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1 If viewing a printed copy of this policy, please note it could be expired. Got to to view current policies. Department Policy Code: D: PC-5555 Entity: Fairview Pharmacy Services Department: Fairview Home Infusion Manual: Policy and Procedure Manual Category: Home Infusion Subject: Implanted Ports-Venous Purpose: Qualified staff are responsible for maintenance of implanted central vascular line systems and will follow established policies and procedures to provide safe and appropriate patient care. Points of Information: I. The implanted venous port is a long-term vascular access device attached to a port body and all components are placed under the surface of the skin inside a surgically created pocket. The implanted port body consists of housing made of titanium, plastic or stainless steel; the center of the port body is hollow and covered by a septum made of dense silicone. I IV. The implanted venous port catheter terminates in the venous system (e.g. superior vena cava or right atrium) and is made of polyurethane or silicone. The venous port may be implanted in the chest wall, lower abdomen, or in the arm. Ports must be accessed with a Huber (non-coring) needle to prevent damage to the septum. Implanted ports may be single or dual lumen, with a dual port having two totally separate ports and a single catheter with two lumens. V. General guidelines for protection of implanted venous ports includes: A. Never use scissors near the catheter B. Routine clamping of an open ended port is necessary when not in use C. A needleless system shall be utilized in administering Page 1 of 10

2 all intravenous therapies D. All connections in the intravenous system (catheter and tubing) shall be luer lock E. Catheter occlusions will be cleared to restore patency with a prescriber order and protocols with clinical evidence to support the procedure. See policy Alteplase (tpa) Central Vascular Access Device Clearance Policy: I. The nurse shall be competent in implanted vascular access port use and maintenance, including port access, identification of potential complications, and appropriate nursing intervention, including patient and caregiver education. Written prescriber orders for initiation, care and management of the implanted venous port shall be documented on the plan of care and include: I IV. A. Type of device including the name and number of lumens B. Use of anesthetic (e.g. emla cream) for access, if appropriate and indicated C. Concentration, amount and frequency of saline and heparin flushing solution, if applicable D. Type and frequency of site care E. Whether or not the access device may be used for blood drawing, if applicable. Only Huber non-coring needles, inserted perpendicular into the silicone septum of the port, are to be used to access the device. A 90 degree Huber needle with attached extension tubing should be used when continuous access for therapy is required. The implanted port must be accessed, flushed, and locked every 28 days when not in use. V. Huber needles used for ongoing infusion therapies should be changed every 7 days. VI. Patency is always determined during the accessing of the port by obtaining a blood return before any medication is infused or injected. If a blood return is not observed after the second attempt at re-access notify the prescriber for an order for Alteplase for catheter clearance or OK to use port for Page 2 of 10

3 V VI IX. prescribed therapy. (chemotherapy infusion REQUIRES a blood return) Nurses, patients and caregivers must assess (or be taught to assess) the port for swelling, pain, erythema or drainage before, during and after completing prescribed therapy. The size of the Huber needle is determined by the patient s therapy, patient s size, and port location. Access should be done using sterile technique by the infusion nurse. X. The nurse may use an implanted venous port to obtain blood with an MD order. XI. Procedure: Access of the Venous Port The patient/caregiver may perform site care when there is a prescriber order and after demonstrating competence. I. Perform Hand Hygiene I IV. Verify the patient s identity using 2 independent identifiers. Explain procedure to patient. Assess patient s pain tolerance and preferences regarding use of local anesthetic prior to port access. V. Gather Supplies. VI. V VI A. Mask B. Gloves, sterile C. Antiseptic solution D. Noncoring Huber needle with extension tubing E. Needleless connector F. Sterile prepackaged preservative-free 0.9% sodium chloride (USP) prefilled syringe G. Heparin 100 units/ml 3- to 5-mL prefilled syringe. H. Sterile transparent semipermeable membrane (TSM) dressing Administer local anesthetic (i.e. emla cream) if ordered. Place patient in a comfortable position with head turned away from implanted port. Assess skin over and around implanted port; palpate port to locate septum. Check for redness, pain, swelling, drainage. Assess for edema of the neck, face, shoulder, arm or Page 3 of 10

