South Staffordshire and Shropshire Healthcare NHS Foundation Trust

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1 South Staffordshire and Shropshire Healthcare NHS Foundation Trust Document Version Control Document Type and Title: Authorised Document Folder: New or Replacing: Document Reference: Policy for the Insertion and Monitoring of Intravenous and Subcutaneous Cannula and Infusions YELLOW Clinical Policy. Replacing C/YEL/ic/26 v1 (February 2012) C/YEL/ic/26 Version No. v2 Implementation Date: Author: Approving body: Elizabeth Blackham, Diane Hughes, Judy Carr Quality, Effectiveness and Risk Committee Approval Date: 10 th Ratifying body: Trust Board Ratified Date: 24 th Committee, Group or Individual Monitoring the Document: Infection Control Committee Review Date: April 2015

2 Contents Page 1 Policy Statement 3 2 Scope of the Policy. 3 3 Related Trust Policies 3 4 General Principles 3 5 Guidance on Insertion and Care of Peripheral Intravenous Cannula (PVC) and Intravenous Infusions 4 6 Administration of Subcutaneous Fluid 7 7 Staff Training 10 8 Monitoring compliance 11 9 References 12 Appendix One Visual Infusion Phlebitis Score (VIPS) and Record of Intravenous Cannula 13 Appendix Two Intravenous Infusion Rate Calculation 14 Appendix Three Intravenous Infusion Rate Record Sheet 15 Appendix Four Subcutaneous infusion Monitoring form 16 2

3 1. Policy statement The purpose of this policy is to provide guidance for staff on the insertion and care of peripheral intravenous cannulae (PVC) and Intravenous Infusions subcutaneous cannulae and subcutaneous infusions. 2. Scope of the policy This document applies to all South Staffordshire and Shropshire employees and all those visiting the Trusts premises such as contractors, agency/bank/locum staff, students and volunteers. 3. Related Trust Policies Hand Decontamination Policy Standard Precautions and personal Protective Equipment Policy Guidelines for Glove usage in Clinical Practice Policy Management of clinical sharps injuries and exposure to blood and high risk body fluids Mental Capacity Act Decontamination of equipment policy 4. General Principles Peripheral Intravenous Cannula must only be inserted by a suitably qualified clinician, e.g. Doctors, nurses or support workers who have received appropriate training. A number of principles apply to all aspects of the management of peripheral intravenous cannulae, subcutaneous cannulae and associated devices. The following points should be adhered to at all times. Hands must be decontaminated in adherence of the infection control policy, prior to and after the insertion of, and before and after any manipulations of a cannula or any part thereof. Personal protective clothing must be worn if there is a risk of contamination with bodily fluids. The skin must be disinfected prior to insertion of a cannula using 2% chlorhexidine gluconate (CHG) in 70% isopropyl alcohol (IPA)swab for a minimum of 30 seconds, then allow to dry for a further 30 seconds this is vital to ensure removal of skin bacteria. An aseptic technique must be used during the insertion and maintenance of a cannula. All equipment must be sterile prior to first use. A fresh pair of non-sterile gloves must be worn when manipulating any cannula or associated device, e.g. giving/administration set. Any blood contaminated and/or sharp items must be disposed of in a sharps bin, which must be taken to the patient s side. 3

