Peripheral Cannulation. Procedural guidelines for use with adult patients in community and community hospital settings.

Transcription

1 Peripheral Cannulation. Procedural guidelines for use with adult patients in community and community hospital settings. Description: The document describes how clinicians will prepare for and carry out the insertion of a peripheral cannula in readiness for intravenous drug therapy in adults. Key Words: Version: Name of Author: Cannulation, Peripheral, Guidelines Version 1 Guideline David Leeson Name of Clinical Effectiveness Group responsible Committee: Date issued for October 2016 publication: Review date: March 2019 Expiry date: October 2019 Target audience: Clinical staff 1

2 Contents Section Page - Title Page - - Contents Version Control and Summary Equality Statement Definitions Purpose Summary of content Introduction Duties within organisation Training needs Monitoring and Compliance Indications for peripheral cannulation Choice of Cannula Procedure for Intravenous Peripheral Cannulation Post Cannula Insertion Care Procedure for the removal of an intravenous Peripheral 11 Cannula 15.0 References and Associated Documentation 12 Appendix 1 Visual Infusion Phlebitis Score (VIPS) - Appendix 2 Cannula checklist - Appendix 3 Monitoring Requirements - Appendix 4 Stakeholders and Consultation - Appendix 5 Due Regard -

3 1.0 Version Control and Summary of Changes Version number 1 Date Oct 2016 Comments (description change and amendments) New guidelines previous document was policy document For further information contact: David Leeson Clinical Education Lead Leicestershire Partnership NHS Trust Charnwood Mill, Sileby Rd, Barrow on Soar, Leics, LE12 8LR Tel: Mobile: / Office: david.leeson@leicspart.nhs.uk 2.0 Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and promotes equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development and review. 2

4 3.0 Definitions that apply to this clinical guidance Advanced Nurse Practitioner Anaphylaxis Asepsis Aseptic Non Touch Technique Highly experienced and educated members of the care team who are able to diagnose and treat your health care needs or refer you to an appropriate specialist if needed. NMC (2006) A severe, life- threatening, generalised or systemic hypersensitivity reaction. Free of, or methods to keep free of, pathogenic micro-organisms A technique that maintains asepsis and is non-touch in nature (ANTT) Clean Technique Cannula Phlebitis Measures taken to control the number of micro-organisms, but not aiming for sterility Hollow tube made of silastic, rubber plastic or metal used for accessing the body Inflammation of a vein; may be accompanied by pain, erythema, oedema, streak formation and / or palpable cord. Rated by a standard scale Visual Infusion Phlebitis Score. 3

5 4.0 Purpose of the document The aim of this document is to provide clinicians with the necessary best practice information to safely insert and maintain peripheral cannulae. 5.0 Summary and Key Points Within this document clinicians find step by step procedures to the following: Introducing a peripheral cannula. Removing a peripheral cannula. The organisations adopted templates for monitoring peripheral cannulas. 6.0 Introduction 6.1 The majority of medicines that are administered in the community and community hospital setting are via the oral route. However, in certain clinical circumstances, administration of medicines via the intravenous route is preferred and in order to facilitate this it may be necessary to introduce the medication via a peripheral cannula. 6.2 National drivers including Five Year Forward View (2014) have highlighted the need for care to be delivered differently, utilising a broader range of facilities and healthcare professionals. Patients should only be admitted to acute hospital services as an absolute necessity. As a result of this the organisation needs to be able to provide peripheral cannulation to patients in a setting appropriate to them. 6.3 The organisation appreciates the importance of having such service provision in the community but also recognises the risks associated with such activities these clinical guidelines and the training of staff in this competency will ensure that patients receive the best care appropriate to their needs. 7.0 Duties within the Organisation 7.1 The Trust Board has a legal responsibility for Trust policies and for ensuring that they are carried out effectively. 7.2 Trust Board Sub-committees have the responsibility for ratifying policies and protocols. 7.3 Divisional Directors and Heads of Service are responsible for: Ensuring appropriate measures are put into place to ensure the delivery of clinical care is safe and effective. 4

