Date Authorised 28 September 2015 Dissemination Target Audience All Trust Staff Dissemination and Implementation Plan Action Owner Due by

Transcription

1 Peripheral Venous Cannula Insertion and Management (Adults) Policy HH(1)/IC/636/15 Previous document(s) being replaced Location Policy No Policy Name HHFT HH(1)/IC/636/13 Peripheral Venous Cannula Insertion and Management (Adults) Policy Document Summary This policy will provide information about the correct technique for peripherally cannulating a vein aseptically and the subsequent care of the peripheral venous cannula. By using this policy the user will act to reduce the risks to patients and staff associated with peripheral venous cannulation. These include thrombosis, pain, local or systemic infection; occupational sharps injury and inappropriate cannula insertion. Ownership Author Helen O Horan Job Title Vascular Access Nurse Document Type Level Level 1 Trustwide Related Documents Document Details Hand Hygiene Policy Aseptic Technique Policy Relevant Standards CQC Outcome 8, 11 & 12 Equality Analysis Form Completed by Steve Mullen Date Completed 8 August 2015 Final Document Approval Committee Policy Approval Group Date Approved 22 June 2015 Final Document Committee Executive Committee Ratification Date Ratified 24 September 2015 Authorisation Authoriser Mary Edwards Job Title Chief Executive Officer Signature Date Authorised 28 September 2015 Dissemination Target Audience All Trust Staff Dissemination and Implementation Plan Action Owner Due by Publication of policy on intranet Healthcare Library Within one week of authorisation Communication sent to all senior managers Healthcare Library Within one week of publication Publicise details of new document via Intranet and Midweek message Communications Team Within one week of publication Review Review date 31 May 2018 Page 1 of 19

2 Document Control Document Amendments Version No. Details Key amendments to note By whom Date 1 Review of BNHFT & WEHCT policies to produce harmonised HHFT policy Sandy Kirk December Complete review of policy and documentation to bring in line with Epic3 Length of Cannula indwell time increase if required from 72 to removal when clinically indicated. Twice daily checking of VIP score on the Cannula Insertion and Management form Cleaning of skin to be via a criss cross motion rather than circular 22 gauge cannula to be first choice for routine fluid management Staff able to cannulate to include HCA who have achieved NVQ level 3, who have their manager s support Helen O Horan August 2015 Page 2 of 19

3 Contents 1. Introduction Purpose Scope Explanation of Terms Duties Clinical Need and Practice Stakeholders Engaged During Consultation Training Monitoring Compliance with the Document Contributors Appendix A: Equality Analysis Form Appendix B: Guide to Peripheral Venous Cannulation (Adult) Appendix C: Guide to management of Peripheral Venous Cannulation (Adult) Appendix D: Cannula Insertion and Management Form Page 3 of 19

4 1. Introduction Aseptic peripheral venous cannulation is undertaken to provide venous access for either diagnostic or therapeutic purposes: Short term intravenous fluid therapy of usually less than 3 4 days (if intravenous access is needed for longer periods, other options should be considered) Administration of bolus injections in outpatients or in day case surgery Vascular access for fluids or drugs at time of particular procedure e.g. surgery, endoscopy It is essential that infection control is seen as an organisational responsibility and priority, that adequate isolation facilities and resources are provided, and that appropriate infection control staff and support services are available. 2. Purpose The aim of this policy is to inform best practice on the aseptic insertion of peripheral venous cannulation (PVC) of adults. The implementation of this policy will reduce the risks associated with this procedure including thrombosis, pain, local or systemic infection; occupational sharps injury and inappropriate cannula insertion. 3. Scope This policy extends to cover and will be applied fairly and consistently to all Hampshire Hospitals NHS Foundation Trust employees regardless of their protected characteristics as defined by the Equality Act 2010 namely age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage or civil partnership, pregnancy and maternity. For employees this policy also applies irrespective of length of service, whether full or part time or employed under a permanent or a fixed term contract, irrespective of job role or seniority within the organisation. Where an employee has difficulty in communicating, whether verbally or in writing, arrangements will be put in place as necessary to ensure that the processes to be followed are understood and that the employee is not disadvantaged during the application of this policy and related procedures. The application of this policy is completely clinically based and ensuring prompt testing/treatment would be the priority, however the Trust would endeavour to continue to meet patients individual needs as far as is practicable. In line with the Equality Act 2010, the Trust will make reasonable adjustments to the processes to be followed where not doing so would disadvantage an employee with a disability during the application of this policy. This policy complements professional and ethical guidelines and the Nursing and Midwifery Council (NMC) Code of Professional Conduct (2015). Page 4 of 19

