minimise risk of cross infection. 13. Put gloves on and check equipment for faults. To detect faulty equipment. DO NOT WITHDRAW THE NEEDLE FROM THE CANNULA 14. Anchor the vein by applying tension to skin below the site and insert the needle/cannula level up at degree angle. Penetrate skin and advance into vein. Maintaining anchor tension with one hand and holding flashback chamber or thumb plate with the other, advance the cannula forward over the needle. Successful cannulation is confirmed by free flow of blood into flashback chamber. Slightly lower angle of cannula until almost flush with skin. 15. Adjust direction of cannula and advance a few mms into the vein and with draw the needle slightly, observing flashback of blood in shaft. Maintaining anchor tension with one hand and holding the flashback chamber or thumb plate with the other, advance the cannula forward over the needle. 16. Only one vascular access device should be used for each cannulation attempt. To immobilise the vein wall and to ensure a successful cannulation and this angle reduces risk of needle passing through the vein. To avoid the vein wall and to ensure cannula is in a patient vein. To ensure the vein remains immobilised thereby reducing risk of venous wall puncture. To maintain asepsis 17. Release tourniquet To decrease pressure in the vein Policy on Peripheral Cannulation v2 Page 13 of 31

19 INSERTION PROCEDURE 18. Apply digital pressure above tip of cannula and remove needle. Discard directly into sharps bin. NEVER REINSERT THE NEEDLE RATIONALE To reduce risk of needle stick injury 19. Attach the needle-free connector. To prevent air entry/protect against contamination. 20. Apply dedicated sterile highly permeable IV dressing (from pack) 21. Flush the cannula with 2.5-5mls of sterile sodium chloride 0.9% for injection then commence IV therapy as appropriate. 22. Discard gloves and decontaminate hands. 23. Remove waste into appropriate container. 24. A cannula inserted in an emergency situation where aseptic technique is compromised should be replaced in 24 hours. 25. Document: Insertion time, Date, Site, Size of cannula, Batch number Name of person inserting the device. Record the review/removal date (72 hours). To minimise risk of infection and to secure the cannula. To prevent occlusion. To minimise risk of cross infection. To ensure safe disposal. To minimise risk of infection. To meet legal and patient care requirements. See V above Policy on Peripheral Cannulation v2 Page 14 of 31

20 5.3 MANAGING THE PERIPHERAL CANNULA WHILE IN SITU MANAGEMENT OF THE CANNULA 1. The number of lines and ports will be kept to a minimum consistent with clinical need 2. A needle free system should always be used on all vascular access devices. 3. IV administration sets should always be changed: At 24 hour intervals When the vascular device is replaced Blood transfusion administration sets should be changed: as new for each new solution Administration sets should be changed with every unit of blood (or every 4 hours, whichever is the shortest) 4. Discard intermittent administration sets after each use e.g. antibiotic infusion bags. Never disconnect an IV line for reattaching later 5. The maximum expiry date for any infusion prepared in a clinical area is 24 hours or less in accordance with the manufacturer s specification of product characteristics. 6. Bandages should be avoided wherever possible. However, if a bandage is used it should be removed at least daily or once every 8 hours in a patient setting in order to inspect the insertion site. Clean Tubifast is an alternative RATIONALE To reduce the risk of cross infection (DH 2018)) RCN (2017) DH (2018) h_the_infusion_nursing.12.aspx To reduce the risk of infection DH (2018) to help avoid the risk of infection Early detection of any infection. Policy on Peripheral Cannulation v 2 15

21 MANAGEMENT OF THE CANNULA 7. Devices designed for splinting should be used to facilitate infusion delivery only when the device is placed in or around an area of flexion or is at risk of dislodgement e.g. being used in a child: Splints should be removed and the circulatory status of the patients` extremity should be assessed at regular intervals. Splints must be effectively decontaminated between patients 8. When manipulating the line/cannula an aseptic non-touch technique should be applied. Ensure equipment in contact with the circuit is sterile e.g. syringes 9. Prior to access, use chlorhexidine 2% in 70% alcohol (single use wipe) to disinfect needle free device, unless contraindicated by manufacturers recommendations in which case use 70% alcohol 10. The cannula should be flushed at least once daily and pre and post drug administration with 2.5ml 5ml sodium chloride for injection (0.9%) in a 10ml syringe. *The sodium chloride (0.9%) should be prescribed on the drug chart/prescription sheet if using ampoules and not Posiflush device RCN (2017) RATIONALE To prevent cross infection RCN (2017) Essential to prevent entry of micro-organisms into the system via the portal To maintain patency 11. The dressing should only be To reduce the risk of cross changed when it becomes loose, infection damp or soaked if dressing is clean and intact then do not disturb. Document this in the patient s record Policy on Peripheral Cannulation v 2 16

