Clinical Guidelines Intravenous Access Care and Maintenance for Adult Patients in hospital and at home

Transcription

1 Policy Number LCH-140 This document has been reviewed in line with the Policy Alignment Process for Liverpool Community Health NHS Trust Services. It is a valid Mersey Care document, however due to organisational change this FRONT COVER has been added so the reader is aware of any changes to their role or to terminology which has now been superseded. When reading this document please take account of the changes highlighted in Part B and C of this form. Part A Information about this Document Policy Name Clinical Guidelines Intravenous Access Care and Maintenance for Adult Patients in hospital and at home Policy Type Board Approved (Trust-wide) Trust-wide Divisional / Team / Locality Action No Change Minor Change Major Change New Policy No Longer Needed Approval As Mersey Care s Executive Director / Lead for this document, I confirm that this document: a) complies with the latest statutory / regulatory requirements, b) complies with the latest national guidance, c) has been updated to reflect the requirements of clinicians and officers, and d) has been updated to reflect any local contractual requirements Signature: Date: Part B Changes in Terminology (used with Minor Change, Major Changes & New Policy only) Terminology used in this Document New terminology when reading this Document Part C Additional Information Added (to be used with Major Changes only) Section / Paragraph No Outline of the information that has been added to this document especially where it may change what staff need to do Part D Rationale (to be used with New Policy & Policy No Longer Required only) Please explain why this new document needs to be adopted or why this document is no longer required Part E Oversight Arrangements (to be used with New Policy only) Accountable Director Recommending Committee Approving Committee Next Review Date LCH Policy Alignment Process Form 1

2 SUPPORTING STATEMENTS This document should be read in conjunction with the following statements: SAFEGUARDING IS EVERYBODY S BUSINESS All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or by professional judgement made as a result of information gathered about the child / adult; knowing how to deal with a disclosure or allegation of child / adult abuse; undertaking training as appropriate for their role and keeping themselves updated; being aware of and following the local policies and procedures they need to follow if they have a child / adult concern; ensuring appropriate advice and support is accessed either from managers, Safeguarding Ambassadors or the trust s safeguarding team; participating in multi-agency working to safeguard the child or adult (if appropriate to your role); ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation; ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session EQUALITY AND HUMAN RIGHTS Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership. The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices. Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act. Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

3 Clinical Guidelines For NHS North West Intravenous Access Care and Maintenance for Adult Patients In Hospital and at Home Developed by Collaborative Intravenous Nursing Service (CINS) If you would like further information about using these guidelines, contact Mrs A Young Version 11 Issue date September 2014 Review date due September 2016

4 Index Page 1 Background and Objectives 2 Terms of Reference 3 STC1 Care and Maintenance of a Skin Tunnelled Catheter 4 STC2 Skin Tunnelled Catheters - Saline Flush and Hepsal Lock 6 STC3 Skin Tunnelled Catheters Blood sampling 9 STC4 Skin Tunnelled Catheters Administration of antibiotics/infusion/additives 12 CVC1 Care and Maintenance of a non tunnelled Central Venous Catheter 17 CVC2 Central Non-Tunnelled Catheters - Saline Flush and Hepsal Lock 19 CVC3 Central Non-Tunnelled Catheters Blood Sampling 22 CVC4 Central Venous Non-Tunnelled Catheters Administration of antibiotics/infusion/ Additives 25 PL1 Care and Maintenance of a Peripheral Inserted Central Catheter (PICC) 30 PL2 Peripherally Inserted Central Catheter Sodium Chloride Saline Flush 33 PL3 Peripherally Inserted Central Catheter Blood Sampling 36 PL4 Peripherally Inserted Central Catheter Administration of antibiotics/infusion/ additives 39 PM1 Care and Maintenance of a Peripheral Midline Catheter 45 PM2 Peripheral Midline - Saline Flush and Hepsal Lock 47 PM3 Peripheral Midline Administration of antibiotics/infusion/additives 50 DST1 Disconnection of Ambulatory Chemotherapy Infusor from Central Venous Access Device 54 TIVAD1 Care and Management of an Implantable Venous Access Device 57 TIVAD2 Care and Management of an Implantable Venous Access Device 60 TIVAD3 Administration of antibiotics/infusion/additives via implantable port 63 PCN1 Care and Management of Peripheral cannula 66 NFS1 Changing a needle-free system 69 Trouble Shooting Guides 70 Care Plans 74 Appendix/Contributors 94