5 4. Explanation of Terms Aseptic Technique clinical practices used to protect the patient from micro organisms by preventing contamination of wounds, manipulated devices and other susceptible sites. Aseptic technique involves the use of appropriate hand hygiene, use of sterile equipment, no touch technique and robust patient skin/site disinfection. Venous Cannulation procedure for insertion of a hollow fine bore tube into the venous system. Health care professional a registered or trained member of staff including but not exclusively nurses, doctors and operating department practitioners, this may include Health Care Assistants (HCA) who have achieved NVQ level 3 and who have their manager s support. Infection entry of a harmful microbe into the body and its multiplication in the tissues. Peripheral cannula a specifically designed flexible tube designed for insertion into a blood vessel, with a proximal connector to allow injection or infusion of liquids. Sizes range from: Yellow 24g Blue 22g Pink 20g Green 18g Grey 16g Orange 14g 22g (Blue) is for administration of intermittent medicines 20 18g are required for the administration of radio opaque contrast medium 16 14g are routinely used to administer fluids in acute situations i.e. haemorrhage Phlebitis inflammation of a vein Thrombosis formation, development or existence of a blood clot within the vascular system. 5. Duties Post Holders The Chief Executive Officer (CEO) has overall responsibility for the strategic and operational management of the Trust ensuring there are appropriate strategies and policies in place to ensure the Trust continues to work to best practice and complies with all relevant legislation in regard to the insertion and management of PVCs. Page 5 of 19

6 The Director of Infection Prevention and Control (DIPC) is the Trust Director responsible to the board for the delivery of IPC standards. The Director of Nursing will ensure that the Divisional Directors take clinical ownership of the policy. The Divisional Operational Directors will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training. They are responsible for ensuring adequate facilities and resources are available to adhere to this policy. The Clinical Service Managers/Leads will ensure that the current version of this policy is available in all of their areas. They will ensure that all health care workers comply with this policy and that all health care workers attend mandatory infection prevention and control training. Medical Staff who handle and care for PVCs should be competent to do so. This should be assessed by their Educational Supervisor. Additional training can be offered by the Vascular Access Nurse. All Trust employees will comply with this policy and inform the Infection Prevention and Control Team about any issues or concerns relating to the policy. All staff will attend mandatory Infection Prevention and Control training annually. Infection control is the responsibility of ALL staff associated with patient care. A high standard of infection control is required on ALL wards and units, although the level of risk may vary. It is an important part of total patient care. Groups/Committees The Infection Prevention and Control Team (IPCT) will act as a resource for information and support. They will provide education in relation to this policy which includes mandatory training. They will monitor the implementation of this policy via audit within clinical areas and be responsible for regularly reviewing and updating it. The Health4Work department will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and health care workers regarding the use of personal protective equipment. The Health and Safety Team will act as a resource for information, and support and consult with managers, the Infection Prevention and Control Team and health care workers regarding the use of personal protective equipment. 6. Clinical Need and Practice Patients should be assessed to identify the clinical need for cannulation, this should include an assessment of the patients veins and treatment plan to ensure an Page 6 of 19