22 MANAGEMENT OF THE CANNULA 12. An aseptic non-touch technique should be used when changing the dressing as per Merseycare NHS Infection Control and Prevention Manual RATIONALE Skin cleansing/antisepsis of the insertion site is one of the most important measures for preventing cannula related infections. See section A cannula that has migrated externally should not be re advanced prior to re stabilisation 14. The site should be examined to ensure the device has not become dislodged, for signs of infection and extravasion. 15. If VIP score = 2 then remove cannula. If an infection is suspected or VIP > 2 then do the following : To reduce the risk of cross infection To identify mechanical complications and signs of infection. The microbiology results may indicate which antibiotic is required should the patient develop signs of septicaemia 1. Take a swab and send to laboratory for Culture & sensitivity 2. Take the tip of the cannula and sent to laboratory for culture & sensitivity (see section 5.7) 3. Complete an IR1 4. Report any infection to Infection Control Team and IV therapy team Leader. 16. Along with any incidence of phlebitis, intervention, treatment and corrective action should be documented in the patient s notes To provide evidence of any action taken and aid communication Policy on Peripheral Cannulation v 2 17

23 MANAGEMENT OF THE CANNULA 17. Peripheral cannulae should not be used for routine blood sampling. However, if necessary, the cannula can be used to draw blood using a syringe no larger than 10mls) ONLY ONCE immediately following insertion. Reapply the tourniquet above the cannula, wait for vein engorgement and draw blood SLOWLY using minimal force. 18. If a peripheral venous cannula is not being used/required for access, it must be removed. RCN (2017) RATIONALE To prevent haemolysis in the sample To prevent thrombophlebitis of the vein The longer a peripheral venous cannula remains in situ, the greater the risk of infection. 5.4 REMOVAL OF PERIPHERAL CANNULA Equipment selection : 1 Examination gloves 2 Alcohol Gel 3 Sterile gauze and tape 3 Sharps bin Policy on Peripheral Cannulation v 2 18

24 5.4.2 REMOVAL OF PERIPHERAL CANNULA RATIONALE 1. Peripheral cannula should be re-sited every 72 hours wherever clinically possible 2. Removal of the intravenous cannula should be an aseptic procedure 3. Explain procedure to the patient and gain consent 4. Decontaminate hands using liquid soap as per as per Mersey Care NHS Trust Hand Hygiene Policy 5. Apply clean examination gloves as per Mersey Care NHS Trust Standard Precautions Policy DH (2017) To prevent cross infection/contamination of the catheter tip To ensure patient understanding To reduce cross infection To maintain universal precautions 6. Remove dressing To expose cannula site 7. Hold sterile gauze over site and gently withdraw cannula using a slow, steady movement, keeping hub parallel with skin 8. Check integrity of cannula before disposing into sharps bin 9. Apply pressure for 2-3 minutes with sterile gauze 10.When bleeding has stopped apply gauze dressing 11. Document the date and time and removal in the patients notes including the name and designation of the person removing the device 12. If the site appears infected (VIP score of 2 or greater), a swab should be taken and sent with the tip of the cannula to Microbiology for culture and sensitivity See section 5.7 To ease withdrawal and prevent damage to the vein To ensure all removed To prevent bleeding and possible haematoma To aid healing To meet legal requirement The microbiology results may indicate which antibiotic is required should the patient develop signs of septicaemia Policy on Peripheral Cannulation v 2 19

25 5.5 Documentation Process Documents titled: Visual Inspection of Intravenous Access Device (VIIAD). (See appendices) will reflect the process of care of a cannula, the cannula condition and specific nursing actions taken to resolve or prevent adverse incidents (see table 4): The Viiad document is to be completed on each shift. If the cannula has been sited in Secondary care the Viad documentation should be transferred with the patient. See appendix 2. VIAD documents are to be kept in the patient s case notes. Table 4 Erythema score, used to detect complications in intravenous therapy is a reliable indicator on white skin. In some cases of black skin, it may be masked. For guidance on detecting skin changes. See VIADS. Also note that there are many other signs and symptoms to detect abnormality. 5.7 Managing a cannula related infection. (see V, above) Phlebitis: Phlebitis can predispose to infection. Ensure adequate skin preparation Ensure sound hand washing and aseptic techniques at every contact Closely monitor with VIIAD tool. If cannula is not being used it should be removed as a potential cause of infection Infected site If the insertion site appears infected (VIP score > 2 or more), the tip of the cannula should be sent for culture & sensitivity. Policy on Peripheral Cannulation v 2 20