5 Intravenous Access Care and Maintenance 2 Background Every effort has been made to present accurate and up to date information from the best and most reliable sources. However, the results of caring for individuals depend on a variety of factors not under the control of the authors of these documents. Therefore, neither the authors nor any publishers assume responsibility for, nor make any warranty with respect to the outcomes achieved from the guidance herein. The service provision for patients who require intravenous care and management has been variable with no universally agreed competency based framework. It has been extremely difficult for district nurses to obtain clarity about which protocol/procedures they should follow. Several guidelines can be in circulation at any one time from different Trusts. As a result of these inconsistencies the Collaborative Intravenous Nursing Service (CINS) was formed to gained consensus for universally agreed guidelines, competencies, care plans and resources for the Cheshire and Merseyside strategic Health Authority. The CINS group has since developed into a network of lead nurses, key experts and others with a specific interest in IV therapy. These leads have contributed to the development of these guidelines and have consulted locally with key experts. Key Objectives To provide universal guidelines for care and maintenance of venous access devices, care plans and troubleshooting guidelines for members of the CINS network. To provide a competency framework for individuals in caring and maintaining venous access devices To provide a training programme. To ensure that those individuals caring for venous access devices have received an annual update. To develop an expert group that will ensure that the best evidence based practice is available.

6 3 CINS Network Venous Access Clinical Group Terms of Reference The purpose of the group is to ensure that all nurses with relevant competencies across Cheshire CINS network utilise universal guidelines, competencies and training. To act as the primary source of advice on issues relating to the care and maintenance of venous access devices (VADs). To provide a resource for the implementation, co-ordinated procedures and guidelines across the CINS network To promote consistent clinical competencies for VADs across the CINS Network. To collaborate with workforce and education stakeholders to promote consistent clinical competencies and ensure the availability of the VAD training programmes. To ensure that there is a network of support for nurses involved in IV therapy. To ensure that in development of CINS resources appropriate consultation across multi-agencies and multi-professional groups is sought. Membership All Hospital Trusts, Primary Care organisations and other relevant stakeholders within Cheshire and Merseyside North West Strategic Health Authority were invited to take part in the development of these guidelines. All healthcare professions with an interest in IV therapy who are members of the CINs network. Chair/Reporting The chair will be a member of the group who is dually elected. The group will report to the Directors of Nursing Group within the region and to NHS North West. Use of the Guidelines This document contains several guidelines which can be utilised as required.

7 Care and Maintenance of a Skin Tunnelled Catheter (STC1) 4 EXIT DRESSING CHANGE (Weekly) Equipment required Action Rationale Dressing Pack containing sterile towel and Gloves Surgical tape 2% Chlorhexidine in 70% Isopropyl alcohol impregnated applicator ( SEPP) Chlorhexidine 2% wipe (e.g. sani cloth) Skin fixation device (e.g. Stat lock or grip lock) Semi- Permeable transparent IV dressing Alcohol hand rub or gel Plastic apron Care of Exit site Dressing changes should be performed on a weekly basis or when dressing is dirty or loose. Explain the procedure to the patient. Ensure that valid consent is gained. Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic apron should be worn. Maintain aseptic technique at all times. Ensure working area is clean. Ensure all equipment is gathered before commencing the procedure and all packaging is intact and in date. Take equipment/trolley to patient. To prevent/reduce patient anxiety. To prevent infection. Maintain safety. To prevent infection and catheter contamination.

