Infection Prevention in Vascular Access & Subcutaneous Infusion Devices

Transcription

1 Infection Prevention in Vascular Access & Subcutaneous Infusion Devices Disclaimer BCPFT staff must have received specific training, have completed the enclosed competency assessment & be deemed as competent in the procedures BEFORE they are able to care for patients with IV or SC infusions. Alternatively patient s requiring this type of treatment will require transfer to the nearest local Acute Hospital for assessment & appropriate treatment. Target Audience Who Should Read This Policy All clinical staff Version 2.0 July

2 Contents 1.0 Introduction Scope of Policy Risks of Cannula insertion Objectives Criteria for Practitioners Involved General Principles Patient Safety Incidents Monitoring & compliance Standards / key performance indicators Equality Impact Assessment Data Protection Act and Freedom of Information Act Training References 16 Appendices 1.0 Algorithms for IV fluid therapy in adults (NICE 2016) Visual Infusion Phlebitis Score Peripheral IV Cannula Record Chart - VIP Score Care plan for the management of a patient with a Vascular Access Device Inpatient Adult Peripheral Cannula Insertion Record Saving Lives: Audit for VAD Insertion Medical & Registered Nurse Competency Assessment Framework Vascular Access Devices 28 Version 2.0 July

3 Explanation of terms used in this policy Infection Prevention in Vascular Access & Subcutaneous Infusion Devices Policy Aseptic non-touch technique - Using practices and procedures to prevent contamination from pathogens, applying strict rules to minimize the risk of infection. Bacteraemia - The presence of bacteria in the bloodstream EC- European conformity (MHRA 2016a) Embolism- Obstruction of a blood vessel by foreign matter e.g. blood clot, fat globule or air bubble Erythema- Redness of the skin along a vein resulting from capillary congestion. Extravasation - Accidental leakage of fluid from an IV infusion in the vein into the surrounding tissues Haematoma- A localised collection of blood outside the blood vessels, caused by a break in a blood vessel. Hypodermoclysis- The subcutaneous administration of fluids to the body in the form of saline or glucose solution Induration- The hardening of a normally soft tissue due to inflammation or accumulation of blood. Infection- The presence of microorganisms on/in the body that is causing an adverse effect or host- response the person is unwell and has signs and symptoms of an infection Infiltration- Inadvertent administration of IV fluid into surrounding tissue Lumen- Interior space of a tubular structure such as a blood vessel or cannula Medical device- According to the Medical Devices Directive (MDD), a medical device is described as any instrument, apparatus, appliance, software, material or other article used alone or combined for humans to: diagnose, prevent, monitor, treat or alleviate disease. Phlebitis- Inflammation of a vein, pain, swelling, redness and tenderness are common symptoms. Peripheral cannula- Is defined as one that is less than or equal to 3 inches (7.5cm) in length & is used for short term therapy of 3-5 days and for bolus injections or short infusions. Risk Assessment- A process used to identify any potential hazards and analyse what could happen, and to identify steps to be taken to reduce or minimise the risk. Single use device- A single-use device is used on an individual patient during a single procedure and then discarded. It is not intended to be reprocessed and used again, even on the same patient. Syncope- A faint or temporary loss of consciousness some people may faint during this procedure. Thrombophlebitis- An inflammatory process that causes a blood clot to form and block a vein. Vascular Access Device (VAD)- Vascular access device e.g. cannula, butterfly needles etc. Vasoconstriction- Narrowing or diminution of the calibre of the blood vessels resulting in reduced blood flow Visual Infusion Phlebitis (VIP) Score- The visual infusion phlebitis scale is used for assessment of the early signs of phlebitis, along with prompt removal of peripheral intravenous cannulas. Version 2.0 July

4 1.0 Introduction Many patients admitted to hospital or in receipt of health care in other settings, including their own homes, will become recipients of one or more infusion therapies at some stage which can have implications for patient care and safety. The priorities for a patient requiring therapy will depend upon an assessment of their clinical needs. Generally, Black Country Partnership Mental Health Trust patients will be recipients of short-term intravenous drugs or fluids and will require full nursing support for the duration of treatment. Patient assessment is not just about identifying the most suitable vein to site an IV cannula. It should also include consideration of the types of medication required and for how long, the volumes of fluids anticipated, this should then be matched against types of cannula, etc. Infusion therapy is now an integral part of the majority of nurses professional practice. It can range from caring for a patient with a subcutaneous or peripheral cannula in situ to nursing a patient requiring multiple parenteral drugs/infusions. Whatever the route, subcutaneous, peripheral or central, infusion therapy is not without risks. Patients have a right to receive a uniformly high standard of care, and nurses have a responsibility to deliver evidence based care. Research findings should be used to expand the evidence base of nursing knowledge in order to validate and improve practice, to advance professional accountability for the benefit of all patients. 2.0 Scope of Policy The contents of this policy apply equally to medical staff as well as nursing staff. Subcutaneous or intravenous therapy is assessed as being necessary for the care of some patients within Black Country Partnership Foundation Trust. This may be carried out for the induction of anaesthetic, short-term fluid replacement, nutritional support or palliative care. These procedures are more commonly undertaken on our older adult units at Edward Street & Penn Hospitals. A significant complication of venous and arterial devices is infection, which may be localized or systemic, therefore knowledge of the relevant anatomy and physiology and skills in the insertion and subsequent care of these devices is vital. This policy applies only to peripheral venous cannula (PVC) and subcutaneous devices commonly known as Vascular Access Devices (VADs) and does not cover the insertion and management of central venous catheters (CVC). This policy also refers to devices that may be attached to VADs after insertion e.g. infusion sets and extension sets. BCPFT staff must have received specific training, have completed the enclosed competency assessment & be deemed as competent in the Version 2.0 July

