Review of Clinical Guideline Contributes to CQC Core Standard No: 9, 12

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1 ` CANNULATION BY NON-MEDICAL PERSONNEL IN MATERNITY SERVICES CLINICAL GUIDELINE Register No: Status: Public Developed in response to: NICE Guidelines Review of Clinical Guideline Contributes to CQC Core Standard No: 9, 12 Consulted With Post/Committee/Group Date Anita Rao/Alison Cuthbertson Miss Dutta Sam Brayshaw Alison Cuthbertson Paula Hollis Chris Berner Wendy Patarou Sheena Smith Claire Fitzgerald Deborah Lepley Clinical Director for Women s and Children s Division Consultant for Obstetrics and Gynaecology Consultant Anaesthetist Head of Midwifery Lead Midwife Acute Inpatient Services Lead Midwife Clinical Governance Team Leader Labour Ward Senior Midwife, DAU Pharmacy Senior Librarian, Warner Library August 2017 Professionally Approved By Miss Rao Lead Consultant for Obstetrics and Gynaecology August 2017 Version Number 6.0 Issuing Directorate Women s and Children s Ratified by DRAG Chairmans Action Ratified on 29 th October 2017 Executive Management Group Date November 2017 Next Review Date October 2020 Author/Contact for Information Susie Denhart, Practice Development Midwife Policy to be followed by (target staff) Midwives, Obstetricians, Paediatricians appropriately trained health care professionals Distribution Method Trust intranet and website Related Trust Policies (to be read in conjunction with) Standard Infection Prevention Hand Hygiene Guideline for Maternity Record Keeping including Documentation in Handheld Records Medicines Management Strategy Document Review History: Version No Author/Reviewed by Active Date 2.0 Julie Bishop October Karen Bartholomew May Karen Bartholomew June Gemma May October Susie Denhart, Practice Development Midwife 7 November

2 INDEX 1. Purpose 2. Equality and Diversity 3. Background 4. Psychological preparation of the patient 5. Infection Prevention 6. Equipment 7. Choice of vein 8. Cannula Selection 9. Improving Venous Access 10. Site Preparation 11. Inserting the Cannula 12. Securing the Cannula 13. Care of the Cannula 14. Removal of the Cannula 15. Possible Complications 16. Replacement 17. Infection Prevention 18. Staff Training 19. Professional Midwifery Advocates 20. Audit and Monitoring 21. Guideline Management 22. Communication 23. References 24. Appendices A. Appendix A High Impact Intervention (HII) Form B. Appendix B The Visual Infusion Phlebitis Score C. Appendix C- Cannulation Competency Form 2

3 1.0 Purpose 1.1 This guideline exists to ensure that intravenous (IV) peripheral cannulation is performed by appropriately trained health care professionals. 1.2 This guideline should be read in conjunction with: NMC Code of Professional Conduct NMC Administration of Medicines DoH Saving Lives High Impact Intervention 2 (HII2) 2.0 Equality and Diversity 2.1 Mid Essex Hospital Services NHS Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 3.0 Background 3.1 Only healthcare professionals who have attended a theoretical training course recognised by Mid Essex Hospitals NHS Trust and completed a practical assessment, can perform intravenous (IV) cannulation (Refer to Appendix C). 3.2 Trained individuals may only place peripheral cannulation for the purpose of delivering prescribed IV fluids, medicines or in cases of emergency. 4.0 Psychological Preparation of the Patient 4.1 Explain the forthcoming procedure to the patient in order to allay anxiety and obtain informed consent. Verbal consent must be gained from the patient whenever possible, however there may be instances where this is not possible i.e. emergencies. 4.3 It is important to find out if the patient has ever undergone such a procedure before, as patients who have previously had a bad experience may feel especially nervous prior to insertion. Fear of the procedure can trigger an autonomic response known as vasovagal reaction, which can result in vasoconstriction and reduced venous access. 5.0 Infection Prevention 5.1 Asepsis is vital, to prevent microbial contamination. Decontaminate hands before and after each patient contact and before applying examination gloves. Use correct hand hygiene procedure. (Refer to the guidelines entitled Medicines management strategy ; register number 08081; Hand hygiene ; register number 04072) 6.0 Equipment All equipment required for the procedure must be collected and taken to the patient. Biovalve Safe Cannula Blue ANNT Tray or Sharps bin with tray Swab impregnated with 70% isopropyl alcohol (chloroprep) 3