8 Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to troubleshooting guide. Decontaminate hands Open sterile pack and use a non-touch technique to place inner pack onto clean working area. Open out sterile pack to create an aseptic field. Open remaining equipment using a non touch technique, ensuring no contamination of aseptic field. Loosen exit site dressing. To loosen dressing lift lower-end and gently ease the dressing off, from the skin using an aseptic technique. Decontaminate hands Put on sterile gloves Place sterile towel as near as possible to the catheter. Clean around the catheter and exit site with Chlorhexidine 2% impregnated applicator. The solution should be applied with friction but should not be too vigorous or the skin's natural defence may be destroyed. Using a Chlorhexidine 2% wipe, carefully clean the catheter from the exit site to the part of the catheter that will be covered by the sterile dressing. Allow to dry. Apply new securing device i.e. Skin closure strips or skin fixation device (if required) Apply new dressing to exit site without touching the adhesive site. Remove the dressing towel Remove gloves. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley if used during the procedure with multi-surface detergent wipes. Wash hands. Document care on patient s records. Exit site dressings are important in preventing trauma and the extrinsic contamination of the site of entry (Jones 2004). To avoid contamination of aseptic field. To allow for an aseptic environment for accessing intravenous catheter, and to reduce incidence of infection. Chlorhexidine-based solutions are recommended (in alcohol) as per policy (DOH 2001). To prevent accidental removal of the catheter and friction or trauma to skin surface. Alcohol Chlorhexidine combines the benefits of rapid action and excellent residual activity (DOH 2001) Semi-permeable transparent IV dressings are well tolerated by patients (Campbell et al 1999, Treston-Aurand et al 1997, Wille 1993) and are easy to apply and remove (Wille 1997). 5

9 6 Skin Tunnelled Catheters 0.9% Sodium Chloride and Heparin 10 units/ml in 0.9% Sodium Chloride for injection Lock (STC2) for weekly maintenance Flush Action Rationale Equipment Required Dressing Pack containing sterile towel and gloves Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe (sani cloth) x 3 10ml syringe x 2 (1 if using a prefilled saline syringe) 10ml 0.9% Sodium Chloride (or 0.9% Sodium Chloride prefilled syringe) 5ml Heparin 10units/ml in 0.9% Sodium Chloride One blue needle/filter straw (for glass ampoules). Sharps container Surgical tape Alcohol hand rub/gel Plastic apron 10ml syringes should always be used; smaller syringe sizes may damage the catheter (Hadaway 1998). Needle free I/V access connector change as per manufacturer s guidelines see NSF1 Cins guideline NB. 5ML HEPARIN SODIUM (10 UNITS/ML)FOR OPEN ENDED CATHETER Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy for the administration of medications. Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic apron should be worn. Maintain aseptic technique at all times. Reduce anxiety Patient compliance Maintain asepsis and safety. Reduce risk of infection. To avoid contamination. To ensure that the procedure can be

10 Ensure working area is clean. Ensure all equipment is gathered before commencing the procedure and all packaging is intact and in date. Take equipment/trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to troubleshooting guide Open sterile pack and use a non-touch technique to place inner pack onto clean working area. Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using a non-touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands. Put on sterile gloves. Connect needle/ filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up 5ml Heparinised Saline into 10ml syringe and place on sterile field. Place sterile towel as near as possible to the catheter Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe over a period of 30 seconds. Allow to dry. Attach syringe with 0.9% Sodium Chloride flush and inject the flush using a push/pause action, clamping as the last ml of solution is instilled into the catheter. Remove the syringe and discard. If open ended skin tunnelled catheter repeat this procedure using syringe containing 5ml Heparin 10units/ml in 0.9% Sodium Chloride. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the carried out safely. To maintain a sterile field. Chlorhexidine-based solutions are recommended (in alcohol) as per policy (DOH 2001). There is no requirement to routinely withdraw blood and discard it prior to flushing (except prior to blood sampling although the first sample can be used for 7

11 catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact the hospital team who placed the catheter for advice. Wrap the end of the line in sterile gauze (gauze cot). Tape this to the patients chest. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves. Wash hands. Clear away equipment disposing of sharps and waste as per organisational policy. Wipe down the trolley (if used) with multi-surface detergent wipes Decontaminate hands Document care in patient s records. blood cultures (RCN 2010). There is an increased risk of infection and occlusion when withdrawing blood via a central venous catheter (RCN 2010), therefore for routine flushing of a line withdrawal of blood is not required. The pulsated flush creates turbulence within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998). 8 Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000)

12 9 Skin Tunnelled Catheters Blood Sampling (STC3) Equipment Required Action Rationale Dressing Pack containing sterile towel and gloves Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe (Sani Cloth) x 3 10ml syringes x 4 (or appropriate size syringe to collect the blood sample) 10ml 0.9% Sodium Chloride for injection prefilled syringe (or a 10ml ampoule of 0.9% Sodium Chloride) 5ml Heparin10units/ml in 0.9% Sodium Chloride One blue needle/filter straw. Sharps container Surgical tape Alcohol hand rub/gel Plastic apron Needle free I/V access connector change as per manufacturer s guidelines see NSF1 Cins guideline NB 5ML HEPARIN 10 UNITS/ML IN SODIUM CHLORIDE WITH OPEN ENDED CATHETER Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy for the administration of medications. Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic apron should be worn. Maintain aseptic technique at all times. 10 ml syringes should always be used. Smaller syringe sizes may damage the catheter (Hadaway 1998) Reduce anxiety Patient compliance To ensure that the procedure can be carried out safely. Reduce risk of infection To avoid contamination