5 procedures BEFORE they are able to care for patients with IV or SC infusions. Alternatively patient s requiring this type of treatment will require transfer to the nearest local Acute Hospital for assessment & appropriate treatment. This policy must be applied in any area within the Trust where VADs and associated equipment is used. 3.0 Risks of Cannula insertion It must be recognised that intravenous cannulation is an invasive procedure. must be carried out to monitor any risks associated with this procedure. These include localised infection, but also phlebitis, infiltration, extravasation and haematoma, all of which predispose the patient to an increased risk of local and systemic infection, bacteremia and therefore mortality. The importance of using effective infection prevention and control measures are integral to all aspects of infusion therapy and associated devices. 4.0 Objectives To ensure safe and effective subcutaneous and peripheral cannulation at all times. To ensure that infection control measures are observed through the insertion, management and removal of all vascular access devices. To maintain the patency of the device. To maintain the comfort and safety of the patients. To maintain a closed infusion system to reduce the risk of contamination. 5.0 Criteria for Practitioners Involved The Nursing and Midwifery Council (NMC) code of professional conduct The Code (NMC 2015) emphasises the need to base care on the best available evidence. The Health Care Professional (HCP) responsible for the management (including device insertion and ongoing management) of infusion therapy should be competent in all clinical aspects of infusion care which they carry out and have the skills and knowledge pertinent to their role. The HCP in addition should have validated clinical competence in accordance with the NMC s Code (2015) or other relevant health professional Standards of conduct performance and ethics, in order to maintain their knowledge and skills. The HCP will have undergone theoretical and practical training as part of a competency assessment (see Appendix 7) Version 2.0 July

6 Training for insertion and management may be undertaken during pre-registration period (i.e. Medical staff) or post registration courses (i.e. Nursing staff) 6.0 General Principles Initial assessment should include whether or not infusion therapy is required and have other routes been considered and excluded. A number of broad principles apply to all aspects of the management of all infusions and associated devices. Specific guidance is given regarding each particular device but the following should be adhered to at all times. Individuals who require VADs/infusion therapy should have the opportunity to make informed decisions about their care and treatment in partnership with the health professional looking after them. It may not be possible for some of our patients to understand or give verbal consent; this should be clearly documented in Medical/Nursing notes. When the patient does not have capacity to make decisions, healthcare professionals should follow the DH guidelines and Trust policy on consent to treatment. Infusion fluids must be prescribed by a doctor following an assessment of the patients fluid and electrolyte needs remembering the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment, and offer infusion therapy as part of a protocol (See NICE Algorithm for IV therapy in Appendix 1) Infusion fluid therapy should only be used for patients whose needs cannot be met by oral or enteral routes, and must be reviewed daily and stopped as soon as possible. Administration Sets ( giving sets ) Administration sets also known as giving sets used for a continuous infusion MUST be changed every 96 hours unless indicated otherwise by the manufacturer, they become disconnected, or the integrity of the product or system has been compromised. Date/time labels must be applied to ensure administration sets are changed at the correct interval. Administration sets must be changed under aseptic conditions using standard precautions and following manufacturer s recommendations. Used equipment must be discarded as clinical waste. Administration sets used for intermittent infusion should be changed every 24 hours if remaining connected to a device or discarded after each use if disconnected. These should be changed using aseptic technique and observing standard precautions. Date/time labels must be applied to ensure administration sets are changed at the correct interval. Used equipment must be discarded as clinical waste. Roller clamps should always be used to occlude the line when removing the administration set. Manual flow control devices The rate of infusions can be regulated by manual flow control devices to ensure timely delivery of the prescribed therapy e.g. resuscitation situations. Version 2.0 July