26 It is easy to contaminate the cannula tip on removal by wiping across the surface of the skin. Therefore when taking a cannula tip for culture, follow these instructions: (I) Swab the surrounding skin and any pus. (2) Clean the surrounding skin with chlorhexidine 2% in 70% alcohol and allow it to dry fully. (3) Remove the cannula and with sterile scissors, snip 1cm of the cannula into a sterile container. (4) Use separate containers for each and send both the skin swab and the cannula tip to the laboratory. (5) Inform Infection Control Team and IV Therapy team Leader if infection is suspected. 6. Training Requirements Training to recognised practitioners must be fulfilled using a recognised competency framework, which relates to a completed a programme of preparation founded on principles of theory and practical learning, linked to a practical assessment provided by IV Therapy team. Please refer to training needs analysis. Practitioners will be expected to sign a declaration of cannulation practice. See Appendix 5 Competency will be guided by Merseyside and Cheshire Cancer Network with the Royal Liverpool and Broadgreen Hospitals NHS Trust, Clatterbridge Centre for Oncology, Mersey Care Community IV team and all trusts and PCTs within the North West Merseyside and Cheshire Strategic Health Authority, where consensus has been universally agreed relating to guidelines, competencies, care plan and resources. See Appendix 6 for competency sign off sheet. This process of this is ensured by the Intravenous Services Lead and In- Patient Kent Lodge/CCAU, Matron who will be responsible for ensuring that their own practitioners learning, assessment and peer review. That is within the in-patient unit, the Community Clinical Assessment Unit is the designated area for this training and Intravenous peripheral cannulation practical training is provided by the unit s Nurse Clinician and the IV Therapy team. Within the community intravenous team services, the practitioner will receive learning, assessment and peer review, including cannulation practical training within the community by the intravenous team leader. On completion of training, Mersey Care NHS Trust will have on record (Learning and Development Bureau) that the practitioner and the Trust are confident that the practitioner has the skills and knowledge to practice safely and effectively as defined by the NMC, scope of professional practice (NMC 2017). Policy on Peripheral Cannulation v 2 21

27 7. Implementation, Monitoring and Review 7.1 The Chief Executive is responsible for implementing this policy. This process has been delegated to the Intravenous Service Lead and In-patient Services Matron. 7.2 The Director of Operations and Executive Nurse is responsible for ensuring that this document is reviewed and if required, revised in the light of legislative guidance or organisational change. This process will be delegated to the Intravenous Service Lead and In-Patient Services Matron. 7.3 Review shall be within one year unless practice changes in the interim. 7.4 Compliance with this document will be monitored by The Mersey Care NHS Trust incident reporting system to the Trust s clinical governance committee on incidences of infection. Clinical audit. This process is delegated to the Intravenous Team Leader for the community intravenous therapy team Audits will be devised in conjunction with Infection Control Team to monitor compliance with Nice Guidelines This process can be delegated to ward managers, Intravenous Therapy caseload holders A Daily Visual Inspection Phlebitis score (VIP) (the uniform standard inspection scale (Jackson 1998) which are reflected within the VIIAD documents (see appendix 2) and retained in the patients case notes. The Clinical Effectiveness lead or the Clinical Governance Team can be contacted for support/advice. 8. Impact Assessment An impact assessment has been undertaken and evidence has been retained by both authors and the Equality and Diversity Lead, Mersey Care NHS Trust. 9. Linked areas/associated Documents Accident and Incident Reporting and Management Policy Infection Control Policies Policy on Peripheral Cannulation v 2 22

28 CINS - Collaborative Intravenous Nursing Service. Cheshire Merseyside Policy on Peripheral Cannulation v 2 23

29 10. Relevant Legislation/Statutory Requirements Nursing and Midwifery Council (2008b) Code of professional conduct: standards for conduct, performance and ethics. Royal College of Nursing (2010) Standards for Infusion Therapy, RCN, London 11. List of Appendices Appendix 1 Vein Selection Appendix 2 - VIIAD Appendix 3 Visual inspection Phlebitis Score Appendix 4 Declaration of cannulation practice Appendix 5 Competency assessment form 12. References Anderson K N, & Anderson L E, (1995) Mosby's Pocket Dictionary of Nursing, Medicine and Professions Allied to Medicine. Mosby London British Association of Parenteral and Enteral Nutrition (BAPEN) British National Formulary (BNF 2018) Intravenous Antibiotic Therapy 5. Sept page 282 British National Formulary (BNF 2018) Intravenous Nutrition Sept 9.3 p 518 CINS Collaborative Intravenous Nursing Service. Cheshire Merseyside INS (2017) Standards for Infusion Therapy. Royal College of Nursing. IV Therapy Forum appendix 6 Jackson A, (1998). A battle in vein: infusion phlebitis, Nursing Times (94) 4: Perdue M B (2001) Intravenous complications. Infusion therapy in clinical practice. 2 nd edition. Pennysylvania: W B Saunders, Chapter 24, Policy on Peripheral Cannulation v 2 24