4 All medical equipment used in association with peripheral intravenous therapy or subcutaneous therapy must be cleaned daily and following each patient use, including drip stands, tourniquets, splints etc. 5. Guidance on Insertion and Care of Peripheral Intravenous Cannulae (PVC) and Intravenous Infusions Risks of Cannulation It must be recognised that intravenous Cannulation is a minor surgical procedure and there are a number of risks that must be observed for, and if possible, prevented. These include localised infection, phlebitis (inflammation of the vein which can lead to blood clot formation, causing thrombophlebitis, a very serious condition that can lead to pulmonary embolism if not picked up promptly and treated), extravasation (leakage of IV fluids into the tissue surrounding the vein), haematoma and induration (hardening of the tissues), all of which predispose the patient to an increased risk of local and systemic infection, bacteraemia and therefore mortality. Site Selection Veins considered for PVC insertion should be on the dorsal and ventral surfaces of the upper extremities and include the metacarpal, cephalic and basilica veins. Veins in the lower extremities should not be used routinely in adults due to the increased risk of embolism and thrombophlebitis. By choice, select the patient s non-dominant arm and the most distal site for initial cannulation, subsequent cannulations should be in sites proximal to the initial site. Avoid bruised, painful or infected skin and if possible, avoid areas of flexion i.e. wrist and elbow, as this may compromise flow and increase catheter movement which increases the risk of complications. Selection of appropriate Cannula In general the shortest and smallest gauge cannula should be used to prevent damage to the intima of the vein and to ensure minimal risk of vascular complications. Assess type of use cannula is required for. See general guide below. Gauge (G) Colour Flow rate (ml/min) General suggested uses 14 Brown 270 Theatres or emergency for rapid transfusion of blood or viscous fluids 16 Grey 230 As for 14G. Used in maternity services due to increased risk of haemorrhage 18 Green 100 Blood transfusions, parenteral nutrition, stem cell harvesting and cell separation, large volumes of fluids 20 Pink 65 Blood transfusions, large volumes of fluids 22 Blue 40 Most medications and fluids 24 Yellow 24 Medications, short-term infusions, fragile veins, children 4

5 In this Trust, in most cases except emergency, a size 20 (pink) or 22 (blue) will be sufficient and will be the most appropriate size to use. Even in emergency situation where large volumes of fluids may be infused, no larger than an 18G (green) should be required. Basic Procedure a. Explain procedure to patient and gain verbal consent. b. Collect appropriate equipment in a clean receiver and wash hands. c. Hair removal is only necessary if adhesion of the sterile dressing will be compromised. Only use scissors or clippers, never shave as this increases bacterial shredding. d. Apply the tourniquet and using methods to encourage venous distension (e.g. fist clenching), assess and select the vein to be cannulated. Light tapping of the vein may be used but not too hard as to cause pain. Fear of cannulation can trigger a vasovagal reaction in the patient, resulting in syncope and vasoconstriction. If vasoconstriction is a problem, using a warm compress or immersing the limb in warm water may encourage venous distension. e. Once insertion site is selected, clean the surrounding area with a 70% isopropyl alcohol swab for a minimum of 30 seconds, then allow to dry for a further 30 seconds this is vital to ensure removal of skin bacteria. f. For the remainder of the procedure do not re-palpate the vein or touch the surrounding disinfected skin g. Remove the selected cannula from the packaging and inspect for faults. h. Stabilise the vein by applying manual traction to the skin. i. Ensuring the cannula is in the bevel up position; place the device over the vein. Insert the cannula at the selected angle (10-45 ) according to the depth of the vein. j. Wait for the first flashback of blood into the flashback chamber of the needle. k. Level the device by decreasing the angle between the cannula and the skin and advance the cannula slowly to ensure entry into the lumen of the vein. l. Withdraw the needle from the cannula slightly and a second flashback of blood should be seen along the shaft of the cannula. Never reinsert the needle. m. Maintaining skin traction, slowly advance the cannula off the needle into the vein. n. Release the tourniquet and apply pressure to the vein above the cannula tip before removing the needle. o. Securely attach the luer lock cap or an infusion set. p. Dispose of all sharps and contaminated waste in the sharps box. q. Apply a sterile adhesive breathable dressing. Record the date of cannula insertion on the dressing. r. Decontaminate hands using alcohol hand rub. s. Flush cannula with 0.9% sodium chloride to ensure patency, observing the site for signs of swelling or leakage and ask the patient if any pain or discomfort is felt. t. In order to prevent unnecessary trauma to the patient, if first attempt is unsuccessful, only 2 attempts should be made by any practitioner. A new cannula must be used at each attempt. 5