7 The healthcare professional should demonstrate knowledge and competency which has been assessed relative to the manual infusion device including indications for use, and regulating the flow to deliver the prescribed therapy. The healthcare professional responsible for the care and management of the patient is accountable for the use of manual flow control infusion devices, if deemed competent in the use of manual flow infusion devices. Electronic Infusion Devices The use of an infusion pump to regulate the flow of IV or SC fluid is recommended all Medical Devices used are standardized across the Trust and must be approved for use by the Medical Devices Committee and included on the medical devices asset register. The healthcare professional should demonstrate knowledge and competency which has been assessed relative to electronic infusion device including indications for use, programming the device to deliver the prescribed therapy, mechanical operation, the use of lock-out safety devices, troubleshooting, monitoring and safe use. The healthcare professional is responsible for monitoring the patient and is accountable for the use of electronic flow control infusion devices. N.B. training and assessment of competency in the use of medical devices is provided by the Medical Device Nurse Trainer. All infusion pumps must be configured correctly for their required application. (Configuring means selecting the appropriate mode for the intended use). Administration sets should be compatible with the infusion pump and fitted with an antifree flow device. The correct pump should be specified on the administration sets packaging. Roller clamps should always be used to occlude the line when removing the administration set. Infusion devices must be decontaminated after each use as per the manufacturer s instructions. Syringe pumps Always ensure that the syringe is compatible with the syringe pump with attention to the positioning and securement of syringe barrel, syringe barrel clamp, syringe plunger clamp and syringe finger grips. Use the prime or purge facility on the syringe pump to reduce mechanical backlash. NEVER prime or purge the line with the extension set still attached to the patient. The healthcare professional is responsible for monitoring and documenting the infusion rate of the prescribed therapy. The healthcare professional should demonstrate knowledge and competency which has been assessed relative to electronic infusion device including indications for use, programming the device to deliver the prescribed therapy. N.B. training and assessment of competency in the use of medical devices is provided by the Medical Device Nurse Trainer. Version 2.0 July

8 6.1 Preventing Infection general principles Infection Prevention in Vascular Access & Subcutaneous Infusion Devices Policy There is risk of infection when the device is inserted and while it remains in situ. The risks inherent in insertion of VADs include bypassing the skin, which is such an important barrier against microorganisms gaining entry to sterile sites such as the tissues and bloodstream, and leaving a foreign body in the patient for several days or longer which is likely to become colonised by microorganisms. Skin organisms colonisation of the external surfaces of the device by microorganisms from the patients skin around the insertion site. This can occur through contamination of the cannula tip at the time of insertion or migration of skin organisms at the insertion site into the cutaneous cannula tract after insertion Contamination of the cannula hub with distal spread of the organisms down the intraluminal surface. This is largely thought to occur during handling of the connections at the cannula/line junctions. Occasionally the cannula might become haematogenously seeded from another focus of infection. Contamination of the fluid infuscate occurs on rare occasions Risk factors for VAD related blood stream infections Prolonged hospitalisation before the VAD is inserted. Prolonged placement of the device Heavy microbial colonisation of the insertion site that contaminates the cannula during insertion and migrates along the cutaneous cannula track. Heavy microbial colonisation of the cannula/hub, usually secondary to contamination from healthcare professional hands during care interventions. Potential sources for indwelling device contamination: Minimising the risk of blood stream infections from VADs Adherence to the Trust Hand Hygiene policy and procedure including correct selection and use of PPE prior to all interventions and patient care episodes. Version 2.0 July

9 To minimise the risk to patients, VADs should only be used when absolutely necessary. VADs must be removed as soon as they are no longer needed or alternative means are available to deliver appropriate care e.g. fluids/medication. Prior to insertion suitable skin prep with rapid acting skin antiseptics e.g. 70% isopropyl alcohol with 0.5% chlorhexidine is recommended for procedures penetrating the skin (including subcutaneous infusions). Standard precautions and aseptic non-touch technique must be used when inserting or handing VADs and associated equipment and uses sterile equipment ensuring checks that packing intact, products in-date etc. Use of sterile occlusive cannula dressings ensuring the insertion site remains visible though the dressing. Dressing changed as recommended e.g. if soiled or loosened (see section 7.6.1) Daily use of the VIP score assessment tool and device replacement when clinically indicated. If a VAD is inserted in an emergency, remove within 24 hours and insert a new device under appropriate conditions. Replacement of administration sets every 96 hours when used for continuous infusion or after each use if used for intermittent infusion and disconnected from the device or every 24 hours if remains connected to the device (see section 7) 6.2 Peripheral Venous access Veins that should be considered for peripheral cannulation are those found in the forearm or hands, generally IV s are started at the most peripheral site that is available and appropriate for the situation. Where possible use the non-dominant forearm. Site selection should avoid areas of flexion although this may not always be possible. The healthcare professional should have the necessary knowledge and competence to select the most appropriate site and device for the patient and the intended therapy. 6.3 Use of Subcutaneous (SC) Devices The administration of fluids by the subcutaneous route is a safe and reliable method of treating dehydration and symptoms of thirst in the elderly and palliative care patients. It is particularly useful in patients who have difficulty in taking fluids orally, such as those who have dysphagia, which results in decreased oral intake. Setting up a subcutaneous infusion is a relatively simple procedure and carries far less infection risk than an intravenous infusion. This method involves the insertion of a 21 or 23 gauge butterfly cannula under aseptic conditions into subcutaneous tissue. These may be inserted at an angle of 45 degrees and secured with a sterile transparent dressing. Only one device should be used for each insertion attempt for that particular device and patient (following failed insertion attempts discard equipment and select a new device) Version 2.0 July