13 Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is intact and in date. Take equipment /trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to troubleshooting guide Open sterile pack and use a non-touch technique to place inner pack onto clean working area. Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using a non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands. Put on sterile gloves. Connect needle/ filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up 5ml Heparinised Saline into 10ml syringe and place on sterile field. Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe, over a period of 30 seconds. Allow to dry. Attach empty 10ml syringe into needle free system and aspirate at least 3 to 5ml of blood from the catheter. Note if taking blood samples from a parenteral nutrition line or for INR sample at least 10-20mls of blood should be taken and disguarded before taking the sample (check local policy). If unable aspirate blood from the line attach the syringe containing the saline solution to the needle free system gently flush with 1-2mls To maintain a sterile field. Chlorhexidine-based solutions are recommended (in alcohol) as per policy (DOH 2001). Check catheter patency. Remove any residual solution from catheter. 10

14 0.9% Sodium Chloride for injection (do not use force) then aspirate blood from catheter. Discard blood aspirated as per policy 11 Attach an empty syringe and withdraw amount of blood required for analysis. Attach syringe with 0.9% Sodium Chloride for injection flush and inject the flush using a push/pause action, clamping as the last ml of solution is instilled into the catheter. Remove the syringe and discard. If open ended skin tunnelled catheter repeat this procedure using 5ml Heparin 10units/ml in 0.9% Sodium Chloride for injection. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter. The solution should flow easily. If resistance is felt refer to the trouble shooting guide or contact IV access team. Wrap the end of the line in sterile gauze (gauze cot). Tape this to the patients chest. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley that has been used during the procedure with multi-surface detergent wipes. Wash hands Document care in patient s records. The pulsated flush creates turbulence within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998). Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000).

15 Skin Tunnelled Catheters Administration of IV medications/infusion (STC4) Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion. Always use 10ml syringe, never use force to flush the catheter. Action Rationale Equipment Required Dressing pack containing sterile towel and gloves Chlorhexidine Gluconate 2% in 70% Isopropyl alcohol impregnated wipe 10ml syringes x 4 2 x 10ml 0.9% Sodium Chloride for injection prefilled syringes (or 2 x 10mls 0.9% Normal Saline ampoules) 5ml Heparin10units/ml in 0.9% Sodium Chloride for injection Two blue needle/ filter straw. Sharps container Surgical tape Alcohol hand rub/gel Antibiotics/Infusion/additives as prescribed Plastic apron 10 ml syringes should always be used. Smaller syringe sizes may damage the catheter (Hadaway 1998) 12 NB 5ML HEPARINISED SALINE 10 UNITS/MLWITH OPEN ENDED CATHETER Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy for the administration of medications. Medication reconstitution should be performed in a clean clinical environment. This may be performed in an area designated for drug preparation or next to the patient as part of this procedure. Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic apron should be worn. Maintain aseptic technique at all times. Ensures patient compliance and reduce anxiety Reduce the risk of infection and contamination Maintain asepsis.

16 Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is intact and in date. Take equipment/ trolley to the patient Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to troubleshooting guide Open sterile pack and use a non-touch technique to place inner pack onto clean working area. Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using a non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up 5ml Heparinised Saline into 10ml syringe and place on sterile field. Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe, over a period of 30 seconds. Allow to dry. Attach syringe with 0.9% sodium chloride for injection, aspirate enough blood to colour 0.9% Sodium Chloride solution then inject the flush using a push pause action clamping as the last ml of the solution is instilled into the catheter. Remove the syringe and discard. If unable to aspirate blood from the line continue to administer prescribed medication To check catheter patency and to remove residual solution from catheter. The RCN Standards for infusion Therapy state, the nurse should aspirate the catheter and check for blood return to confirm patency prior to the administration of medications and/or solutions (INS 2000). On no account 13