7 appropriate vascular access device is inserted (Jackson et al 2013), Hand washing should be adhered to as in the hand hygiene policy HH(1)IC All vascular access devices should be inserted and cared for using good aseptic technique, please refer to Aseptic Technique policy HH(1)IC Skin must be decontaminated using single use application of 2%Chhlorhexidine Gluconate in 70% isopropyl alcohol unless the patients have sensitivity, for 30 seconds and allowed to air dry before insertion of cannula(dh 2010, Loveday et al 2013) Upper extremities should be used out of preference to reduce the risk of catheter related blood steam infections and phlebitis, any device placed in the foot or leg of an adult patient should be replaced with a vascular access device in the upper extremity as soon as possible (O Grady et al 2011) Single use disposable tourniquets should be used at all times, reusable tourniquets have been shown to harbour multiple pathogens and so put our patients at considerable risk of infection when used (Gottlieb et al 2011, Rouke et al 2001). Peripheral cannulae should be covered with a vapour permeable dressing that allows visualisation of the insertion site and pathway of the cannula (Loveday et al 2013, Marsh et al 2015), dressings should be labelled with the date and time of cannula insertion. Extension lines should be placed on cannula used in inpatient settings, use the minimal number of lines possible so as to reduce the risk of infection, Needle free access devices should not be connected directly to the cannula. The cannulae should be flushed with 5 10ml 0.9% saline to ensure correct positioning and patency using a pulsatile flush and positive pressure (Dougherty 2008, RCN 2010). Prefilled saline syringes are available for Health care practioners, which do not require a prescription as considered a medical device (MHRA 2013). Management All cannulae should be inspected at the beginning of each shift and the visual infusion phlebitis score recorded, all cannulae should be removed at the first sign of phlebitis, blockage or as soon as the cannula is no longer required (Webster et al 2013), Cannulae should be re sited when clinically indicated or according to the manufacturers specific recommendations (Loveday et al 2013). Dressings should be changed if they become soiled or loose using a aseptic technique, skin around the insertion site should be decontaminated with 2%Chhlorhexidine Gluconate in 70% isopropyl alcohol unless the patients have a sensitivity, allow to air dry before replacement of the dressing, after any dressing change re label with date and time of the insertion of the cannula (Loveday et al 2013). Page 7 of 19

8 Before administration of any fluid or medication the access port should be decontaminated according to current guidelines, cannulae should be flushed with 3 5ml 0.9% saline prior to the administration of any medication to ensure the patency of the cannula and to prevent any complication. Administration sets in continuous use do not need to be replaced more frequently than every 96 hours unless device or pharmacological recommendations indicate otherwise, they should be replaced immediately if they become disconnected or if the cannula is replaced (Loveday et al 2013), all administration sets in use for longer than two hours should be labelled with date and time of commencement to ensure appropriate replacement. 7. Stakeholders Engaged During Consultation Stakeholder Date of Consultation Infection Prevention and Control (Lead Infection Prevention & 6 February 2015 Control Nurse) Health and Safety (Health and Safety Advisor) 9 February 2015 Safeguarding (Trust Safeguarding Lead) 9 February 2015 Information Governance (Information Governance Manager) 9 February 2015 Risk and Compliance Manager (Risk and Compliance) 9 February 2015 Divisional Directors and Divisional Directors (Operational) 9 February 2015 Head of Health4Work 9 February 2015 Infection Prevention and Control Committee 9 February 2015 Consultant Microbiologists 9 February 2015 Clinical Service Managers/Leads 9 February 2015 Operational Service Managers 9 February Training Individuals in the Trust should receive annual infection prevention and control training to ensure they are aware of their responsibilities. Education and Training will be provided in accordance with the Trust Training Needs Analysis (Learning and Development Policy). Prior to undertaking any cannulation procedure, all staff must be able to demonstrate clinical competence and a clear understanding of the underlying principles of practice. This will be achieved by: Nursing and other health care staff complete the Trust venous cannulation competency pack attend a cannulation study day complete a period of supervised clinical practice Page 8 of 19

9 (Staff who have been trained and practised in a previous post may be allowed to demonstrate an equivalent level of competence through a period of supervised practice only). Medical staff Post registration house officer (PRHO) induction will include training by Trust trainers on local Policies and principles of practice. Senior House Officer s and Registrars will be assumed competent unless identified otherwise by their supervisor. If problems are identified, the staff member will be required to: complete the Trust venous cannulation competency pack attend a cannulation study day complete a period of supervised clinical practice 9. Monitoring Compliance with the Document Minimum Requirements Effectiveness of policy Clinical Supervision Requirement Reviewed by Infection Prevention and Control Team Method of Monitoring Quality control audits to ensure continued standards and adherence of Policy during care and management of Peripheral Venous Cannula Frequency of Review Monthly Supervisors Clinical practice Ongoing N/A Committee where Monitoring is Reported to Infection Prevention and Control Committee/Divisional Governance Boards 10. References Department of Health (2010) Clean Safe Care. High Impact Intervention. Central Venous Catheter Care Bundle and Peripheral IV Cannula Care Bundle. London: Department of Health. Dougherty, L. (2008) Obtaining peripheral vascular access In: Dougherty, L. & Lamb, J. (eds) Intravenous Therapy in Nursing Practice (2nd edn) Oxford: Blackwell Publishing, pp Dougherty L and Lister S (eds) (2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedures (9th edn) Chichester : Wiley Blackwell Gottlieb T., Phan T., Cheong E.Y.L., Sala G., Siarakas S., Pinto A. (2011) Reusable tourniquets. An underestimated means for patient transfer of multi resistant bacteria BMC Proceedings. 5/, Page 9 of 19