10 Once the cannula is inserted it is attached to a giving set and connected to a bag of fluids (either 5% Dextrose or 0.9% Saline), commonly infused at a rate of 2 litres over a 24hr period. Small volumes of fluid/medication should be administered using a syringe driver. Prolonged use with large volumes of fluids in one site can result in localized pain and oedema. NB. This policy does not specifically refer to infusions for the purposes of palliative care SC Site Selection The best sites for the continuous infusion of drugs or fluids are the lateral aspects of the upper arms and thighs but the most common site is the abdomen in the umbilical region. This is because these sites usually have adequate amounts of subcutaneous tissue. The skin should be cleansed and be gently pinched into a fold to elevate the subcutaneous tissue, which lifts the adipose tissue away from the muscle. Sites that should NOT be chosen are: Limbs with pre-existing lymphedema - the absorption rate may be affected but the cannula breaches the integrity of the skin and increases the risk of infection to an already compromised limb. Sites over bony areas. Skin which has received radiotherapy Sites near a joint, where movement could displace the cannula 6.4 Insertion of all Vascular Access or Subcutaneous (SC) Devices Placement of any vascular access or subcutaneous device is a procedure that should only be undertaken by a Healthcare Professional (HCP) who have had appropriate training, has a comprehensive understanding of anatomy and physiology, vascular assessment and insertion techniques appropriate to the specific device, and has completed appropriate training and deemed competent to do so. In addition the HCP should have the necessary knowledge and competence to select the most appropriate site and device for the patient and the intended therapy (See competency requirements in Appendix 7). Cannulation and venepuncture is an invasive procedure involving a breach of the skins integrity from the skin surface to the bloodstream. Use of aseptic technique method and standard precautions in conjunction with product sterility are required to prevent infection. Use of personal protective equipment is required based on assessment of risk of transmission of microorganisms and the risk of contamination of the healthcare worker. Gloves MUST be worn for invasive procedures. Version 2.0 July

11 Preparation The healthcare practitioner must wash hands prior to the procedure, select appropriate PPE and use an aseptic technique. Preparing equipment All equipment collected together Integrity of packaging and expiry dates checked All devices selected must have engineered sharps injury protection mechanisms; these mechanisms should be activated immediately after use and prior to disposal. Hands must be decontaminated both before and after the insertion / removal and before all manipulations of a device. (See Hand Hygiene Policy) Checking Identity of patient Any allergies the patient has e.g. to tape, skin cleaning solutions, latex etc. Positioning patient and preparing environment Encouraging venous filling Patient comfortably positioned Good lighting and privacy The healthcare practitioner must use hand sanitising gel prior to donning non-sterile procedure gloves. There are various methods of dilating veins to assist selection of a suitable vein for cannulation and improve venous access: Apply tourniquet 4-5 finger widths above the planned puncture site only venous blood flow should be suppressed, to ensure a pulse id palpable distal to tourniquet. Place limb below level of the heart. Ask patient to open and close fist Light tapping of vein may seem helpful but can be painful and may cause a haematoma therefore rubbing the skin is recommended. If vasoconstriction is a problem the application of a warm compress or the immersion of the limb in warm water can promote venous distension. Selecting a vein and preparing the site Once a suitable vein has been selected the tourniquet should be removed and the site prepared. Hair removal Removal of hair is only necessary if adhesion of the sterile dressing may be difficult Before cleaning the site any excessive hair should be clipped with scissors, not shaved this will help to enhance visualisation of the vein & eliminate undue discomfort when the dressing is removed. (Shaving increases the risks of infection) Version 2.0 July