4 Transparent semi-permeable membrane dressing to allow observation of insertion site. Sharps bin Tourniquet (single use) Peripheral line insertion sticker to be inserted in patients records following insertion. 7.0 Choice of Vein 7.1 Never cannulate a limb with an arterial venous fistula 7.2 An assessment of the patient and her veins must take place before the site and device is chosen. There should be privacy and adequate lighting, and the patient should be in a comfortable position. There are many factors that may influence the choice of vein. Such factors include: Age of patient Previous uses and condition of the veins Weight obese/malnourished Clinical status of the patient e.g. dehydrated/shocked Other clinical procedures Type and length of treatment Medications i.e. steroids / warfarin Patient preference Patient co-operation/previous experiences 7.3 The assessment should start with a visual inspection of both arms, followed by palpation of the veins most likely to be used. This is important in determining the condition of the vein and differentiating it from a pulsating artery. The continual use by the individual of the same two fingers for palpation will increase their sensitivity. 7.4 The most distal site of the extremity should be selected, although this will depend on the condition of the vein. The most favourable sites are the cephalic, basilica and ante brachial veins in the lower arm and the veins in the dorsum of the hand. A vein in the non-dominant hand is usually preferable. The most prominent vein is not always the most suitable 4

5 7.5 A good vein is: Bouncy Soft Refills when depressed Visible Has a large lumen Is well supported Straight 7.6 Veins to avoid include those which are: Thrombosed, sclerosed, fibrosed Inflamed, bruised Hard Thin, fragile Mobile, tortuous Near bony prominences Near painful areas or sites of infection Have undergone multiple punctures 8.0 Cannula Selection 8.1 Generally the smallest size cannula possible, relevant to its subsequent use, should be used. However due to the potential for blood loss in labouring women the largest cannula (i.e. 16 gauge) possible should be used. The cannula should be visually inspected carefully after removing it from the packaging to ensure it has no defects. 9.0 Improving Venous Access 9.1 The application of a tourniquet promotes venous distension. The tourniquet should be tight enough to impede venous return but not to affect arterial flow. The Tourniquet should be applied 2 above the cannula insertion site and time should be allowed for the veins to fill 9.2 Other methods used to improve venous access include lowering the extremity below the level of the heart and opening and closing of the fist Site Preparation 10.1 If the skin is very dirty, wash the area with soap and water before disinfecting with antiseptic solution The risk of infection from the skin flora of the patient can be reduced, by disinfecting with an antimicrobial solution such as a 70% alcohol (i.e. chloroprep) Wiping the cannulation site horizontally for 15 seconds and vertically for 15 seconds The area must be left until dry The skin must not be touched or the vein re-palpated once the skin has been cleaned. 5

6 10.5 Potential sources for contamination of intra-vascular devices 11.0 Inserting the Cannula 11.1 Anchor the vein by holding the patient s hand or arm, using your thumb to keep the skin taut. This prevents the vein rolling. Skin stabilisation is one of the most important elements of a successful cannulation Ensure the cannula is in the bevel-up position, to facilitate entry and produce fewer traumas to the skin and vein on puncture Place the device in line with the vein and insert the cannula through the skin and tissue at an angle of between 10 and 45 degrees, according to the depth of the vein in the subcutaneous tissue On entering the vein, you will notice a first flashback of blood into the chamber of the stylet, which indicates successful entry. Level the device by decreasing the cannula angle slightly and advance the cannula slowly to ensure entry into the lumen of the vein Withdraw the stylet slightly and a second flashback of blood will be seen along the shaft of the cannula. Never re-insert the stylet Slowly advance the cannula into the vein, anchoring the vein throughout the procedure Release the tourniquet and apply pressure to the vein above the cannula (to prevent leakage of blood) then remove the stylet Dispose of the stylet into the appropriate sharps container Attach the giving set, extension set or cap Securing the Cannula 12.1 It is important to secure the cannula to prevent mechanical phlebitis using a transparent semi-permeable dressing. A transparent dressing has the benefit of allowing continuous observation of the cannula site, without disturbing the site/dressing. 6