6 Delegate the responsibility to service leads for ensuring appropriate clinicians are trained in the skill of cannulation within the organisation. Ensure appropriate mechanisms are in place to support service delivery, quality and continuity. Ensure that there are appropriate resources provided within their service area to implement and adhere to the guidance. Delegate the investigation of incidents associated with peripheral cannulation appropriately. 7.4 Managers and Team leaders are responsible for: Ensuring that all appropriate clinicians in their service are aware of this guidance and that there is a clear process of dissemination. Ensure that staff are released from duty to meet their training needs and that completed competency assessment and records of attendance are kept. Ensure that line managers are supported in monitoring compliance with this guidance. Ensuring that staff work in line with this guidance. Ensure staff work in line with the organisations Incident Reporting and Management Policy 7.5 Responsibility of Staff Clinicians are responsible and accountable for their practice and should always work within their competence in according to their relevant professional standards such as The Code (NMC, 2015). Clinicians must attend the required training run within house by the Clinical Trainers and education team if new to t his s k ill and also identify to their manager any ongoing training needs. Clinicians must seek to refresh their knowledge and skills as required. Clinicians should only make two attempts to gain venous access with a peripheral cannula without seeking further help. 5

7 8.0 Training needs There is a need for training identified within this guidance for those clinicians new to this skill. In accordance with the classification of training outlined in the Trust Learning and Development Strategy this training has been identified as role development training. The course directory e-source link below will identify who the training applies to, delivery method, the update frequency, learning outcomes and a list of available dates to access the training. Link to course directory: Link to Ulearn: A record of the event will be recorded on the Ulearn system. 9.0 Monitoring Compliance and Effectiveness See appendix 3. 6

8 10.0 Indications for Peripheral Cannulation Patients should not be routinely cannulated within the organisation. Patients should only be cannulated if: Indicated by the admitting / referring Doctor / Advanced Nurse Practitioner The patient is to receive IV medication or fluids The patient is to be given a blood transfusion. The patient has been assessed as being medically unstable and at risk of acute deterioration or is a medical emergency. There is a need to replace a cannula to continue treatment. It is the responsibility of the clinician to justify the need for a cannula when requesting one be placed or when placing it. The reason for cannulation should be clearly documented in the patients care plan Choice of Cannula There are 6 choices of cannula from 24g = smallest to 14g = largest SIZE COLOUR USE 24g Yellow Medication/ Short term infusion fragile veins 22g Blue Medication / Infusion Blood transfusions 20g Pink Blood transfusions and large volume of fluids 18g Green Blood transfusions and parenteral nutrition 16g Grey Emergency / Theatre rapid infusion 14g Orange As per 16g A selection of cannula will be held in clinical areas to accommodate patient needs. Where available needle safe sharps devices should be used. (E.U. 2010) The literature suggests that the smallest, shortest cannula for any given situation should be used. In practical terms the first line choice of cannula should be Blue 22g unless the patient has fragile veins or needs another alternative. 7

9 12.0 PROCEDURE FOR INTRAVENOUS PERIPHERAL CANNULATION ACTION 1. Correctly identify the patient and discuss the procedure with patient /carer and obtain informed consent to the treatment. Exception Emergency Treatment Only RATIONALE & REFERENCE To ensure patient safety and ensure that they understand the procedure and gives his or her valid consent. (LPT Consent Policy 2015) 2. Check for patient allergies To ensure patient safety and reduce the risks of an allergic and anaphylactic reaction. (LPT Anaphylaxis Policy 2015) 3. Assemble all equipment required including a dedicated cannulation pack. Check all expiry dates and that flushes and packaging are not damaged and have been stored correctly. Assess the need for eye protection to be worn as part of PPE. Ensure sharps container is situated at the point of use. If inpatient the saline flush is to be checked by two practitioners 4. Wash hands with liquid soap and water and dry thoroughly with single use disposable paper towels. Cover any visible broken skin with a waterproof dressing. 5. Protect the patients clothing and surrounding area and support the patients arm with a pillow. 6. Identify the appropriate vein and site for cannulation taking into account any specific sites that should be avoided and patient preference. Brief use of tourniquet may be required. Recheck size of cannula. 7. Open all equipment onto sterile field maintaining asepsis. Open flush ready for drawing up. Don protective apron from cannulation pack / dressing pack. 8. Don sterile gloves and prime extension line with 0.9% Saline for injection. To ensure patient safety, assist with fluidity of procedure and comply with NMC Standards for Medicines management (2008) and LPT Intravenous Medication Policy (2012) To ensure appropriate disposal of sharps in a safe system of work. To reduce the risk of bacterial contamination during the procedure. To minimise the risk of becoming contaminated by blood, body fluids or micro organisms LPT policy for hand hygiene (2016) To maximise patient safety and comfort. Selection should reflect type and length of treatment. By avoiding compromised sites complications may be reduced. Select the smallest practical device to reduce trauma to the vein. Royal Marsden Guidelines 9 th Edition (2015) Allows for the preparation of equipment prior to the procedure without contamination. Use of extension lines allow for ease of management of the cannula once in situ and reduce risks of cannula mobility. LPT Intravenous Medication Policy (2012) and RCN Standards for Infusion Therapy (2010) 8