17 unless this is a vesicant drug/infusion, in this case refer to algorithm on persistant withdrawal occlusion. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact the hospital team who placed the catheter for advice. Administer IV antibiotics/infusion/additives as prescribed following trust policy. Flush catheter again with 10ml 0.9% Normal Saline using a push/pause action. Remove the syringe and discard. If open ended skin tunnelled catheter and this is the final dose of treatment for the day, repeat this procedure using 5ml Heparin 10units/ml in 0.9% sodium chloride clamping as the last ml of solution is instilled into the catheter to maintain catheter patency. Remove the syringe and discard Clean the needle free connector again with a sani cloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to the patients chest. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley that has been used during the procedure with multi-surface detergent wipes. Wash hands Document care in patient s records. should a vesicant drug or vesicant infusion be administered through a vascular access device where difficulty is experienced in withdrawing blood (Masoorli 2003). Creates turbulence in catheter, preventing clotting in the catheter. Maintains positive pressure and prevents backflow of blood into the catheter. 14

18 Algorithm persistent withdrawal occlusion (PWO) i.e. fluids can be infused freely by gravity but blood cannot be withdrawn from the device 15 Blood return is absent Check equipment, Position, clamps, kinking. etc Ask patient to cough, deep Breathe, change position, stand up or lie with foot of the bed tipped up. Ascertain possible cause of PWO Blood return obtained - use central venous catheter as usual Flush central venous catheter with 0.9% Sodium chloride in 10ml syringe using a brisk push pause technique. Check for flashback of blood No Blood return is still absent Patient to receive highly irritant/vesicant drugs or chemotherapy Dormant line If unable to aspirate. Do not continue. Refer to Medic close line and label Blood return is still absent No Proceed if happy to do as long as there are no other complications or pain Adapted from Standards for Infusion Therapy RCN (2010) Yes Yes SECONDARY CARE ONLY The following steps should initially be done on admission or prior to drug administration and documented in nursing care-plan so that all staff are aware that patency has been verified Step 1 Administer a 250ml normal saline challenge (unless serum sodium 120 mmol/l) via an infusion pump over 15 minutes to test for patency the infusion will probably not resolve the lack of blood return (unless the patient has a high sodium or fluid restricted go to step 2) If there have been no problems, therapy can be administered as normal. If the patient experiences ANY discomfort or there is any unexplained problems then stop and seek medical advice. It may be necessary to verify tip location by chest X Ray. OR Step 2 Instill Urokinase 12,500iu in 2 mls and leave for minimum of 2 hours. After this time withdraw the urokinase and assess the catheter again. Repeat as necessary. If blood return is still absent, it may be necessary to verify tip location by chest X Ray.

19 1. Department of Health (DOH) (2001) Guidelines for preventing infection associated with the insertion and maintenance of central venous catheters, Journal of Hospital Infection, 47 Supplement S47 S Department of Health (DOH 2003). Winning Ways: Working together to reduce health care associated infection in England 3. Department of Health (DOH 2005). Saving Lives: A delivery programme to reduce health care associated infection including MRSA 4. Goodwin M, Carlson I (1993) The peripherally inserted catheter: a retrospective look at 3 years of insertions, Journal of Intravenous Nursing, 16 (2) Hadaway L (1998) Catheter connection, Journal of Vascular access devices 3 (3), INS (2000) Infusion Nursing Standards of Practice, Journal of Intravenous Nursing 23 (6S) supplement 7. Treston-Aurand J et al (1997) Impact of dressing materials on central venous catheter infection rates. Journal of Intravenous Nursing 20(4): Wille JC (1993) A comparison of two transparent film-type dressings in central venous therapy. Journal of Hospital Infection 23(2): Pratt RJ et al (2006) National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (epic 2). Thames Valley University, London. 10. RCN (2010) Standards for infusion therapy. Cambridge, MA: INS and Becton Dickinson (III). In RCN Standards for Infusion (2005) 11. Masoorli S (2003) Extravasation injuries associated with the use of central venous access devices. Journal of vascular access devices Spring

20 Care and Maintenance of a non tunnelled Central Venous Catheter (CVC1) All lumens on a non-tunnelled access device should be flushed using an aseptic technique. 17 EXIT DRESSING CHANGE (Weekly) Equipment required Action Rationale Dressing Pack containing sterile towel and Gloves Surgical tape Chlorhexidine 2% impregnated applicator (SEPP) Chlorhexidine 2% wipe (sani cloth) Semi-Permeable transparent IV dressing Alcohol hand rub or gel Care of Exit site Dressing changes should be performed on a weekly basis or when dressing is dirty or loose. Explain the procedure to the patient. Ensure that valid consent is gained. Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic apron should be worn. Maintain aseptic technique at all times. Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packing is intact and in date Take equipment/trolley to patient. Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please To prevent/reduce patient anxiety. To prevent infection To prevent infection and catheter contamination.

