GUIDELINES FOR THE PREVENTION OF INFECTIONS ASSOCIATED WITH PERIPHERAL VENOUS CATHETERS

Transcription

1 Edition No: 6 ID Number: GUCPCM007 Dated: August 2016 Review Date: August 2019 Document ID: Corporate Document Type: Guideline Directorate: Nursing Category: Patient Care & Management Department(s): Infection Prevention and Control Author: Infection Prevention and Control Team Sponsor: Director of Infection Prevention & Control Policy Dissemination Intranet Consultation Process Title of Individuals Consulted Director of Infection Prevention & Control Consultant Microbiologist/Infection Control Doctor Chairman of Anaesthesia Consultant Surgeon Consultant Anaesthetist Director of Medical Education Deputy Directors of Nursing Practice Development Nurse, Intensive Care Unit Head of Infection Control and Team Head of Dietetics Matrons for Adult Medicine and Surgery Name of Committee / Group Consulted Date Intravenous Multi-Disciplinary Working Group September 2015 Infection Control Committee August 2016 Corporate Approval Committee / Job Title Date Infection Control Committee August 2016 Edition No: 6 Page 1 of 19

2 TABLE OF CONTENTS POLICY DISSEMINATION... 1 CONSULTATION PROCESS... 1 CORPORATE APPROVAL... 1 DOCUMENT CONTROL / HISTORY... 3 REFERENCES: INTRODUCTION AIM OBJECTIVE DEFINITIONS ROLES & RESPONSIBILITIES PERIPHERAL VENOUS CATHETERS INSERTION PERIPHERAL LINE INSERTION PACKS MUST BE UTILISED (EXCEPT IN OPERATING THEATRES) MAINTENANCE REMOVAL TRAINING AND COMPETENCY EQUALITY IMPACT ASSESSMENT STATEMENT MONITORING AND REVIEW APPENDIX 1 EQUALITY IMPACT ASSESSMENT APPENDIX 2 MY 5 MOMENTS FOR HAND HYGIENE APPENDIX 3 CATHETER USE FOR VENOUS AND ARTERIAL ACCESS APPENDIX 4 PHLEBITIS SCALE APPENDIX 5 INFILTRATION SCALE APPENDIX 6 10 IMPORTANT POINTS FOR THE CARE OF PERIPHERAL CANNULAE APPENDIX 7 HIGH IMPACT INTERVENTION DOCUMENT Edition No: 6 Page 2 of 19

3 Document Control / History Edition No Reason for Change 1 New 2 Reviewed 3 Reviewed 4 Reviewed 5 Policy reviewed and amended as part of the Working Party review 6 Updated guidance References: Document: Ref No: Dougherty, L. (2008) Obtaining peripheral access, in Dougherty, L. and Lamb, J (eds) Intravenous Therapy in nursing practice (2 nd edition) Oxford Blackwell Publishing Morris, M and Tay, M (2008) Strategies for preventing peripheral intravenous cannula infections British Journal of Nursing 17: 19pp. S14- S21 Policy for the Administration of Blood and Blood Products and the Management of Transfused Patients. Medway NHS Trust (2005). Saving Lives High Impact Interventions June 2007 RCN Infusion Therapy 2010 Quality Commission Essential Standards of Quality & Safety Outcome 8 & 11 Pratt RJ, Wilson JA, Loveday HP, el al. epic 3: National evidencebased guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect S1: S1-70 Adams D, Elliot TS. Skin antiseptic used prior to intravascular catheter insertion. [Review] [27 refs]. British Journal of Nursing 2007 Mar 8; 16(5): Royal College of Nursing Standard Infusion Therapy. June 2010 Quality Commission Essential Standards of Quality and Safety Outcome 8 & 11 Nursing and Midwifery Council Code of Professional Conduct 2008 NICE Clinical Guideline 139 Trust Associated Documents: Isolation Policy for Patients Mattress Policy Arrangements for the Control of an Outbreak of Infection in Medway NHS Trust Policy for the Management of Viral Gastroenteritis due to Norovirus Policy for the Management of Suspected or Confirmed Tuberculosis (including MDR TB) Management of MRSA (Meticillin Resistant Staphylococcus aureus) Guidelines for the Management of Clostridium difficile POLCGR37 POLCGR38 POLCGR39 POLCGR40 POLCGR41 POLCGR42 POLCGR43 Edition No: 6 Page 3 of 19