6 Dressing In order to secure the cannula to prevent it moving around in the vein, causing pain and inflammation, a sterile dressing must be used. A transparent semi-permeable dressing should be used, as the insertion site must be visually inspected at least twice daily. If at any time the dressing becomes loose or moist, it must be replaced immediately. After removing the soiled/loose dressing, the site must be cleaned, using an aseptic technique with 0.9% sodium chloride and then disinfected with a 2% chlorhexidine gluconate (CHG) in 70% isopropyl alcohol (IPA) wipe and allowed to dry, before applying a new sterile dressing. Prophylactic antimicrobial creams should not be used on insertion sites. Ideally, peripheral cannula sites should not be covered with bandages as this makes it impossible to observe the insertion site. However, exceptions may be made in children or confused patients who may be likely to dislodge the cannula. If the site is bandaged, the bandage must be removed twice daily to allow inspection of the insertion site. Care of Intravenous Cannulae Documentation is essential and a record of cannula insertion and dressing changes etc. must be kept. The insertion site should be observed at least twice daily for any signs of phlebitis or infection. The phlebitis scoring tool (Appendix One) should be used and a phlebitis score (VIP) recorded twice daily.in community settings this may be once daily or at each use of the cannula. Hands should be decontaminated and gloves worn before any handling or manipulation of the cannula or any drugs given or infusions attached/detached. The cannula should be flushed with at least 10ml of 0.9% sodium chloride before and after administration of any drugs. All PVC s should be removed or re-sited every 72 hours to minimise the risk of phlebitis. In addition, if the patient s phlebitis score is 2 or above the cannula should be removed immediately. The cannula should be re-sited only if necessary. In some circumstances, e.g. if a patient has very poor venous access and there is a need to continue IV therapy, the cannula may remain in place longer than 72 hours (but never longer than 5 days), providing that the phlebitis score is closely monitored. If a patient s phlebitis score exceeds 1 when the cannula has been in situ longer than 72 hours it should be removed immediately. Administration Sets and other Consumables Additions such as extension sets and 3-way taps should be avoided if at all possible. The more connections and manipulations there are increases the risk of microbial contamination. Administration sets used for continuous IV therapy must be sterile at first use and must be changed every 72 hours, or if any contamination or compromise of the set is suspected. More frequent routine changes increase the amount of manipulations of the cannula and therefore increase the risk of cannula related infection so should be avoided. The exception to this is when blood or blood products are being transfused, these transfusion sets should be replaced every 24 hours as the risk of 6

7 infection related to these products is greater than the risk of manipulation of the device. If infusion administration sets are disconnected for any reason, e.g. for transfer to another ward/department or for intermittent antibiotic infusions, the infusion set must be replaced. Removing and changing administration sets must be done under aseptic conditions. Intravenous Solutions and Infusions All IV fluids should be replaced every 24 hours routinely, and whenever the administration set and the cannula is changed or replaced. A non touch technique should be used when replacing/changing bags of fluid. All IV infusions must be prescribed by a clinician on the patient s drug chart. An infusion must be set up by a qualified nurse and checked by a second person. Except in community settings where infusions may be checked by one person, except when controlled drugs are being administered. Once the infusion is set up and running and the appropriate flow rate set, this should be documented on the infusion chart. Infusions must then be checked each hour to ensure that the flow rate is still correct and that there are no problems with the cannula. These checks must be recorded. 6. Administration of Subcutaneous Fluids Introduction The infusion of a solution into the subcutaneous tissues is called hypodermoclysis. The subcutaneous compartment (hypodermis) is a layer of loose supporting tissue under the skin. Subcutaneous fluid absorption is possible due to the large number of capillaries ensuring complete and rapid absorption from the site. There is however a risk of subcutaneous oedema especially of the gluteal and genital regions Hypodermoclysis has a number of advantages compared to the intravenous route. These include: ease of administration, low incidence of infection, little pain or discomfort, no need for prolonged immobilisation and minimal medical intervention therefore greater continuity of fluid provision. Indications The main indication for hypodermoclysis is dehydration. This technique is particularly useful in the elderly. Clinical situations in which hypodermoclysis should be considered for fluid replacement rather than intravenous infusions are: When adequate oral fluid intake is not feasible When there is no acute or specific indication requiring a direct intravenous line i.e. mild to moderate dehydration When the establishment or maintenance of an intravenous line presents problems 7