7 12.2 If the device is located over a joint, the joint should be splinted to prevent movement and possible dislodgement. Do not apply bandage Care of the Cannula 13.1 All key parts of the cannula should be decontaminated using 2% chlorhexadine gluconate in 70% isopropyl alcohol, and allow to dry prior to accessing the cannula for administration of fluid or injections Once sited, the cannula should be flushed with normal saline using a 5ml syringe via the cannula port as prescribed. This may only be undertaken by a registered practitioner who has received the appropriate training. All intravenous flushes must be prescribed It is the responsibility of the healthcare professional siting the cannula to complete the Saving Lives: High Impact Intervention Monitoring tool (HII) 13.4 The site must be inspected 8 hourly and the VIP score documented on the device management form. If the VIP score is 2 or greater then the cannula must be removed immediately The transparent dressing should be intact and dry Administration sets should be replaced immediately after administration of blood or blood products The cannula should be replaced after 72 hours or earlier if clinically indicated, however if venous access is limited, the cannula can remain in situ if there are no signs of infection Removal of the Cannula 14.1 Decontaminate hands and apply non sterile gloves Remove all the tape / dressing from the cannula. Do not use scissors. The device should be removed carefully, nearly flush with the skin, to prevent damage to the vein Visually check to ensure the cannula is complete on removal. Pressure should be applied to the site, instantly and firmly, to prevent bleeding. Do not rub, as haematomas can occur. The site must then be covered with a sterile dressing and secured with tape Document in the device management form (HII) the date and time of removal in the device management form Possible Complications 15.1 If the cannulation is unsuccessful, do not re-insert the stylet into the cannula, as it may shear off the cannula and lead to a catheter embolism. A new device must be used, as the used cannula will be contaminated and fraying of the cannula tip may occur If a professional has had two unsuccessful insertion attempts, a more experienced colleague should evaluate the patient s venous access. 7

8 15.3 Further insertion attempts should only be made if the venous access is deemed to be adequate. Multiple unsuccessful attempts will limit future vascular access and cause unnecessary trauma to the patient. If the patient has limited venous access, alternative routes should be explored If any bruising occurs while the cannulation is being performed, the tourniquet should be removed immediately. It may be the vein wall has been punctured, in which case the device should be removed. Pressure should be applied to the vessel and a cold pack may be required, to reduce the haematoma Replacement 16.1 Peripheral cannulae should be re-sited every 72 hours or sooner to reduce the risk of phlebitis. Peripheral cannula inserted in an emergency situation where aseptic technique has been compromised should be replaced within 24 hrs. The sterile, transparent semi permeable dressing should only be changed when the integrity of the dressing has been compromised Infection Prevention 17.1 All staff should follow Trust guidelines on infection control by ensuring that they effectively decontaminate their hands before and after each procedure All staff should ensure that they follow Trust guidelines on infection prevention. All invasive devices must be inserted and cared for using High Impact Intervention (HII) guidelines to reduce the risk of infection and deliver safe care. This care should be recorded in the Saving Lives High Impact Intervention Monitoring Tool Paperwork (Medical Devices) Staff Training 18.1 All staff should ensure that their knowledge and skills are up-to-date in order to complete their portfolio for appraisal Professional Midwifery Advocates 19.1 Professional Midwifery Advocates provide a mechanism of support and guidance to women and midwives. Professional Midwifery Advocates are experienced practising midwives who have undertaken further education in order to supervise midwifery services and to advise and support midwives and women in their care choices Audit and Monitoring 20.1 The procedure must be recorded in the patient s healthcare records and the HII form (Saving Lives High Impact Intervention Device Monitoring Tool). The sticker should be completed and placed in the patients notes and any significant observations noted Audit of compliance with this guideline will be considered on an annual audit basis in accordance with the Clinical Audit Strategy and Policy (register number 08076), the Corporate Clinical Audit and Quality Improvement Project Plan and the Maternity annual audit work plan; to encompass national and local audit and clinical governance identifying key harm themes. The Women s and Children s Clinical Audit Group will identify a lead for the audit. 8