4 Control of Infestations: Scabies, Head Lice, Pubic Lice, Body Lice POLCGR44 Varicella Zoster Virus (VZV) Chickenpox and Shingles POLCGR45-5 Viral haemorrhagic Fever (VHF) POLCGR46-6 Policy for Investigating Hospital-Acquired Legionellosis POLCGR47 Guidelines for Laundry POLCGR50 Hand Hygiene Guidelines POLCGR51 Cleaning/Disinfection Policy POLCGR52 Guidelines for the Management of Transmissible Spongiform POLCGR53 Encephalopathy (TSE) including Creutzfeldt-Jakob Disease (CJD) Policy for the Prevention of Blood Borne Viruses Preventing Infections Associated with Indwelling Urinary Catheters Meningococcal Meningitis/Septicaemia Control of Glycopeptide Resistant Enterococci (GRE) Policy for the Management of Risks Associated with Infection Prevention & Control Control of Multi-Resistant Gram Negative Bacilli Blood Culture Policy Principles of Asepsis and Aseptic Non Touch Technique (ANTT) Policy for the Prevention of Infections Associated with Vascular Access Devices Guidelines for the Prevention of Infections Associated with the Insertion and Maintenance of Central Venous Devices Guidelines for Flexi-seal Infection Control in the Built Environment Environmental Policies and Infection Prevention and Control Adult Valved Peripherally Inserted Central Catheters (PICCs) Placement and Management Management and control of Carbapenemase producing enterobacteriaceae Medway NHS Foundation Trust [2011] POLCGR54 GUCPCM011 POLCGR060 POLCGR66 POLCGR067 POLCGR068 POLCGR-069 POLCGR070 POLCCPM026 GUCPCM006 GUCGR017 POLCGR088 POLCGR091 POLCPCM075 POLCGR121 Edition No: 6 Page 4 of 19

5 1 Introduction 1.1 These guidelines must be read in association with the Policy for the Prevention of Infections Associated with Vascular Access Devices September 2013 and Kent & Medway Cancer Network Vascular Access Guidelines. 2 Aim 2.1 The aim of these guidelines for peripheral cannula care are: To prevent intravascular device-related infections by identifying potential sources and ports of entry of pathogenic organisms and taking the necessary precautions To set standards that can be the subject(s) of clinical audit in order to improve the quality of patient care devices To ensure intravascular devices are removed at the earliest opportunity when no longer required. 3 Objective 3.1 To ensure all clinical directorates follow these guidelines. 3.2 Ensure standardised practice of peripheral venous catheter device management across the Trust 3.3 To ensure staff are competent and trained to insert and care for these devices. 3.4 To ensure all peripheral venous catheter device insertions receive adequate documentation and monitoring. 3.5 To audit compliance of documentation and monitoring at periodic intervals. 4 Definitions 4.1 These guidelines apply to peripheral lines inserted for therapeutic care. 5 Roles & Responsibilities 5.1 Persons responsible for implementation: Medical Director Director of Nursing 5.2 Persons responsible for monitoring: Clinical Directors Clinical Governance Leads Edition No: 6 Page 5 of 19

6 5.3 Persons responsible for audit: Deputy Directors of Nursing/Matrons Infection Prevention and Control Team 6 Peripheral Venous Catheters 6.1 Peripheral intravenous cannulae present a high risk for HCAIs; the need for an intravenous cannula requires careful consideration and should not be a routine procedure when admitting/assessing patients. 6.2 Due care should be taken when handling sharps/needles to avoid sharps/needle stick injury; please refer to the Trust s Sharps/Needle Stick Injury Policy. 7 Insertion Peripheral Line Insertion Packs must be utilised (except in Operating Theatres) 7.1 The procedure must be carried out as an aseptic non touch technique (ANTT). Equipment required is: Dressing trolley Appropriate PPE non-sterile gloves/aprons. Cannulation pack Cannula Tourniquet Needleless connector Skin decontamination with 2% chlorhexidine 70% Isopropyl alcohol Normal saline 0.9% flush Semi-permeable cannula dressing. 7.2 Ensure expiry and dates (where applicable) and integrity of packaging of equipment. 7.3 Hand Decontamination - use soap and water or alcohol hand rub for hand hygiene immediately prior to cannula insertion. (Appendix 2) 7.4 Ensure correct patient identity is determined in line with Trust policy, and ensure consent is gained. 7.5 Support patient arm in a comfortable position, apply tourniquet and locate suitable vein. Avoid site of flexion due to increase risk of phlebitis. 7.6 Use a skin decontamination containing 2% chlorhexidine 70% Isopropyl alcohol. Ensure skin is thoroughly cleansed for 30 seconds and allow to dry naturally for 30 seconds. Effective skin preparation will remove bacteria from hair; hair removal is only to allow the dressing to adhere. DO NOT re-palpate the vein after cleaning. 7.7 Select an appropriately sized cannula for type and volume of treatment, whilst considering the size of vein available. Only one cannula should be used for each cannulation attempt. 7.8 Insert cannula as per Trust protocol. Staff must have received training and demonstrated competence prior to insertion of cannula. Edition No: 6 Page 6 of 19