4 IX. prominent superficial veins. Notify the prescriber if signs or symptoms are present before proceeding. Perform hand hygiene. X. Assemble supplies on sterile field. XI. X XI XIV. XV. XVI. XV VI XIX. XX. XXI. Don mask and sterile gloves. Cleanse implanted port access site with antiseptic solution; allow to dry completely. A. Chlorhexidine solution (preferred): apply using a back-and-forth motion for at least 30 seconds. B. Povidone-iodine: apply using swab sticks in a concentric circle beginning at the catheter insertion site, moving outward; it must remain on the skin for at least two minutes or longer to dry completely for adequate antisepsis. Attach needleless connector to noncoring needle with extension set, and prime set with sterile preservative-free 0.9% sodium chloride (USP) prefilled syringe. With non-dominant hand, palpate and stabilize implanted port. Insert noncoring needle perpendicular to the skin through septum of the port until the needle tip comes in contact with the back of the port. Aspirate for blood to confirm device patency and flush with preservative- free 0.9% sodium chloride (USP). If medication is not going to be administered and this is a monthly port access and flush; flush port with 3-5cc 100 units/ml Heparin and clamp extension set and de-access port (see procedure for de-accessing an implanted port.) If patient s port will remain accessed, apply sterile TSM dressing. The dressing can be changed every 7 days (with the Huber needle change) if an occlusive transparent semi-permeable dressing is applied allowing the site of the needle to be visible for assessment of possible complications. If the port is not visible with the dressing, the dressing must be changed every 48 hours Initiate infusion therapy as ordered. Discard used supplies in appropriate receptacles. Remove gloves and perform hand hygiene. Page 4 of 10

5 XX XI Document procedure in the patient s permanent medical record including assessment of the site, needle gauge and length, presence or absence of a blood return, and date/time. Document procedure in the medical record including assessment of the site, needle gauge and length, presence or absence of a blood return, and date/time. Port De-access I. Perform hand Hygiene Verify the patient s identity using 2 independent identifiers. Explain procedure to patient. I Gather Supplies. A. Gloves, nonsterile B. Alcohol pads to clean needleless connector C. Preservative-free 0.9% sodium chloride (USP) prefilled syringe D. Heparin 100 units/ml 3- to 5-mL prefilled syringe. E. 2 x 2 gauze pad and tape or a Band-Aid IV. Apply nonsterile gloves. V. Disinfect needleless connector with alcohol pad using friction and a scrubbing motion for 15 seconds; allow to air dry completely. VI. Flush port with 5-10mL of preservative- free 0.9% sodium chloride (USP) (see flushing and Locking procedure) V Lock port by flushing with 3 or 5mL 100 units/ml heparin, as prescribed (see flushing and locking procedure); clamp extension tubing as indicated. VI Remove dressing, noting any drainage, redness, or swelling, and discard. IX. Stabilize port and needle hub using thumb and forefinger of non-dominant hand. X. Grasp needle with dominant hand and remove, engaging safety mechanism; discard into sharps container. XI. Apply gauze dressing to site if bleeding occurs. X Discard used materials in appropriate receptacles. XI Remove gloves and perform hand hygiene. XIV. Document procedure in patient s permanent medical record. Flushing with medication administration I. Flushing is performed to ensure and maintain patency of the catheter, and to prevent mixing of medications and solutions that are incompatible. Page 5 of 10

6 I Flushing with anticoagulant citrate will be performed to maintain catheter patency for patients requiring a heparin flush who are allergic to heparin. The volume or amount of the anticoagulant citrate will be equal to the amount of heparin used to flush the vascular access device. Routine flushing shall be performed with the following: A. Blood sampling B. Administration of incompatible medications or solutions C. Intermittent therapy D. When converting from continuous to intermittent therapies Flushing Procedure - General I. Perform hand hygiene I IV. Gather supplies A. Nonsterile gloves B. Alcohol pads C. Preservative free 0.9% sodium chloride (USP) prefilled syringe(s) D. Heparin lock solution 100 units/ml in 3 or 5 ml prefilled syringe(s) or other anticoagulant, if applicable Don nonsterile gloves Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion; allow to dry completely V. Attach syringe of preservative-free 0.9% sodium chloride (USP) to needleless connector. VI. V VI Open clamp, if present Slowly inject 5-10mL preservative-free 0.9% sodium chloride (USP) as prescribed using a pulse flush technique, into the implanted port, noting any resistance or sluggishness of flow. A. Never inject against resistance B. VAD will require further evaluation if unable to flush freely. Remove syringe and discard. Page 6 of 10