10 Jackson T., Hallam C., Corner T., and Hill S. (2013) Right line, right patient, right time: every choice matters. British Journal of Nursing. 22(8), IV Supplement. p.s24 S28. Loveday H.P, Wilson J.A. et al (2014) epic3: National evidence based guidelines for preventing Healthcare associated Infections in NHS Hospitals in England. Journal of Hospital infection 86 (Supplement 1) S1 S70 Marsh N, Webster J, Mihala G, Rickard CM (2015) Devices and dressings to secure peripheral venous catheters to prevent complications Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD MHRA (2013) Borderlines between medicinal devices and medical products NMC (2015) The Code Professional standards of practice and behaviour for nurses and midwives O Grady NP, Pearson ML, Raad II et al (2011) Guidelines for the prevention of intravascular catheter related infections Clinical Infectious Diseases 52 (9): e162 e193 RCN (2010) Standards for Infusion Therapy, (3rd edn). London: Royal College of Nursing. Rourke C, Bates C, Read RC (2001). Poor hospital infection control practice in venepuncture and use of tourniquets. Journal of Hospital Infection 49 (1): Webster J, Osborne S, Rickard C, New K (2013) Clinically indicated replacement versus routine replacement of peripheral venous catheters Cochrane Database of Systematic Reviews Issue 8. Art. No.: CD Legislation Department of Health (2003) Winning ways: working together to reduce healthcare associated infection in England. Report from the Chief Medical Officer. Department of Health (2015) The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance. [Online] uidance/dh_ Council Directive 2010/32/EU (2010) Prevention from sharp injuries in the hospital and healthcare sector. [Online] Associated Documentation Hand Hygiene Policy Aseptic Technique Policy 10. Contributors Contributor Job Title Vascular Access Nurse Contributor Name Helen O Horan Page 10 of 19

11 Appendix A: Equality Analysis Form Document Name: Peripheral Venous Cannula Insertion and Management (Adults) Policy Part 1 Policy Author to complete and forward on to an EA Lead for sign off 1. Could the application of this document have a detrimental equality impact on individuals with any of the following protected characteristics? (See Note 1) Yes/No/ NA Summarise the equality and diversity related elements within the policy a Age No b Disability No c Gender reassignment No d Race No e Religion or belief No f Sex No g Sexual orientation No h Marriage & civil partnership No i Pregnancy and maternity No 2. If Yes to question 1, do you consider the detrimental impact to be valid, justifiable and lawful? If so, please explain your reasoning. N/A 3. Specify with which, if any, individuals and groups you have consulted in reaching your decision. Part 2 Equality Analysis Lead to complete and forward back to the Policy Author Provide a brief summary of the potential impact of the policy and whether sufficient consideration has been given to the Equality Duty. 1. Is this document recommended for publication? If yes go to question 3 if No complete number 2 below. 2. This document is not recommended for publication because: a Amendments are suggested as follows: b A more detailed equality analysis should be undertaken as follows: c Other (please specify) 3. Specify with which, if any, individuals and groups you have consulted in reaching your decision. Name: Steve Mullen Job Title: Risk & Compliance Advisor Date: 08 August 2015 Page 11 of 19