7 7.9 Attach the needleless connector and flush cannula with 5-10 mls saline and observe for signs of pain or swelling around cannula site Following insertion, the cannula should be firmly anchored and a sterile vapour permeable dressing should be applied to the insertion site maintaining visibility of the insertion site (to allow for the assessment every time the cannula is used) Ensure all sharps are disposed of as per Trust policy Bandages should be avoided where possible as they prevent observation of the insertion site The date, time of insertion, the site and size of the cannula must be documented in the medical/nursing notes along with the review date and the name of the individual inserting the device Saving lives high impact intervention document commenced. (Appendix 7) 8 Maintenance 8.1 The number of lines and ports will be kept to an absolute minimum consistent with clinical need. 8.2 A needle free device should be used for access. The port on top of the cannula should not be used. 8.3 The cannulae should be flushed pre and post use, and if not being utilised at least daily with 5-10mls of normal saline 0.9% solution and documented. All flushes should be prescribed prior to administration. 8.4 Prior to accessing the device the needle free device should be cleaned with a swab/wipe containing 2% Chlorhexidine/70% Isopropyl alcohol. 8.5 Cannulae should be changed according to clinical need up to a maximum of seven days. 8.6 IV administration sets require changing as follows: For medication: If the medication is infused continuously, change the set every 24 hours. If the infusion is intermittent, a new giving set must be used each time Blood transfusion sets should be used to administer 2 units only and then changed, or between different blood components For general administration of clear fluids change the set every 96 hours Changing of giving sets should be documented in the medical/nursing notes. All lines must be labelled with the time and date. 8.7 IV fluids should be renewed at least every 24 hours and whenever the administration set is changed. Edition No: 6 Page 7 of 19

8 8.8 Administration sets should be labelled with the date of commencement of therapy. 8.9 A visible inspection should be done each and every time the cannula is utilised, including when changing IV bags, and at a minimum of three times daily for signs of phlebitis/infection (e.g. inflammation, redness, discharge) using the Visual Infusion Phlebitis Score (VIP, see Appendix 3). If the VIP is greater or equal to 2 the cannula should be removed. If required, a new cannula should be inserted and the old cannula removed. Observations of the previous cannula site must be documented in the medical/ nursing notes daily. At each inspection the on-going need for a cannula must be reviewed Dressings should be changed when stained or soiled, when no longer intact or when moisture collects at the insertion site. Care should be taken to avoid wetting the dressing during patient washing When changing the dressing an aseptic non-touch technique must be used. The area should be cleaned moving from the catheter site outwards with 2% chlorhexidine 70% Isopropyl alcohol should be used. The area should be allowed to dry and a sterile dressing applied A cannula that has migrated externally must not be re-advanced prior to re-stabilisation Variable inspection must be documented daily on the High Impact Intervention Tool. (Appendix 7) 9 Removal 9.1 Peripheral cannulae must be removed as soon as no longer required. (no BSAFfE criteria) 9.2 Peripheral cannulae should be re-sited according to clinical need or removed after a maximum of seven days. 9.3 Peripheral cannulae must be removed if signs of infection, VIP 2. If signs of infection are present, the tip of the cannula must be sent to Microbiology for culture and sensitivity. If signs of sepsis blood cultures should be taken from a peripheral vein. Refer to Blood Culture Policy POLCGR The date of cannula removal must be documented in the medical/nursing notes. 9.5 If a peripheral venous cannula is not being used/required for access, it should be removed. 10 Training and Competency 10.1 All staff undertaking venous cannulation are expected to both be trained and assessed as competent in the procedure Staff should first attend a classroom session to learn the theory of cannulation, and then should perform at least 10 successful procedures whilst being observed by someone competent on cannulation. Edition No: 6 Page 8 of 19