8 Contra indications Hypodermoclysis should not be used for patients who require more than 2-3 litres of fluid in 24 hours. It should never be regarded as an alternative to the intravenous route and should not be used to treat: acute life threatening conditions i.e. major dehydration shock diabetic coma It should be used cautiously in patients with: coagulation defects possible tissue fibrosis resulting from previous radiotherapy, injury or surgery, since absorption will be decreased Pre-existing heart disease. Subcutaneous fluids (like intravenous fluids) can lead to fluid overload. Care needs to be taken with the volume and rate of the infusion as well as the total sodium load. Pre-existing Oedema Poor tissue perfusion i.e. Peripheral Vascular Disease Siting a subcutaneous infusion device Selection of appropriate butterfly. There is evidence that metal butterfly cannula can be uncomfortable and cause small localised abscesses. Cannula with removable inner metal inserts are favoured e.g. Teflon. This reduces insertion site complications and the need for frequent needle changes. Other recommended devices may be used in paediatric settings for specialist treatment for example insuflons. Gauge 21 or 25 is the preferred size. The butterfly cannula should be inserted at an angle of 45 degrees When choosing a site for infusion factors, to consider include: patient mobility comfort access skin condition Any area with adequate subcutaneous tissue may be used. Potential sites include: abdomen anterior and lateral aspects of chest wall anterior thigh upper arm Scapula 8

9 Areas that should not be used for cannula placement include: Lymphoedematous limbs: The rate of absorption would be adversely affected. A break in the skin integrity would increase the risk of infection in a limb that is already susceptible. Over bony prominences: The amount of subcutaneous tissue is diminished therefore impairing the rate of absorption. Previously irradiated skin areas: Radiotherapy can cause sclerosis of small blood vessels, thus reducing skin perfusion. Near a joint: Excessive movement may cause cannula displacement and patient discomfort. Near a surgical or chronic wound site. Sites of infection Areas of inflammation To maximise absorption, rotate the infusion site and document accordingly. Indicators for the need for rotation are: pain at administration site localised inflammation skin surrounding insertion site becoming white and hard blood is present in giving set/butterfly dislodged needle localised oedema bleeding/bruising Best Practice when resiting or restarting an infusion, recommends that the site selected is rotated using a figure of eight principle to maximise site absorption. Type of infusion fluid The type of infusion fluid administered depends on patient requirements. The solution must be isotonic e.g. 0.9% normal saline or 4% glucose in 0.18% saline. Non electrolyte containing isotonic solutions i.e. 5% glucose should alternate with 0.9% normal saline, as electrolyte free solutions can lead to fluid shift. Solutions containing up to 34 mmol potassium/litre fluid may be given however there is a risk of local ulceration with a higher concentration of potassium. If irritation occurs at the cannula site, infusion without potassium should be used instead. Basic Procedure a. Explain procedure to patient and gain verbal consent. b. Collect appropriate equipment in a clean receiver and wash hands. c. Hair removal is only necessary if adhesion of the sterile dressing will be compromised. Only use scissors or clippers, never shave as this increases bacterial shredding. d. Once insertion site is selected, clean the surrounding area with a 2% chlorhexidine gluconate (CHG) in 70% isopropyl alcohol (IPA) swab for a minimum of 30 seconds, then allow to dry for a further 30 seconds this is vital to ensure removal of skin bacteria. e. Site butterfly according to guidelines for 'Siting a Subcutaneous Infusion Device'. See Page 8 f. Document date and time of insertion to facilitate rotation of site 9

10 g. Check the patient details, on the prescription chart, with the patient. Check with the prescription chart that the type of fluid, route and rate is correct (refer to local drug administration policy). h. Prime the giving set to ensure no air is present i. Attach butterfly cannula to luer end of giving set and regulate the prescribed flow rate and monitor rate of infusion. Rate of Infusion The rate of administration is generally less than 125ml/hr provided that the total daily volume does not exceed 2-3 litres in 24 hours solutions should be infused by gravity rather than controller as this reduces the chance of local oedema formation. Care of site The site should be checked every 4 hours for bruising, reddening, oedema, leaking, pain, pooling or unresolved blanching. It is recommended that the insertion site should be rotated after infusion of a maximum of two litres of fluid at a rate of approximately 1ml per minute. The giving set should always be changed with each new butterfly insertion. 7. Staff Training As training is an essential component in improving practice and increasing awareness of risks staff will receive training with regards to this policy. The organisations expectations with regard to training are detailed in the Trust s Training Needs Analysis 8. Monitoring and Compliance This policy will be reviewed three yearly or earlier in light of new national guidance or other significant change in circumstances. Compliance with this policy will be monitored through the mechanisms detailed in the table below. Where compliance is deemed to be insufficient and the assurance provided is limited then remedial actions will be drawn together through an action plan. This progress against the action plan will be monitored at the specified committee/group. The results of the annual audit will be escalated to the appropriate committee/group where appropriate. 10