12 Part 3 Policy Author to complete on receipt of part 2 and before forwarding for final policy approval 1. I have reviewed the Part 2 assessment and have made the necessary amendments to the policy. If you have answered no, please explain why not Name: Helen O Horan Job Title: Vascular Access Nurse Date: 8 August 2015 Note 1 Under the terms of the Equality Act 2010 public sector Equality Duty, the Trust has a legal responsibility to think about the following three aims of the Equality Duty as part of our decision making and policy development. Eliminate unlawful discrimination, harassment and victimisation; Advance equality of opportunity between people who share a protected characteristic and people who do not share it; and Foster good relations between people who share a protected characteristic and people who do not share it. Page 12 of 19

13 Appendix B: Guide to Peripheral Venous Cannulation (Adult) CLINICAL PRACTICE Action Rationale Identify clinical need for cannula insertion To prevent inappropriate insertion and exposure to associated risks. Collect equipment needed including: To ensure procedure is performed without Cannula disruption Dressing trolley (Cleaned) Plastic tray (cleaned) Sterile gauze Single use tourniquet Choice of cannula must be based on clinical Clean gloves need but the smallest cannula should be Sharps box chosen to reduce risk of complications associated with larger bores. 2% Chlorhexidine and 70% alcohol (Sanicloth CHG 2% or Clinell skin wipe) Sterile cannula dressing Saline flush (Pre filled 10ml saline flush e.g. Posiflush) If required Local anaesthetic (1% Lidocaine) orange needle and 2ml syringe Identify patient by surname, first name and date of birth To ensure correct identification of the patient Wash hands with soap and water as per To reduce the risk of infection the Trust Hand Hygiene Policy Place White tray onto clean dressing trolley. Open equipment into the clean To minimise the risk of contamination of sterile equipment tray. Explain to the patient the importance of keeping the site clean and dry and advise of risks of infection, ascertain if the patient has any allergies Decontaminate hands with alcohol gel or wash with soap and water Place single use tourniquet around arm 8 10cm above proposed cannulation site. To ensure patient compliance and reduce risk of infection To minimise the risk of allergic reaction To reduce the risk of infection To reduce risk of arterial rather than venous cannulation and reduce risk of infection. Palpate potential sites these include: The hand a lower risk of phlebitis The wrist or forearm increasing risk To reduce the risk of phlebitis and complications of IV therapy. The lower limb (feet or legs ) have a higher risk of phlebitis and should NOT be routinely used Page 13 of 19

14 When potential site is identified, remove tourniquet, position patient comfortably with appropriate limb below the level of the heart. Removing excess hair (shaving is not recommended clippers are better) Encourage patient to exercise limb muscles (e.g. repeatedly making a fist and opening hand) Decontaminate hands with alcohol gel or wash with soap and water and don clean gloves Clean insertion site using a spiral motion from the proposed puncture site outwards with 2% chlorhexidine in 70% alcohol (from pre soaked wipe Sani cloth CHG 2%/Clinell skin wipe) for at least 15 seconds and then allow to dry Apply proximal a single use tourniquet, without obstructing arterial flow. Optimal time for application is 3 to 5 minutes if additional time is needed release tourniquet as vein will tend to disappear. Administration of local anaesthetic (1% Lidocaine) which can be used to minimise patient discomfort when inserting size 16g cannulas or larger. To allow dependent veins to fill with blood Local trauma can be caused by shaving, increasing risk of infection Muscle pump forces blood into veins to distend them further To reduce the risk of infection To reduce risk of infection To distend veins To ensure patient comfort Alternatively apply prescribed topical local anaesthetic cream 45 mins prior to procedure. Inserting the cannula Gently pull on skin, distal and lateral to insertion site. Do not touch the cannula or the insertion site. Insert cannula (bevel uppermost) through the cleaned skin area at an angle of aprox degrees, depending on the depth of the vein. Advance until just in the vein, a flash back will be seen in the back of the cannula and then lower the cannula until it is parallel with the skin, at this point pull the needle back 1 2mm (a flashback of blood is usually seen along the shaft of the cannula) To fix the skin and the superficial veins underlying it. To use the sharpened needle to introduce the plastic cannula into the vein. Page 14 of 19