10 9. Cleanse skin prior to inserting cannula using 70% alcohol and 2% Chlohexidine Leave to dry for 30 seconds. Remove gloves. 10.Apply tourniquet taking care not to contaminate site of swabbing 11. Decontaminate hands with alcohol rub and apply new sterile gloves 12. Remove the needle guard and visibly inspect the device for any faults such as obvious bends or barbs. To maintain asepsis by removing skin flora RCN Standards for Infusion Therapy (2010) To promote venous filling whilst not stopping arterial drainage. To minimise risk of infection To detect faulty equipment that must be reported in case an equipment recall is needed. 13. Stabilise the vein prior to insertion by using your thumb to apply manual traction to the skin 2-3 cm below the proposed site of insertion. 14. Insert the cannula assembly through the skin at an angle of degrees. Advance the cannula assembly into the vein until there is the first flashback of blood in the flashback chamber 15.Level the device until it is almost flush with the skin advancing the cannula slightly 16.Withdraw the introducer needle 2-3 mm from the cannula point and a second flashback of blood will be seen along the shaft of the cannula 17. Whilst stabilising the introducer advance the cannula forward into the vein. Release the tourniquet and apply finger pressure over the vein above but not over the cannula tip. 18. Remove the introducer and dispose of into a designated sharps container. Counter tension facilitates a smooth needle entry and reduces the risk of vein movement. Royal Marsden Guidelines 9 th Edition (2015) To reduce the risk of passing the cannula through the vein Flashback confirms that the cannula assembly is in the vein. Royal Marsden Guidelines 9 th Edition (2015) To avoid advancing too far and damaging the vein wall. Royal Marsden Guidelines 9 th Edition (2015) Confirms that the cannula is in the vein. Royal Marsden Guidelines 9 th Edition (2015) To prevent blood spillage Reduce the risk of sharps injury 19. Attach the primed extension line. Increases the ease of access to the device and reduces risk of movement. Royal Marsden Guidelines 9 th Edition (2015)and RCN Standards for Infusion Therapy (2010) 20. Secure the cannula with a sterile transparent IV dressing. Aids inspection of the cannula site in line with Visual Phlebitis Score RCN Standards for Infusion Therapy (2010) 9

11 21. Flush with 5mls 0.9% sodium Chloride for Injection using a pulsated flush technique. This should be authorised via a PGD or individually prescribed 22. Remove personal protective equipment and dispose of according to local policy. Wash hands with liquid soap and water and dry with a single use disposable towel. 23. Complete documentation including Cannula checklist. To ensure as much relevant information is captured in case of untoward event. NMC The Code (2015) 13.0 Post cannula insertion care All patients who have a intravenous peripheral cannula inserted will be monitored in the following way: Completion of the Visual Phlebitis Score and Cannula checklist at least twice a day for inpatient settings and at each bolus / infusion for patients at home up to twice a day. Appendices 1 and 2. Patients should be prescribed and authorised to have 5ml 0.9% Sodium Chloride for injection flush daily to keep the cannula patent should no medication be being administered via the line. Patients should also be prescribed and authorised to have 5ml 0.9%Sodium Chloride for injection flushes both pre and post bolus / infusion. Unless clinically justifiable i.e. poor venous access, peripheral venous cannulas should be removed after 72 hours in line with the Visual Phlebitis Score and Cannula checklist. Once treatment has been completed all peripheral intravenous cannula should be removed and the Visual Phlebitis Score and Cannula Checklist completed. NOTE: Cannulation incidents are reportable at stage 4 of the VIPs chart appendix 1; in these circumstances the trust incident reporting policy should be followed. 10