21 contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide. Decontaminate hands Open sterile pack and use a non-touch technique to place inner pack onto clean working area. Open out sterile pack to create an aseptic field. Open remaining equipment using a non touch technique, ensuring no contamination of aseptic field. Loosen exit site dressing. To loosen dressing lift lower-end and gently ease the dressing off, from the skin. Aseptically remove the dressing Decontaminate hands Put on sterile gloves Place sterile towel as near as possible to the catheter exit site. Clean around the catheter and exit site Chlorhexidine 2% impregnated applicator (SEPP). The solution should be applied with friction, but should not be too vigorous or the skin's natural defence may be destroyed. Using a Chlorhexidine 2% wipe, carefully clean the catheter from the exit site to the part of the catheter that will be covered by the sterile dressing. Allow to dry. Apply new securing device i.e. Skin closure strips or skin fixation device (if required) Apply new dressing to exit site without touching the adhesive site. Remove the dressing towel Remove gloves. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley that has been used during the procedure with multi-surface detergent wipes. Wash hands. Document care on patient s records. To allow for a sterile environment for accessing intravenous catheter, and to reduce incidence of infection. To prevent accidental removal of the catheter and friction or trauma to skin surface. Chlorhexidine based solutions are recommended (in alcohol) as per policy (DOH 2001). Alcohol Chlorhexidine combines the benefits of rapid action and excellent residual activity (DOH 2001). Semi-permeable transparent IV dressings are well tolerated by patients (Campbell et al 1999, Treston-Aurand et al 1997, Wille 1993) and are easy to apply and remove (Wille 1997). 18

22 19 Central Non-Tunnelled Catheters - Saline Flush and Hepsal Lock (CVC2) If each lumen of a triple or quadruple lumen catheter is being used more than once a day there is no need for a Hepsal flush Action Rationale Equipment Required Dressing Pack containing sterile towel and gloves 10ml syringes x 1 Chlorhexidine 2% impregnated wipes x 3 10ml syringes should always be used; 10ml 0.9% Sodium Chloride for injection(saline) prefilled syringes or a 10ml ampoule smaller syringe sizes may damage the of 0.9% Normal Saline catheter (Hadaway 1998). 5ml Heparin 10units/ml in 0.9% Sodium Chloride 1 x blue needle/filter straw Sharps container Surgical tape Alcohol hand rub/gel Plastic apron Needle free I/V access connector change as per manufacturer s guidelines see NSF1 Cins guideline NB 5ML HEPARINISED SALINE 10 UNITS/ML WITH OPEN ENDED CATHETER Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy for the administration of medications. Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic apron should be worn. Maintain aseptic technique at all times. Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is Reduce anxiety Patient compliance To ensure that the procedure can be carried out safely Reduce risk of infection. To avoid contamination.

23 intact and in date. Take equipment /trolley to patient Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide Open sterile pack and use a non-touch technique to place inner pack onto clean working area. Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using a non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline and place near to but not on the sterile field. Decontaminate hands. Put on sterile gloves. Connect needle/ filter straw to the syringe. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up 5ml Heparinised Saline into 10ml syringe (if required) and place on sterile field. Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe, over a period of 30 seconds. Allow to dry. Attach syringe with 0.9% Sodium Chloride (saline) flush and inject the flush using a push/pause action, clamping as the last ml of solution is instilled into the catheter. Remove the syringe and discard. Repeat flush now using Heparinised saline if required. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter. The solution should flow easily. If resistance felt, refer to trouble shooting guide or contact the hospital team who placed the catheter for advice. Clean the needle free connector again with a sanicloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to patient s skin. To maintain an aseptic field Chlorhexidine based solutions are recommended (in alcohol) as per policy (DOH 2001). There is no requirement to routinely withdraw blood and discard it prior to flushing (except prior to blood sampling although the first sample can be used for blood cultures (RCN 2005). There is an increased risk of infection and occlusion when withdrawing blood via a central venous catheter (RCN 2005), therefore for routine flushing of a line 20