9 10.3 Staff from other Trusts who have already demonstrated competence can transfer these skills to the Trust, but are expected to produce a certificate/evidence of training and their line manager must have confidence in their ability. 11 Equality Impact Assessment Statement 11.1 All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to set out arrangements to assess and consult on how their policies and functions impact on race equality. This obligation has been increased to include equality and human rights with regard to disability, age and gender The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. This strategy was found to be compliant with this philosophy Equality Impact Assessments will also ensure discrimination does not occur on the grounds of Religion/Belief or Sexual Orientation in line with the protected characteristics covered by the existing public duties Refer to Appendix 1. Edition No: 6 Page 9 of 19

10 12 Monitoring and Review What will be monitored How/Method/ Frequency Lead Reporting to Deficiencies/ gaps Recommendations and actions Implementation of any required change Use of Saving Lives High Impact Interventions with each cannula insertion Audit by Infection Prevention and Control Team At each insertion Saving Lives HII Weekly/monthly Senior Sisters Head of Infection Control Matrons/ Deputy Directors of Nursing NMAS Staff training as part of IV study day Staff held to account within divisions by Deputy Directors of Nursing / Matrons Required changes in practice will be identified and actioned within a specified time frame and lessons will be shared Monitoring of MRSA/MSSA bacteraemia infection rates and feedback to Infection Control Committee Monthly/ quarterly Head of Infection Control ICC Post infection reviews on each post 48 hour and pre 48 hour (if required) case. Noncompliance fed back to Executive board by responsible division Review of Policy Three yearly or when new guidance received IPCT ICC Edition No: 6 Page 10 of 19

11 13 Appendix 1 Equality Impact Assessment Yes/No Comments 1 Does the policy/guidance affect one group less or more favourably than another on the basis of: Race No Disability No Gender No Religion or belief No Sexual orientation including lesbian, gay and bisexual people No Age No 2 Is there any evidence that some groups are affected differently? 3 If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4 Is the impact of the policy/guidance likely to be negative? No No No 5 If so can the impact be avoided? No 6 What alternatives are there to achieving the policy/guidance without the impact? 7 Can we reduce the impact by taking different action? No No Edition No: 6 Page 11 of 19

12 14 Appendix 2 My 5 Moments for Hand Hygiene Edition No: 6 Page 12 of 19

13 15 Appendix 3 Catheter use for Venous and arterial access Catheter type Features Common use Duration Peripheral Peripheral arterial catheters Peripheral single lumen inserted in veins of forearm or hands in adults Single lumen large calibre. Administration of fluid/ blood/medication Haemodynamic monitoring, access, blood draw. Most commonly placed in radial artery. Alternatives are femoral, axillary and brachial, posterior tibia arteries Short up to a maximum of 7 days. Short up to 7 days Mid Lines Commonly places in proximal basilica or cephalic veins via the antecubital fossa Administration of fluid, blood and medication Short 1 4 weeks Edition No: 6 Page 13 of 19

14 16 Appendix 4 Phlebitis scale All patients with an intravenous access device in place must have the IV site checked at least 8 hourly for signs of infusion phlebitis. The subsequent score and action(s) taken (if any) must be documented. The cannula site must also be observed: When bolus injections are administered IV flow rates are checked or altered When solution containers are changed Bandages must be taken down for inspection of site The incidence of infusion phlebitis varies, the following Good Practice Points may assist in reducing the incidence: Observe cannula site at least 8 hourly Secure cannula with an appropriate transparent dressing Replace loose, contaminated dressings Cannula must be inserted away from joints whenever possible Aseptic non-touch technique must be followed Re-siting the cannula as per clinical indication up to a maximum of seven days. Clear documentation must be written for exceptions Plan and document continuing care Use the smallest gauge cannula most suitable for patient s need Replace the cannula at the first indication of infusion phlebitis (stage 2 on the VIP Score) IV site appears healthy O No signs of phlebitis OBSERVE CANNULA ONE of the following is evident: Slight pain near IV site OR Slight redness near IV site 1 Possibly first signs of phlebitis OBSERVE CANNULA TWO of the following are evident: Pale at IV site Erythema Swelling 2 Early stage of phlebitis RESITE CANNULA ALL of the following signs are evident: Pain along path of cannula Erythema 3 Medium stage of phlebitis RESITE CANNULA CONSIDER TREATMENT ALL of the following signs are evident: Pain along path of cannula Erythema Induration 4 Advanced stage of phlebitis or the start of thrombophlebitis RESITE CANNULA CONSIDER TREATMENT ALL the following signs are evident and extensive: Pain along path of cannula Erythema Induration Palpable venous cord 5 Advanced stage of phlebitis INITIATE TREATMENT RESITE CANNULA Edition No: 6 Page 14 of 19