30 General Practice second edition. Oxford University Press p259 & p632 Royal College of Nursing Standards for Intravenous Therapy (2017) Simon C, Everitt H, Kendrick T (2005), Basic Diagnostic skills. Oxford Handbook of General Practice Policy on Peripheral Cannulation v 2 25

31 Appendix 1 VEIN SELECTION 1. Cephalic vein 2. Basilic vein Policy on Peripheral Cannulation v 2 26

32 Change IV giving set after 72 hours. Signature Appendix 2 VIIAD 1 Peripheral Cannula Note: Use appropriate form for V.I.P. Score 0 5 (see overleaf) Flushed? Peripheral IV Cannula Visual Inspection of Intravenous Access Devices (VIIAD) Ensure that this form is completed each shift by registered nurse. Document any variance overleaf. Use separate form for every peripheral IV cannula. central lines. Patient Name: Indication for Insertion.. Unit No... Insertion date Time Ward Cannula size/colour/type. Site Inserted by Designation Skin disinfected with. Date Shift Time Yes/No/NA E L N E L N E L N Rationale for keeping cannula over 72 hrs.. Signature. Flow problems? Dressing intact? Moisture/leak from site? Needle-free device/octopus used? e.g bionector Yes/No/NA Yes/No/NA Yes/No/NA Yes/No/NA Is venous access required for longer? Yes No If yes, refer to IV Therapy Team on Registered Nurse Signature TO BE COMPLETED ON TIME ON TIME OF REMOVAL. Printed Name Referred by.. Referred on. / /. Date line removed /../ Time... Reason for removal (circle) Elective VIP > 1 Dislodgement Other Removed using aseptic technique by Signature

33 Appendix 3 Visual Infusion Phlebitis (VIP) Score IV site appears healthy One of the following is evident: Slight pain near IV site Slight erythema near IV site Two of the following are evident: Pain at IV site Swelling Erythema All of the following are evident: Pain along the cannula Erythema Swelling All of the following are evident and extensive: Pain along the path of the cannula Erythema Swelling Palpable venous cord All of the following are evident and extensive: Pain along the path of the cannula Erythema Swelling Palpable venous cord Pyrexia No sign of phlebitis Observe cannula Possible first signs of phlebitis Observe cannula Early stages of phlebitis Resite cannula Medium stages of phlebitis Resite cannula Initiate treatment Advanced stage of phlebitis or start of thrombophlebitis Resite cannula Initiate treatment Advanced stage of thrombophlebitis Resite cannula Initiate treatment

34 Appendix 4 Declaration for Cannulation Practice Name Job title Band I confirm that I am competent to practice cannulation I have; Completed/updated as necessary the theory training according to my competence/confidence Undertaken minimum 5 successful, supervised cannulations Demonstrated competent practice Read the associated Trust guidance and policies I understand that I am responsible for keeping my practice up to date and am advised to read policies and procedures as and when they are reviewed. Date for annual update reassessment Name Date Signature Copy for PDR 28

35 Skills Lab Appendix 5 Assessment Record Peripheral IV Cannulation Instruction: Please tick ( ) if performed, cross (X) if not performed, or write N/A if deemed not applicable Surname Forename Ward/Dept Assessment Dates Assessor(s) Correct equipment collected Transporting Preparing the patient Hand washing Performs procedur e Patient comfort & safety Safety Hand washing Documentation Clean tourniquet Sterile glove Syringe, needle and normal saline Cannula pack with appropriate size of cannula Checks packaging and expiry dates Safely transfers equipment to patient Identifies patient and explains procedure Obtains consent from patient Encourages questions Establishes comfort and privacy of patient Washes hands using the Ayliffe technique Selects appropriate limb Applies tourniquet safely and checks pulse. Supports patient s arm Selects appropriate vein Loosens tourniquet Cleanses patient s skin aseptically with chlorhexidine 2% and allows to dry Washes hands/ disinfects hands with alcohol hand gel Opens equipment maintaining sterile field Places blue towel under chosen limb Reapplies tourniquet Disinfects hands with hand gel Applies sterile gloves Introduces needle safely until flashback Removes/loosens tourniquet Introduces of cannula carefully and withdraws introducer at the right time Stabilises cannula Flushes cannula with normal saline Appropriate sterile dressing applied Comfort of patient re-established Explains care of cannula to patient Disposes of sharps appropriately Maintains aseptic technique throughout Washes hands Applies Review by date sticker Completes cannula insertion record Completes VIIAD form If first attempt fails, one further attempt is permitted, if the principles of asepsis are maintained. 29

36 Appendix 6- Image of Posiflush 39

37 31