12 Cleaning the skin Current guidelines recommend skin disinfection with an alcohol swab (2% Chlorhexidine in 70% isopropyl) or Chloroprep solution. The application technique should be as per the manufacturer s instructions allowing for appropriate cleaning (approx. 30 seconds) and drying time. The solution should be allowed to air-dry completely before inserting the cannula. For the remainder of the procedure do not re-palpate the vein or touch surrounding cleaned skin after disinfection Stabilising the vein Superficial veins tend to roll and need to be anchored to keep them stable. Veins are stabilised by using the non-dominant hand to apply traction to the side of the insertion site or below it. Placing the cannula twohanded technique NB: If a practitioner has had two unsuccessful attempts at insertion, another practitioner with more experience should assess the patient s venous access. If reinsertion is attempted a NEW device MUST be used. Stabilising and dressing the cannula Using the dominant hand the HCP inserts the cannula with the bevel up so as to ensure smooth puncture of the vein Skin traction is applied initially using the non-dominant hand. When the stylet is in the vein observe the first flashback, non-dominant hand releases skin traction and withdraws the stylet, observe second flashback then the dominant hand advances the cannula off the stylet. The vein is occluded and the cannula is stabilised and the tourniquet is released and stylet removed. If any bruising occurs while cannulation is being performed the tourniquet should be released at once, the device removed and pressure applied to prevent formation of a haematoma. The cannula should be secured using aseptic technique and in such a way that the cannulation site can be inspected visually and the flow of infusion fluid is not impeded. A sterile transparent semi-permeable membrane dressing and/or gauze should be applied the entry site should remain visible. Attach extension set/giving set or Luer plug If giving IV fluids the primed giving set should be attached to the hub (an extension set is recommended to reduce mechanical phlebitis. If not immediate infusion is required a luer plug should be attached after flushing the cannula. Injection and access caps/ports which are not integral to the device should be changed at established intervals according to the manufacturer s instructions (record on care plan) Injection and access caps/ports that are not integral to the device should be of closed Luer-Lok TM design Version 2.0 July

13 Flushing the cannula Once the cannula has been inserted and secured it should be flushed with 5mls 0.9% NaCL in a 10ml syringe. Excessive force should never be used when flushing as rupture of the vein could occur. The cannula site should also be observed for evidence of infiltration. PVC end caps are single use only and must be discarded after each use Disposal of sharps Used sharps must be disposed of by the user, at the point of use, into a sharps container (conforming to UN 3291 and BS 7320). (See Waste Management Policy) NB All non-disposable medical equipment used in associated with VADs must be cleaned daily when in use and following each patient use e.g. drip stands, splints and electronic infusion devices. Following insertion of a VAD all details must be documented (see Appendix 5) 6.5 Cannula sizes Gauge Length Uses Considerations 24 gauge yellow hub (smallest) 22 gauge blue hub 20 gauge pink hub 18 gauge green hub 16 gauge grey hub 19mm Neonates Paediatric Elderly 25mm Neonates Paediatric 25mm Adolescents Adults Elderly Suitable for extremely small veins slow flow rates Easy to insert Suitable for small or fragile veins Can be used for all IV fluids & medications Approximately 42ml/min Most commonly used for all IV fluids & medications Approximately 67ml/min 32mm Adults Suitable for administration of viscous fluids or when high flow is required Approximately 133ml/min 32mm Adults Suitable for administration of large quantities of IV fluids or when high flow is required Painful insertion, requires a large vein Approximately 236ml/min 6.6 Monitoring the site The condition of the site should be inspected and documented regularly (each shift), for signs of complications such as infection or phlebitis and to also check that the cannula is still firmly secured and the dressing is clean and intact. The VIP score should be used to assess the site (Appendix 2) Following the assessment findings must be recorded (Appendix 3) and the care plan reviewed and evaluated at each shift. (Appendix 4) Changing the dressing The site should be kept clean and dry at all times. The dressing should only be changed if it becomes wet or soiled. Version 2.0 July

14 Aseptic technique should be used for dressing changes. Document on the care plan all interventions Maintaining patency Infection Prevention in Vascular Access & Subcutaneous Infusion Devices Policy Thrombi and fibrin deposits on intravascular devices may provide a site for microbial colonisation. Flushing with 0.9% Sodium Chloride (NaCL) solution should be performed before, between and after administration of medications or solutions by a competent healthcare professional who has be trained and assessed as competent to do so. Document all interventions on the care plan (Appendix 4) & record all use of flushes on the patient s prescription sheet Removing a cannula Peripheral IV cannula should be removed and if necessary replaced after hours. Removal should take place earlier if complications are suspected or the cannula is no longer required. Peripheral cannula only need to be re-sited when clinically indicated and not routinely. The cannula should be removed carefully, slowly and steadily with the hub parallel to the skin. Firm pressure should be maintained until bleeding stops and then a small sterile selfadhesive dressing applied. The cannula should be inspected on removal to ensure that it is intact. Removal must be documented (Appendix 3 & 4) 7.0 Patient Safety Incidents All patient safety incidents that have the potential to, or actually result in harm should be reported via DATIX to ensure that any necessary action can be taken to prevent similar incidents from occurring in the future and in order for learning to take place and be shared. Any adverse incident involving a medical device must be reported to the MHRA using the adverse incident reporting system/yellow card scheme. The Governance Assurance Team and Medical Engineering must be notified immediately and the medical device MUST be retained securely for inspection (this include any disposable single use equipment). Refer to Medical Devices Policy and associated procedures for more detailed information 8.0 Monitoring & compliance Each Division is responsible for monitoring standards of clinical practice Exception reports will be presented to the relevant Division Management Board and the Quality & Safety Steering Group. The reports will include audit data from clinical areas, details of associated infection prevention and control issues. Any areas of non-compliance with this policy will be reported through the Nursing Board for dissemination of any lessons learnt. 9.0 Standards / key performance indicators Version 2.0 July