24 Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley that has been used during the procedure with multi-surface detergent wipes. Decontaminate hands. Document care in patient s records. withdrawal of blood is not required. The pulsated flush creates turbulence within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998). Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000). 10ml syringes should always be used; smaller syringe sizes may damage the catheter (Hadaway 1998). 21

25 Central Non-Tunnelled Catheters Blood Sampling (CVC3) If a triple or quadruple lumen catheter is being used more than once a day there is no need for a Hepsal flush For multi-lumen non-tunnelled catheters ideally one lumen should be used for blood sampling. Action Equipment Required Dressing Pack containing sterile towel and gloves 10ml syringes x 3 2% Chlorhexidine impregnated wipes x 2 10ml 0.9% Sodium Chloride for injection, prefilled syringe (or 10ml ampoule of 0.9% Normal Saline) 5ml Heparin 10units/ml in 0.9% Normal Saline One blue needle/filter straw. Sharps container Surgical tape Alcohol hand rub/gel Apron Needle free I/V access connector change as per manufacturer s guidelines see NSF1 Cins guideline Rationale 10 ml syringes should always be used. Smaller syringe sizes may damage the catheter (Hadaway 1998) 22 NB 5ML HEPARINISED SALINE 10 UNITS/MLWITH OPEN ENDED CATHETER Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy for the administration of medications. Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic apron should be worn. Maintain aseptic technique at all times. Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is intact and in date. Take equipment/ trolley to patient Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. Reduce anxiety Patient compliance Maintain safety. Reduce risk of infection. To avoid contamination. To ensure that the procedure can be carried out safely

26 exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide Open sterile pack and use a non-touch technique to place inner pack onto clean working area. Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using a non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if required) and place near to but not on the sterile field. Ensure easy access to the needle free system. Decontaminate hands Put on sterile gloves. Connect needle/filter straw to the syringe. Place sterile towel as near as possible to the catheter. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up 5ml Heparinised Saline into 10ml syringe (if required) and place on sterile field. Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe, over a period of 30 seconds. Allow to dry. Attach empty 10ml syringe into needle free system and aspirate at least 3 to 5ml of blood from the catheter. If unable to do so attach the syringe containing the saline solution to the needle free system gently flush with 1-2mls 0.9% Sodium Chloride (do not use force) then aspirate blood from catheter. Discard blood aspirated as per policy. Note if taking blood samples from a parenteral nutrition line or for INR sample at least 10-20mls of blood should be taken and disguarded before taking the sample (check local policy). Attach an empty 10ml syringe and withdraw amount of blood required for analysis. Attach syringe with 0.9% Sodium Chloride (saline) flush and inject the flush using a To maintain an aseptic field Chlorhexidine based solutions are recommended (in alcohol) as per policy (DOH 2001). Check catheter patency. Remove any residual solution from catheter. The pulsated flush creates turbulence 23

27 push/pause action, clamping as the last ml of solution is instilled into the catheter. Remove the syringe and discard. Repeat flush now using Heparinised saline if required. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can damage the catheter. The solution should flow easily. If resistance felt, refer to trouble shooting guide or contact IV access team. Clean the needle free connector again with a sani cloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to patients skin. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley that has been used during the procedure with multi-surface detergent wipes. Decontaminate hands. Document care in patient s records. within the catheter lumen, removing debris from the internal catheter wall (Goodwin & Carlson 1993, Todd 1998). Positive pressure within the lumen of the catheter should be maintained to prevent reflux of blood (INS 2000). 24