9 20.3 The findings of the audit will be reported to and approved by the Multi-disciplinary Risk Management Group (MRMG) and an action plan with named leads and timescales will be developed to address any identified deficiencies. Performance against the action plan will be monitored by this group at subsequent meetings The audit report will be reported to the monthly Directorate Governance Meeting (DGM) and significant concerns relating to compliance will be entered on the local Risk Assurance Framework Key findings and learning points from the audit will be submitted to the Patient Safety Group within the integrated learning report Guideline Management 21.1 As an integral part of the knowledge, skills framework, staff are appraised annually to ensure competency in computer skills and the ability to access the current approved guidelines via the Trust s intranet site Quarterly memos are sent to line managers to disseminate to their staff the most currently approved guidelines available via the intranet and clinical guideline folders, located in each designated clinical area Guideline monitors have been nominated to each clinical area to ensure a system whereby obsolete guidelines are archived and newly approved guidelines are now downloaded from the intranet and filed appropriately in the guideline folders. Spot checks are performed on all clinical guidelines quarterly Quarterly Clinical Practices group meetings are held to discuss guidelines. During this meeting the practice development midwife can highlight any areas for further training; possibly involving workshops or to be included in future skills and drills mandatory training sessions Communication 22.1 A quarterly maternity newsletter is issued and available to all staff including an update on the latest guidelines information such as a list of newly approved guidelines for staff to acknowledge and familiarise themselves with and practice accordingly Approved guidelines are published monthly in the Trust s Staff Focus that is sent via to all staff Approved guidelines will be disseminated to appropriate staff quarterly via Regular memos are posted on the Risk Management notice boards in each clinical area to notify staff of the latest revised guidelines and how to access guidelines via the intranet or clinical guideline folders. 9

10 23.0 References Department of Health (2007) Saving Lives: reducing infection, delivering clean and safe care. High Impact Intervention 2. London: Department of Health Carlson K. Perdue MB and Hankins J. Infection control in Infusion Nurses Society (2001) Infusion Therapy in Clinical Practice second Edition. Pennsylvania: W B Saunders Chapter 8, O Grady, P et al (2002) Guidelines for the prevention of intravascular catheter-related Infections, In Morbidity and Mortality weekly report, 51 (RR-10), Department of Health (DH) (2001) Guidelines for preventing infections associated with the insertion and maintenance of central venous catheters. Journal of Hospital Infection, 47 (supplement), S47-S67 Dougherty L (2000) Drug Administration in Malet J & Dougherty L The Royal Marsden Hospital Manual of Clinical Nursing Procedures Fifth Edition: Oxford Blackwell Science 9 th edition 2015 now available Giles, J (2014) Medicines Management Strategy. Policy No Mid Essex Hospitals NHS Trust. Royal College of Nursing (2016) Standards for Infusion Therapy. 4 th Edition. London: Royal College of Nursing 10

11 Appendix A 11

12 12

13 Appendix B The Visual Infusion Phlebitis Score below provides an evaluation tool to record the presence or absence of phlebitis around peripheral and central catheters. 13

14 Jason Dover Appendix C Cannulation Supervised Practice Document Date Supervised Practice Comments Name and Signature (of assessor) 1. Observed 2. Observed Assessment Date Formal Assessment Comments (see overleaf) Competence to be achieved by the 6 th cannula insertion. If further support required please refer to the PDM. Name and Signature (of assessor) I feel I have received sufficient theoretical knowledge and supervised practice to undertake the advanced practice of peripheral intravenous cannulation Practitioner Date Print Name Signature This practitioner has successfully met all the criteria for assessment. As an assessor I am competent in the practical and theoretical aspects of this task. Assessor Date Print Name Signature 14

15 Knowledge Final Assessment Criteria Met Is able to describe the normal anatomy & physiology of the venous system No Yes Demonstrate understanding of the various cannula sizes which may be requested List the criteria used for choosing the vein for cannulation No Yes Explain how to choose the correct equipment for cannulation No Yes No Yes Describe potential complications of cannulation and the appropriate action to take No Yes Skills Criteria Met Appropriate communication with the patient throughout. No Yes Safe technique throughout the whole procedure. No Yes Familiarity with equipment. No Yes Aseptic technique throughout. No Yes Correct positioning of patient and preparation of environment. No Yes Chooses appropriate vein site and equipment for cannulation. No Yes Provides local anaesthesia if required (as per health care organisation policy). Completes cannulation procedure correctly and safely (as per Trust policy). No Yes Disposes of sharps and equipment correctly and safely. No Yes Completes documentation in line with local health care organisation policy. No Yes No Yes Awareness / Attitude Recognises own competency level and can explain implications of accountability when undertaking an advanced practice. Recognises need to maintain competence through practice and further education where needed. Recognises the individual needs of the patient/client and deals with them sensitively. Criteria Met No No No Yes Yes Yes 15