15 Reference: Jackson A, Infection control a battle in vein infusion phlebitis. Nursing Times, 94 (4) (III) Edition No: 6 Page 15 of 19

16 17 Appendix 5 Infiltration Scale Grade Clinical Criteria O No Symptoms 1 Skin blanched Oedema <1 inch (2.5.cm) in any direction Cool to touch With or without pain 2 Skin blanched Oedema 1 6 inches ( cm) in any direction Cool to touch With or without pain 3 Skin blanched, translucent Gross oedema >6 inches (15cm) in any direction Cool to touch Mild to moderate pain Possible numbness 4 Skin blanched, translucent Skin tight, leaking Skin discoloured, bruised, swollen Gross oedema >6 inches (15 cm) in any direction Deep pitting tissue oedema Circulatory impairment Moderate to severe pain Infiltration of any amount of blood product, irritant, or vesicant Edition No: 6 Page 16 of 19

17 18 Appendix 6 10 IMPORTANT POINTS FOR THE CARE OF PERIPHERAL CANNULAE 1. Peripheral cannulae present a high risk for health care acquired infection; the need for an intravenous cannula requires careful consideration. The use of Saving Lives High Impact Interventions as per Trust framework. 2. The insertion procedure must be carried out using an aseptic non-touch technique using a cannulation pack. Thorough hand decontamination is essential. 3. Skin should be decontaminated using Chlorhexidine 2% in 70% Isopropyl alcohol. Gently rub over the skin for 5 seconds and allow to dry. 4. Sterile dedicated IV cannula dressings must be used on all permanent IV cannula sites. Bandages must be avoided as much as possible. 5. The date and site of insertion must be in the medical / nursing notes. 6. Administration sets must be labelled with the date of commencement and anticipated change depending on solutions being administered. 7. The cannulae must be flushed at least daily with a 0.9% normal saline solution or removed if no longer required. 8. The site must be observed at least three times daily and the cannula removed if there are any signs of infection/erythema; document observations daily using VIP scoring. 9. Peripheral cannulae should be re-sited (or removed) up to a maximum of seven days or earlier dependent on clinical need/complications. 10. The injection port should be decontaminated using Chlorhexidine 2% in 70% Isopropyl alcohol before and after use. Edition No: 6 Page 17 of 19

18 19 Appendix 7 High Impact Intervention Document High Impact Intervention No. 2 Peripheral Intravenous Cannula Care Bundle Name: NHS No: Patient no: NB. Replace cannula when complications occur/ when no longer required after 7 days VIP (Visual infusion phlebitis) B Blood transfusion etc IV site appears healthy 0 No phlebitis: observe cannula S Single dose/bolus One of the following is evident : slight pain/ redness near site A Antimicrobial therapy Two or more of the following are evident pain, redness, swelling 1 Possible first signs :observe cannula 2 Early stage of Phlebitis: remove and resite cannula F Fluids/infusions All of the following are evident: pain, redness hardening of surrounding tissue fe parenteral feeding ( no more than 48 hours) As above including palpable venous cord 4 3 Phlebitis/thrombophlebitis: Remove and re site cannula Insertion Action Review Tool: Date inserted State rational B S A F fe Hand hygiene and PPE Skin prep 2% chlorhexadine ANTT Correct Dressing Safe disposal of sharps Cannula size and insertion site Documented in medical notes Signature Ongoing Care Review Tool must be completed daily visual inspection minimum 8 hourly. Date and Time Hand Hygiene Continuing clinical indication B S A F E Site inspection / phlebitis score Dressing clean and intact needle free connectors in situ Administratio n set replaced and labelled (date/time) Comments / Action (Dressing change/ cannula removed etc). initial Insertion Action Review Tool: Date inserted State rational B S A F fe Hand hygiene and PPE Skin prep 2% chlorhexadine ANTT Correct Dressing Safe disposal of sharps Cannula size and insertion site Documented in medical notes Signature Ongoing Care Review Tool must be completed daily visual inspection minimum 8 hourly. Date and Time Hand Hygiene Continuing clinical indication B S A F fe Site inspection / phlebitis score Dressing clean and intact needle free connectors in situ Administratio n set replaced and labelled (date/time) Comments / Action (Dressing change/ cannula removed etc). initial Edition No: 6 Page 18 of 19

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