28 Central Venous Non-Tunnelled Catheters Administration of antibiotics/additives/infusions (CVC4) 25 Administer drugs or IV therapy as prescribed using correct diluent and rate of infusion. Always use 10ml syringe, never use force to flush the catheter. If a triple or quadruple lumen catheter is being used more than once a day there is no need for a Hepsal flush Action Equipment Required Dressing pack containing sterile towel and gloves 2% Chlorhexidine impregnated wipes x 2 10ml syringes x 4 (this will vary depending on amount of medication being administered). 2 x 10ml 0.9% Sodium Chloride (saline) prefilled syringes (or ampoules) 5ml Heparin 10units/ml in 0.9% Sodium Chloride Two needles/ filter straws (this will vary depending on medication being administered). Sharps container Surgical tape Alcohol hand rub/gel Plastic apron Antibiotics/additive/infusion as prescribed Rationale 10 ml syringes should always be used. Smaller syringe sizes may damage the catheter (Hadaway 1998) NB 5ML HEPARINISED SALINE 10 UNITS/MLWITH OPEN ENDED CATHETER Explain the procedure to the patient. Ensure that valid consent is gained. Check the patient identity, prescription and flush required in accordance with trust policy for the administration of medications. Medication reconstitution should be performed in a clean clinical environment. This may be performed in an area designated for drug preparation or at the patient s bedside as part of this procedure. Before the procedure begins make sure that your hands are washed and dried thoroughly and that they continue to be decontaminated during the procedure. A plastic Reduce the risk of infection and contamination. Ensures patient compliance and reduce anxiety

29 apron should be worn. Maintain aseptic technique at all times Ensure working area is as clean as possible. Ensure all equipment is gathered before commencing the procedure and all packaging is intact and in date. Take equipment/ trolley to patient Inspect the catheter exit site for signs of skin discolouration or signs of infection e.g. exudate from exit site. Check observation and VIAD chart for any indications of infection or complications. Ensure the intravenous access device has been comfortable and pain free. Observe for any swelling of the arm/neck. If you suspect any problems please contact the hospital team who placed the catheter for advice. Refer to trouble-shooting guide Open sterile pack and use a non-touch technique to place inner pack onto clean working area. Decontaminate hands. Open out sterile pack to create an aseptic field. Open remaining equipment using a non touch technique, ensuring no contamination of aseptic field. Snap the top from ampoules of Normal Saline 0.9% and Heparinised Saline (if required) and place near to but not on the sterile field. Remove dust cap from antibiotic vial/vials and place near to but not on sterile the field. Ensure easy access to the needle free system. Draw up 10mls Normal Saline into a 10ml syringe and place on sterile field. Draw up 5ml Heparinised Saline into 10ml syringe (if required) and place on sterile field. Reconstitute antibiotics in accordance with manufacturer s guidelines (as appropriate) Maintain asepsis. 26 Decontaminate hands Put on sterile gloves. Connect needle or filter straw to the syringe. Place sterile towel as near as possible to the catheter. Scrub the hub of the needle free system with 2% Chlorhexidine impregnated wipe, rubbing from the top of the needle free connector to the sides. Do this four times using different parts of the wipe, over a period of 30 seconds. Allow to dry.

30 Attach syringe with 0.9% sodium chloride for injection, aspirate enough blood to colour 0.9% Sodium Chloride solution then inject the flush using a push pause action clamping as the last ml of the solution is instilled into the catheter. Remove the syringe and discard. If unable to aspirate blood from the line continue to administer prescribed medication unless this is a vesicant drug/infusion, in this case refer to algorithm on persistant withdrawal occlusion. NEVER FORCE THE SOLUTION INTO THE CATHETER, this can easily damage the catheter. The solution should flow easily. If resistance felt refer to trouble shooting guide or contact the hospital team who placed the catheter for advice Administer IV antibiotics/infusion/additives as prescribed following trust policy. Flush catheter again with 10ml 0.9% Normal Saline using a push/pause action. Remove the syringe and discard. If this is the final dose of treatment for the day, repeat this procedure using 5ml Heparin 10units/ml in 0.9% sodium chloride clamping as the last ml of solution is instilled into the catheter to maintain catheter patency. Remove the syringe and discard Clean the needle free connector again with a sani cloth, then wrap the end of the line in sterile gauze (gauze cot). Tape this to the patient s chest. Ensure that the catheter is secure and comfortable. Remove dressing towel and discard. Remove gloves and apron. Wash hands. Clear away equipment disposing of waste as per organisational policy. Wipe down the trolley that has been used during the procedure with multi-surface detergent wipes. Wash hands Document care in patient s records. To check catheter patency and to remove residual solution from catheter. The RCN Standards for infusion Therapy state, the nurse should aspirate the catheter and check for blood return to confirm patency prior to the administration of medications and/or solutions (INS 2000). On no account should a vesicant drug or vesicant infusion be administered through a vascular access device where difficulty is experienced in withdrawing blood (Masoorli 2003). Creates turbulence in catheter, preventing clotting in the catheter. Maintains positive pressure and prevents backflow of blood into the catheter. 27