11 Aspect of compliance or effectiveness being monitored Appropriate management of patients with Intravenous and Subcutaneous Cannula and Infusions Monitoring method Audit of documenta tion Individual or department responsible for the monitoring Audit department and Infection prevention and control team Frequency of the monitoring activity Annual or as appropri ate Group/ committee/ forum which will receive the findings/monito ring report Infection Prevention and Control committee Committee/ individual responsible for ensuring that the actions are completed Matrons and Ward managers Compliance with Infection Prevention and control policies and practices Annual Infection Prevention and control audits Clinical audit team Annual Infection Prevention and Control committee Matrons and Ward managers Organisation s expectations in relation to staff training, as identified in the training needs analysis Training Reports Learning and Development Department Monthly HR&OD Subcommitte e HR&OD Subcommittee 11

12 9. REFERENCES 1. Barua P, Bhowmick BK (2005) Hypoderclysis a victim of historical prejudice. Age and Aging 34, 3, Brown MK, Worobec F (2000) Hypodermoclysis another way to replace fluids. Nursing 30, 5, Centre for Reviews & Dissemination (2005) A prospective, within-patient comparison between metal butterfly needles & Teflon cannulae in subcutaneous infusion of drugs to terminally ill hospice patients. September, NHS Economic Evaluation Database 4. CDC (2002) Guidelines for the prevention of intravascular catheter-related infections: Morbidity and mortality weekly report 51(10) S35-S Chan H (2001) Effects of injection duration on site-pain intensity and bruising associated with subcutaneous heparin. Journal of Advanced Nursing. 35, Curran ET, Coai JE, McNamee S, Hood J (1999) Multi-centre research surveillance project to reduce infections/phlebitis associated with peripheral venous catheters. Journal of Hospital Infection 46: Dawkins L, Britton D, Johnson I, Higgins B, Dean T (2000) A Randomised Trial of Winged Vialon Cannula and Metal Butterfly Needles International Journal of Palliative Nursing Vol. 6, No Department of Health (2008) The health and social Care act Code of Practice for the NHS on the prevention and control of Healthcare associated infections and related guidance. London. Department of Health 9. Dougherty L, Lister S (2007) (Eds) The Royal Marsden Hospital Manual of Clinical Procedures. Seventh edition Whiley-Blackwell Publishing, Oxford Hypodermoclysis Working Group (1998) Hypodermoclysis: Guidelines on the Technique. CP Pharmaceuticals Ltd, Wrexham 11. Jackson A (1997) A battle in vein: infusion phlebitis. Nursing Times 94(4): Jackson A (2004) Subcutaneous fluid administration (hypodermoclysis). Unpublished internal policy document 13. Khan I, Shah I, White A (1996) The use of subcutaneous fluids in elderly patients Reviews in Clinical Gerontology Vol. 6 No. 1 pp Khan M, Younger G (2007) Promoting safe administration of subcutaneous infusions. Nursing Standard , Royal College of Nursing (2005) Standards for Infusion Therapy. RCN, London 16. Ross et al (2002) A prospective, within - patient comparison between metal butterfly needles and Teflon cannulae in subcutaneous infusions of drugs to terminally ill hospice patients. Palliative Medicine 16: Sasson M, Shvartzman P (2001) Hypodermoclysis an alternative infusion technique. American Family Physician 64, 9, The Epic Project (2001) Developing National Evidence-based Guidelines for Preventing Healthcare Associated Infections. The Journal of Hospital Infection 47 (Supplement): S1-S82. 12