15 Key Performance Indicator Infection Prevention in Vascular Access & Subcutaneous Infusion Devices Policy Method of Assessment 1. Compliance with Hand Hygiene Inpatient Services audited monthly. Community Services audited quarterly. Saving Lives audit for VAD insertion (Appendix 6) should be undertaken each time a unit has a patient with a VAD 2. Compliance with Disposal of Sharps Waste Inpatient Services audited monthly. 3. In all cases of confirmed device associated bacteraemia the CCG is notified Annual Audit Programme for all other areas. The IPCT will notify The CCG of a confirmed case of HCAI within 24hrs (of the next working day). Feedback from CCG on receipt of Divisional quarterly reports. 4. Care of Medical Devices Inpatient services audited by the Matrons 5. Competency of healthcare professional in relation to this policy All Ward Managers are responsible to ensure their staff are competent to perform procedures in relation to this document and where necessary ensure training is provided Assessment part of individual performance reviews and 1-1 s with staff 10.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext or bcpft.equalityimpactassessment@nhs.net 11.0 Data Protection Act and Freedom of Information Act Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to 20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act. Version 2.0 July

16 All staffs have a responsibility to ensure that they do not disclose information about the Trust s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team Training Please refer to the Trust s Mandatory and Risk Management Training Needs Analysis for further details on training requirements, target audiences, and update frequencies. Intravenous therapy treatment MUST NOT commence until the staff involved have received appropriate specific training and deemed competent. Staff must also be competent in the use of all devices and consumables required. The appropriate Ward Manager/Matron will refer staff for training and the Division will secure funding if required. The Divisions will also fund the purchase of devices and infusion pumps. Only devices approved by the Medical Devices Committee may be ordered (See Medical Devices Policy) References 1. Dougherty, L & Lister S (2015) the Royal Marsden Hospital Manual of Clinical Nursing Procedures, 9 th Edition, Blackwell Science. 2. Royal College of Nursing (2016) Standards for Infusion Therapy, 4 th Edition, RCN, London 3. EPIC 3 (2017) Guidelines for Preventing Healthcare Associated Infections. NHS Improvement 4. Jackson, A. (1998) visual Infusion Phlebitis Score. 5. NICE, (2014) Quality statement 5: Vascular access devices. London, National Institute for Clinical Excellence 6. B Braun (2017) Braun Peripheral Cannulation & Venepuncture Training Programme Workbook 7. BCPFT Medical Devices Policy and associated Standard Operating Procedures 8. BCPFT Infection Control Assurance Policy and associated Standard Operating Procedures 9. The Royal Marsden Hospital Manual of Clinical Nursing Procedures (9 th Edition) 2015 Version 2.0 July

17 Appendix 1 Algorithms for IV fluid therapy in adults (NICE 2016) Algorithm 1: Assessment Yes Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient is hypovolaemic and needs fluid resuscitation Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP<100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per minute; NEWS 5 45 passive leg raising suggests fluid responsiveness See Algorithm 2: Fluid Resuscitation No Assess the patient s likely fluid & electrolyte needs History: previous limited intake, thirst, abnormal loses, comorbidities Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension Clinical monitoring: NEWS, fluid balance charts, weight Laboratory assessments: FBC, urea, electrolytes & creatinine Can the patient meet their fluid and/or electrolyte needs orally or enterally? Yes Ensure nutrition & fluid needs are met No Does the patient have complex fluid or electrolyte replacement or abnormal distribution issues? Look for existing deficits or excesses, ongoing abnormal losses, abnormal distribution or other complex issues. No Yes See Algorithm 4: Replacement & Redistribution See Algorithm 3: Routine Maintenance Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the Version 2.0 July 2018 patient is hypovolaemic and needs fluid resuscitation 17 Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP<100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per minute; NEWS 5 45 passive leg raising suggests fluid responsiveness

18 Yes Algorithm 2: Fluid Resuscitation Initiate treatment Identify cause and deficit and respond Give a fluid bolus of 500ml of crystalloid (containing sodium in the range of mmol/l) over less than 15 minutes. Reassess the patient using the ABCDE approach Does the patient still need fluid resuscitation? Seek expert help if unsure Yes No Does the patient have signs of shock? Yes No Assess the patient s likely fluid & electrolyte needs (see Algorithm 1 box 3) >2000 ml given? Yes Seek expert help No Give a further fluid bolus of ml of crystalloid Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient Version 2.0 July 2018 is hypovolaemic and needs fluid resuscitation 18 Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP<100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per minute; NEWS 5 45 passive