15 Then, either; a) Pull the needle back 2mm and push the cannula/needle into the vein up to the hilt Or; b) Hold the needle still and advance the cannula over the needle until the cannula is inserted up to the hilt Discard needle immediately into sharps container at the point of use In the event of unsuccessful cannulation of the vein withdraw the cannula from the puncture site and apply pressure with nonwoven swab. Discard cannula immediately into sharps container at the point of use. Prior to subsequent attempts at cannulation it is the responsibility of the individual practitioner to risk assess the difficulty of further attempts against their own registered competence and experience. If the practitioner anticipates the difficulty level to be beyond their scope of practice, then referral to more experienced, competent practitioners should be made. Remove the tourniquet and apply pressure on the proximal vein, close to the tip of the cannula a second person may be required for this Remove needle and dispose of immediately into a sharps container, cap off cannula with a needle free extension (a needle free bung should NOT be used) Secure cannula with an approved sterile cannula dressing, ensuring it is applied correctly (non sterile, sticky tape fixation or bandage is NOT acceptable). Place date and time sticker to outside of dressing Flush cannula with 5 10 mls saline using a 10ml syringe (or 10ml pre filled saline syringe if available) if not being attached to infusion. If blood samples are require these can be taken from the cannula using an appropriate vacutainer system before the cannula is flushed with saline. Once the cannula is flushed blood samples cannot be To introduce the cannula fully into the vein To prevent sharps injury To minimise haematoma formation and /or excessive bruising To ensure cannulation is always undertaken by competent practioners and minimise risks associated with failed attempts at gaining venous access To prevent excessive bleeding during needle removal. To reduce risk of needle stick injury and prevent blood spillage Needle free bungs increase the risk of mechanical phlebitis in cannulas To reduce risk of infection and secure cannula in position To ensure timely removal To ensure cannula patency To prevent the sample being haemolised when withdrawing blood with a syringe. To prevent risk of needlestick injury when transferring blood samples to bottles. To prevent blood results being corrupted by saline contamination Page 15 of 19

16 taken. Document cannula insertion by completing a Cannula insertion and management form for each separate cannula inserted (See Appendix C). Once cannula has been removed this document is filed in the patient s medical notes. To establish an audit trail and monitor management of cannula Page 16 of 19

17 Appendix C: Guide to management of Peripheral Venous Cannulation (Adult) Ongoing cannula management Decontaminate hands before and after each patient contact. Use correct hand hygiene procedure as per trust policy. Always access cannula by cleaning with 2% chlorhexidine and 70% isopropyl alcohol (Sani cloth CHG 2%/ Clinell wipe) for seconds, and allow to dry before administering fluid or injections. Needle free bungs should NOT be applied directly onto ported cannulas; single or double lumen extensions should be applied. If the cannula has an integrated extension line do not place addition extention lines on to the cannula. The top port should NOT be used other than in specified areas e.g. theatres Cannula site should be inspected at the beginning of each shift and documented on the cannula management form. If the cannula is bandaged this should be removed to ensure adequate visualisation of the cannula site. The cannula should also be inspected for signs of phlebitis each time it is accessed. Cannula dressing should be, intact, dry and adherent. The date and time of insertion must be applied to the dressing. Remove cannula if there is no continuing clinical indication and document date and time of removal on cannula management form. Replace cannula in a new site if still required at the first signs of phlebitis, this must be documented of the VIP form. A VIP score of 2 or above is a clinical incident and a Datix form must be completed Administration sets should be replaced: immediately after blood and blood product administration (Maximum 12 hours) immediately for IV antibiotics and medicines if disconnected from the patient. To reduce the risk of infection To reduce the risk of infection To prevent unwanted movement of cannula in the vein thus causing phlebitis To reduce the risk of infection Observe for signs of infection or phlebitis To ensure that the cannula is replaced or removed on time, thus reducing the risk of infection. To reduce the risk of infection To reduce the risk of infection To reduce the risk of infection Page 17 of 19

18 heparin infusion lines should be replaced every 24 hours all other fluid sets should be replaced after 96 hours (epic3) ALL giving sets in use for longer than 2 hours must be labelled with date and time of commencement of use. All giving sets disconnected from the patient should be disposed of and cannot be reattached. All administration sets should be disposed of intact into a rigid sharps bin designated for this purpose and should not be cut. Page 18 of 19

19 Appendix D: Cannula Insertion and Management Form Page 19 of 19