7 IX. Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion; allow to dry completely X. Administer prescribed medication, XI. X XI XIV. XV. XVI. XV VI XIX. Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion; allow to dry completely Slowly inject 5-10mL preservative-free 0.9% sodium chloride (USP) as prescribed using a pulse flush technique, into the implanted port, Remove syringe and discard. If anticoagulant is ordered, disinfect needleless connector with alcohol wipe using friction and a scrubbing motion; allow to dry completely If ordered, attach syringe of anticoagulant solution, as prescribed, to the needleless connector. Slowly inject solution into the catheter using a pulse flush technique. Clamp the extension tubing on the implanted venous port, if one is present. Remove syringe and discard. Remove gloves and perform hand hygiene Document procedure in patient s permanent medical record. Maintenance Flushing I. Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion; allow to dry completely. I IV. Attach syringe of 0.9% sodium chloride (USP) or anticoagulant solution, as prescribed, to the needleless connector. Slowly inject solution into the catheter using a pulse flush technique. Clamp the extension tubing on the implanted venous port, if one present. V. Remove syringe and discard VI. V Remove gloves and perform hand hygiene Document procedure in patient s permanent medical record. Phlebotomy via Central Vascular Access Device (CVAD) I. Obtain and review prescriber orders. Verify patient s identity using 2 independent identifiers. Page 7 of 10

8 I Explain procedure to patient. IV. Perform hand hygiene. V. Gather supplies: A. Gloves, nonsterile B. Blood collection tubes C. (3) 10 ml preservative-free 0.9% sodium chloride (USP) prefilled syringes (patient > 10kg) or (3) 5ml preservative-free 0.9% sodium chloride (USP) prefilled syringes (patient < 10kg) D. Anticoagulant flush, as prescribed, if applicable E. Empty 10 ml sterile syringe(s), if applicable F. Vacutainer, if applicable G. Labels for tubes H. Transport containers I. Alcohol pads IV. Don nonsterile gloves. V. Discontinue administration of medication prior to obtaining blood samples. VI. Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion; allow to dry completely V Flush (see flushing procedure) implanted venous port with 5 10 ml preservative-free 0.9% sodium chloride (USP) prefilled syringe VI Obtain discard sample: A. Attach empty 10mL syringe and withdraw 4-5mL of blood -or- B. Attach blood-tube holder, advance blood collection tube to obtain 4-5mL of blood NOTE: If unable to obtain blood return: C. Have patient change position, cough, move arm above head, or take a deep breath and hold D. Attempt to flush CVAD with preservative- free 0.9% sodium chloride (USP) E. Replace blood tube or attach a new empty sterile 10 ml syringe and withdraw 4-5 ml of blood XV. Obtain blood samples as ordered. XVI. Transfer blood samples form syringe(s) to appropriate blood specimen tubes, if applicable. XV Change needleless connector (see cap change). VI XIX. Flush port with ml preservative-free sodium chloride (USP) and lock CVAD or resume infusion as ordered (see flush and locking). Label blood samples before leaving the patient s side with Page 8 of 10

9 XX. XXI. XX XI XIV. XXV. the following: A. Patient name B. Patient date of birth C. Date and time of specimen collection D. Your initials Place blood samples in a sealed container for transport. Identify container with BIOHAZARD label. Certain specimens may need to be placed on ice during transport, check with laboratory used by the organization. Discard used supplies in appropriate receptacles. Remove gloves and perform hand hygiene. Document in patient s permanent medical record. Cap Change I. Needleless connectors are changed if there is blood or debris visible within the needleless connector, upon contamination, prior to drawing a blood culture through a catheter, after drawing blood sample and routinely every 7 days. Perform hand hygiene. I Don nonsterile gloves. IV. Remove existing needleless connector. V. Disinfect needleless connector with alcohol wipe using friction and a scrubbing motion; allow to dry completely VI. Attach new, sterile needleless connector. V Discard used supplies. VI Remove gloves and perform hand hygiene. External Ref: Intravenous Nursing Society; Infusion Nursing an evidence based approach, 3rd edition, 2010 Policies and Procedures for Infusion Nursing 4th Edition, 2011 Internal Ref: Source: Clinical Managers; Compliance Department Approved by: Director of Operations,, Medical Director Date Effective: 01/01/1990 Date Revised: 02/14/1995, 02/29/1996, 08/07/1997, 03/19/1999, 01/01/2002, 9/1/2002, 3/18/2009, 8/2012, 6/2015 Date Reviewed: 8/2012, 6/2015 Page 9 of 10

10 Page 10 of 10

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