19 Yes No Algorithm 2: Fluid Resuscitation Assess the patient s likely fluid & electrolyte needs History: previous limited intake, thirst, abnormal losses, comorbidities Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension Clinical monitoring: NEWS, fluid balance charts, weight Laboratory assessments: FBC, urea, electrolytes & creatinine No Can the patient meet their fluid and/or electrolyte needs orally or enterally? Yes Ensure nutrition & fluid needs are met No Does the patient have complex fluid or electrolyte replacement or abnormal distribution issues? Look for existing deficits or excesses, ongoing abnormal losses, abnormal distribution or other complex issues Yes See Algorithm 4: Replacement & Redistribution No See Algorithm 3: Routine Maintenance Give maintenance IV fluids Normal daily fluid & electrolyte requirements: ml/kg/d water 1 mmol/kg/day sodium, potassium*, chloride g/day glucose (e.g. 5% contains 5 g/100ml) *Weight-based potassium prescriptions should be rounded to the nearest common fluids available (for example, a 67kg person should have fluids containing 20 mmol and 40 mmol of potassium in a 24 hour period). Potassium should not be added to IV fluid bags as this is dangerous Reassess and monitor the patient Stop IV fluids when no longer needed Nasogastric fluids or enteral feeding are preferable when maintenance needs are more than 3 days Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient Version 2.0 July 2018 is hypovolaemic and needs fluid resuscitation 19 Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP<100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20 breaths per minute; NEWS 5 45 passive leg raising suggests fluid responsiveness

20 No Assess the patient s likely fluid & electrolyte needs History: previous limited intake, thirst, abnormal losses, comorbidities Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension Clinical monitoring: NEWS, fluid balance charts, weight Laboratory assessments: FBC, urea, electrolytes & creatinine No Can the patient meet their fluid and/or electrolyte needs orally or enterally? Yes Ensure nutrition & fluid needs are met No Does the patient have complex fluid or electrolyte replacement or abnormal distribution issues? Look for existing deficits or excesses, ongoing abnormal losses, abnormal distribution or other complex issues Yes Algorithm 4: Replacement & Redistribution Existing fluid or electrolyte deficits or excesses. Check for: Dehydration Fluid overload Hyperkalaemia Hypokalaemia Estimate deficits or excesses Ongoing abnormal fluid or electrolyte losses. Check ongoing losses and estimate amounts. Check for: Vomiting & NG tube loss Biliary drainage loss High/low volume ileal stoma loss Diarrhoea/excess colostomy loss Ongoing blood loss e.g. malaena Sweating/fever/dehydrati on Urinary loss/polyuria Redistribution and other complex issues, check for: Gross oedema Severe sepsis Renal/liver and/or cardiac impairment Malnourished and refeeding issues Seek expert help if necessary and estimate requirements Prescribe by adding to or subtracting from routine maintenance, adjusting for all other sources of fluid and electrolytes (oral, enteral and drug prescriptions) Monitor and reassess fluid and biochemical status by clinical and laboratory monitoring Version 2.0 July

21 Visual Infusion Phlebitis Score Appendix 2: Version 2.0 July

22 Peripheral IV Cannula Record Chart - VIP Score Appendix 3 Patient Label here Cannula: Cannula: Cannula: Cannula: Gauge: Gauge: Gauge: Gauge: Complete this record each shift & record each cannula inserted Date of insertion: Date of insertion: Date of insertion: Date of insertion: Insertion Site: Insertion Site: Insertion Site: Insertion Site: Date of removal: Date of removal: Date of removal: Date of removal: If the cannula is being accessed regularly for the administration of medication, IV fluids (at least every eight hours) no further flushing will be required. However in the event of infrequent access, the cannula should be inspected, assessed and flushed every eight hours with 5 mls 0.9% saline. Date Time Cannula Site (detail position) Reason for continuing please state clinical indication Site inspection: VIP score Cannula Flushed with 0.9% NaCl Yes No Problems please state (E.g. occlusion, positional, pulled out etc.) Print name Sign Score Visual Infusion Phlebitis (VIP) score 0 IV site appears healthy 1 ONE of the following evident: Slight pain near IV site OR slight redness near IV site 2 TWO of the following evident: Pain at IV site OR Erythema OR Swelling 3 ALL of the following evident: Pain along path of cannula AND Erythema AND Induration 4 ALL of the following evident and extensive: Pain along path of cannula AND Erythema AND Induration 5 ALL of the following evident and extensive: Pain along path of cannula AND Erythema AND Induration AND palpable venous cord AND Pyrexia Continue overleaf Version 2.0 July