13 Appendix one Policy for the Insertion and Monitoring of Intravenous and Subcutaneous Cannula and Infusions/C/YEL/ic/26/v2 Visual Infusion Phlebitis Score (VIPS) (Jackson 1997) Record of Intravenous Cannulae IV site appears healthy, no pain One of the following is evident: Slight pain near IV site Slight redness near IV site 1 Two of the following are evident: Pain at IV site Erythema Swelling Patient Name: Hospital Number: Cannula Number Insertion of Cannula Date of Insertion: Inserted By: Insertion Site: Size/Colour of Cannula: Dressing Applied and Dated: Day 1 Night 1 Day 2 Night 2 Day 3 Night 3 Remove Cannula unless Poor Venous Access Resite only if needed Day 4 Visual Infusion Phlebitis Score All of the following signs are evident: Pain along path of cannula Erythema Induration All of the following signs are evident and extensive: Pain along path of cannula Erythema Induration Palpable venous cord Pus All of the following signs are evident and extensive: Pain along path of cannula Erythema Induration Palpable venous cord Pus Pyrexia Tissue damage No signs of phlebitis: - OBSERVE CANNULA Possible first signs of phlebitis: - OBSERVE CANNULA Early stage of phlebitis: - RESITE CANNULA Medium stage of phlebitis: - RESITE CANNULA - CONSIDER TREATMENT Advanced stage of phlebitis or the start of thrombophlebitis: - RESITE CANNULA - INITIATE TREATMENT - COMPLETE SERIOUS UNTOWARD INCIDENT FORM Advanced stage of thrombophlebitis: - INITIATE TREATMENT - RESITE CANNULA - COMPLETE SERIOUS UNTOWARD INCIDENT FORM Night 4 Day 5 Night 5 Dressing Changed Y N Y N Y N Y N Y N Removal of Cannula Date of Removal: Swab Taken: Y N Y N Y N Y N Y N Tip sent for C&S Y N Y N Y N Y N Y N Sterile Dressing to site Y N Y N Y N Y N Y N 13

14 Appendix two INTRAVENOUS INFUSION RATE CALCULATION All IV Infusions, when not being administered via an infusion pump device, should be prescribed to be given over a set length of time:- e.g. 1 Litre of Normal Saline over 8 hours. Without the use of infusion pumps, it is important that the flow rate of the infusion is set and monitored to ensure that it runs over the required timescale. The flow rate should be set as:?? drops per minute, and should be checked hourly and recorded. There is a formula for working this out accurately, but for ease of reference, the table below has been produced to avoid the need for calculation each time for the most common infusion amounts and timescales. Most standard infusion sets, including the one commonly available in this Trust (Intrafix Safe-Set) has a drop size equal to 20 drops per millilitre of Crystalloid fluid (E.G. Saline, Dextrose or Dextrose/Saline) or 15 drops per millilitre of Colloid fluid (e.g. Blood or Plasma replacement fluids). FORMULA Rate (drops per minute) = vol. solution (ml) x no. drops per ml Time (minutes) So for example, N/Saline 1L to be given over 8 hours with standard giving set would be: x 20 = 42 drops per minute 480 RATE = DROPS PER MINUTE TIME CRYSTALLOID COLLOID HOURS MINUTES 1L = 500ml 1L = 500ml 1000ml 1000ml 1 = = = = = = = = = = = =

15 Appendix 3 Policy for the Insertion and Monitoring of Intravenous and Subcutaneous Cannula and Infusions/C/YEL/ic/26/v2 NTRAVENOUS INFUSION RATE RECORD PATIENT NAME: INFUSION FLUID: PERIOD OF INFUSION: DATE COMMENCED: P NUMBER: AMOUNT: RATE (drops/min): TIME COMMENCED: INFUSION SET UP BY: HOURLY INFUSION RECORD DATE: TIME ACTUAL RATE (drops/min) ACTION SIGNATURE 15

16 Appendix 4 Policy for the Insertion and Monitoring of Intravenous and Subcutaneous Cannula and Infusions/C/YEL/ic/26/v2 Subcutaneous Fluids Monitoring Chart Patients First Name P Number: Ward Surname Date of Birth The infusion should be maintained in accordance with the prescription and any variations clearly documented. All equipment should be dated and changed every 48 hours. Date Date Date Date Date Time 4 hourly Infusate Site / Position Appearance Signature A B C D When considering appearance, please use the following guidelines: Site appears with no pain on palpation, redness, swelling or oozing Slight pain on palpitation and / or redness swelling or oozing to a diameter of less than 0.5cm Pain on palpation and / or redness, swelling or oozing to a diameter of between 0.cm and 2cm. Pain on palpation and or redness, swelling or oozing to a diameter of greater than 2cm. Continue infusion. Continue infusion. Check site more frequently. Discontinue infusion. Resite if appropriate or consider IV hydration. Complete incident form and monitor frequently until symptoms diminish. Discontinue infusion. Re-site if appropriate or consider IV hydration. Complete incident form and monitor frequently until symptoms diminish and apply (appropriate) dressing Sheet Number of 16