23 Date Time Cannula Site (detail position) Reason for continuing please state clinical indication Site inspection: VIP score Cannula Flushed with 0.9% NaCl Yes No Problems please state (E.g. occlusion, positional, pulled out etc.) Print name Sign POSITIVE Blood Culture (BC) results: Date blood culture taken Cannula site Reason BC taken Results Action taken Version 2.0 July

24 Appendix 4 Care plan for the management of a patient with a Vascular Access Device Please print this care plan and keep it in patient s nursing notes. Patient Name: Ward: NHS No.: Date/Time: REASON FOR INFUSION Insert patient s name - has been prescribed an infusion for the following reason/s:- OBJECTIVES: (Expected outcome) To prevent discomfort To prevent any complications that may arise with the infusion / cannulation. To maintain fluid balance To allow intravenous drugs Other please state: INTERVENTIONS: (Plan of nursing care) After the cannula has been inserted: - Observe the area around the cannula for any swelling or inflammation. A phlebitis (VIP) score must be recorded at each shift and the cannula removed if the score is 2 or above The cannula will be checked for patency at least daily and flushed with 0.9% Sodium Chloride if no infusion attached. The cannula needs to remain secure with a dressing - change dressing if it becomes loose. In addition the dressing should remain clean and dry and should be renewed as necessary. Only sterile IV dressings should be used. The cannula is dated on insertion and should be renewed or removed within a hour period. In some circumstances (e.g. if it is difficult to re-cannulate) and there is a need for continuing IV therapy the cannula can remain in place for more than 72 hours provided the phlebitis score does not exceed 2. On removal of the cannula, the site should be cleaned and a dry sterile dressing applied. If the site appears red or inflamed a swab must be taken and the tip of the cannula sent to microbiology & blood culture s obtained if the patient is pyrexial to check if there is any infection present. Bandages should be removed each time the cannula is assessed or 8 hourly (which ever sooner) so that the site can be assessed correctly Bandages should be avoided whenever possible patient s condition permitting If the cannula site has become infected or a cannula related blood stream infection is suspected, inform Infection Control Named Nurse: Signature: Date: Patient: Signature: Date: Relative: Signature: Date: Version 2.0 July

25 *Evaluate this care plan on each shift & document findings overleaf Care plan evaluation for a patient with a Vascular Access Device Patient Name: Ward: NHS No.: Date/Time: Date/time: Evaluation - include VIP score findings Nurse Signature Version 2.0 July

26 Inpatient Adult Peripheral Cannula Insertion Record Appendix 5 The practitioner inserting the peripheral cannula must complete the front of this form & the reverse must be completed by the Nurse caring for the patient as instructed (Please mark boxes with X use black ink) Please print this care plan on Blue Paper and keep it in patient s notes 1.0 Affix patient label: 1.1 Date Cannula inserted Surname: Reg No Forename: Sex: D.O.B. Address: Cons: Ward/Dept. Hosp: 2.0 Environment for Insertion Ward/Department Community A&E Other (specify) ECT 2.0 Cannula Gauge: Specify ward where cannula inserted Blue 22g Pink 20g Other (please specify) Number of cannulation attempts : Skin cleansed with. Identify on the diagram site of cannula insertion 4.0 Surname of clinical practitioner inserting Cannula: 4.1 Signature of clinical practioner (nurse, doctor etc.) 4.2 Designation e.g. Nurse, House Manager, Doctor etc. Standards of Practice Use an aseptic procedure trolley or sharps procedure tray for the cannulation procedure Decontaminate hands prior to cannulating, remembering to use alcohol hand gel Wear gloves and an apron If possible place a sterile dressing towel underneath the arm, hand or area to be cannulated Implement a non-touch aseptic technique and using Chloraprep to decontaminate the insertion site cannulate the patient Post insertion apply an IV3000 peripheral cannula dressing to secure the device Dispose of sharps at point of use into a sharps container & discard any clinical waste into a yellow clinical waste bin Decontaminate hands post procedure Cannulas inserted under non-aseptic conditions should ideally be removed within 24 hours of insertion, provided alternative IV access can be established if required Version 2.0 July

27 Saving Lives: Audit for VAD Insertion Appendix 6 Date: Ward: Undertaken by: Saving Lives: audit for VAD insertion To be used in all wards/departments caring for patients undergoing cannulation/infusion therapy. Monthly records to be sent to the Matron & Infection Prevention & Control Nurse for inclusion in the quarterly infection control reports. Each time a care element is undertaken, insert a tick in the relevant column. If the action is not performed leave it blank. Do these for each patient action, ensuring you tick it only when an element of care is performed correctly for every patient with an IV cannula or infusion. Peripheral IV cannula care bundle review tool INSERTION ONGOING CARE Date & Time Dressing Hand Hygiene Gloves & apron etc. Skin preparation Documentation to record insertion Hand hygiene IV still clinically indicated Site inspection IV set replaced after 72hrs Cannula replaced after 72 hours Version 2.0 July