12 14.0 Procedure for the removal of an intravenous Peripheral Cannula ACTION RATIONALE & REFERENCE 1. Correctly identify the patient and discuss To ensure patient safety and ensure that the procedure with patient /carer and they understand the procedure and gives his obtain informed consent to the procedure or her valid consent. (LPT Consent Policy 2015) 2. Assemble all equipment required. To ensure patient safety and aid fluidity of procedure. 3. Wash hands with liquid soap and water To reduce the risk of bacterial contamination and dry thoroughly with single use during the procedure. To minimise the risk of disposable paper towels. Cover any becoming contaminated by blood. LPT policy visible broken skin with a waterproof for hand hygiene (2016) dressing. 4. Protect the patients clothing and surrounding area and support the patients arm with a pillow. 5. Apply fresh non sterile gloves and fresh disposable apron 6. Remove the dressing from around the cannula and pull back on the cannula to remove it from the vein. 7. Immediately apply pressure to the puncture site using sterile gauze / cotton wool ball until the bleeding has ceased. 8. Once bleeding has stopped cover the puncture site with a sterile dressing (Elastoplast or other). Ask about sensitivities / allergies. 9. Inspect the removed cannula to ensure it is complete. Any incomplete cannula must be reported to a Doctor immediately. 10. Dispose of cannula into an appropriate sharps container at the point of use. To maximise patient safety and comfort. To reduce the risk of bacterial contamination during the procedure. To minimise the risk of becoming contaminated by blood. LPT policy for hand hygiene (2016) To minimise bruising and haematoma formation. To reduce the risk of infection. Mitigate against allergic / sensitive reaction. To ensure no foreign body is left in-situ. To reduce the risk of sharps injury. 11. Remove personal protective equipment and dispose of according to local policy. Wash hands with liquid soap and water and dry with a single use disposable paper towel. 12. Ensure the patient is comfortable and no further bleeding is evident from the puncture site. Document the removal using the cannulation checklist. To ensure as much relevant information is captured in case of untoward event. NMC The Code (2015) 11

13 15.0 References and Associated Documentation Dougherty. L, and Lister. S,(Eds) (2015) The Royal Marsden Hospital Manual of Clinical Nursing Procedures 9 th Edition. Sussex. Wiley-Blackwell European Directive on Prevention From Sharps Injuries (2010) Council Directive 2010/32EU by May 2013 Jackson. A (1998) Visual Infusion Phlebitis Score. Rotherham General Hospital LPT (2012) Intravenous Medication Administration Policy. Leicestershire Partnership NHS Trust LPT (2015) Anaphylaxis Policy. Leicestershire Partnership NHS Trust LPT (2015) Blood Transfusion Policy. Leicestershire Partnership NHS Trust LPT (2015) Consent to Examination and Treatment Policy. Leicestershire Partnership NHS Trust LPT (2016) Hand Hygiene Policy. Leicestershire Partnership NHS Trust LPT (2016) Management of Sharps and Exposure to Blood Born Viruses Policy. Leicestershire Partnership NHS Trust National Clinical Guideline Centre (2012) Infection: Prevention and Control of Healthcare Associated Infections in Primary and Community care NHS (England) (2014) Five Year Forward View. London. NHS NMC (2008) Standards for Medicines Management, London. Nursing and Midwifery Council NMC (2015) The Code Professional standards of practice and behaviour for nurses and midwives, London. Nursing and Midwifery Council RCN (2010) Standards for Infusion Therapy, London. Royal College of Nursing 12

14 VISUAL INFUSION PHLEBITIS SCORE (VIPS) Taken from: Jackson A (1998) Appendix 1. IV Site appears healthy. No pain evident. No signs of phlebitis 0 OBSERVE CANNULA ONE of the following is evident: Slight pain near IV site Slight redness near IV site 1 Possible first signs of phlebitis OBSERVE CANNULA TWO of the following are evident: Pain at IV site Erythema Swelling ALL of the following signs are evident: Pain along the path of cannula Erythema Induration All of the following are evident and extensive: Pain along path of cannula Erythema Induration Palpable venous cord Pus All of the following are evident and extensive: All of the above PLUS Pyrexia Tissue damage Early stages of phlebitis RESITE CANNULA Medium stage of phlebitis RESITE CANNULA and CONSIDER TREATMENT Advanced stage of phlebitis or the start of thrombophlebitis RESITE CANNULA and INITIATE TREATMENT COMPLETE INCIDENT FORM Advanced stage of thrombophlebitis RESITE CANNULA and INITIATE TREATMENT COMPLETE INCIDENT FORM

15 VISUAL INFUSION PHEBITIS SCORE AND CANNULA CHECKLIST Appendix 2 (any score greater than 0 requires an entry in the evaluation of care) Patients Name: Date of Birth: NHS Number: Cannula No Insertion of cannula Date of cannulation Inserted by Insertion site Size / colour of cannula Manufacturer Batch and Expiry date Score Signature Score Signature Score Signature Score Signature Score Signature Day 1 Night 1 Day 2 Night 2 Day 3 Night 3 Remove the cannula unless the patient has poor venous access or clinician can justify leaving in situ. Day 4 Night 4 Day 5 Night 5 REMOVE CANNULA Date of removal & signature Swab taken? Tip sent for C&S? Sterile Dressing applied?

16 Monitoring and Effectiveness Appendix 3 Ref Page 7 Page 11 Minimum Requirements Staff carrying out peripheral cannulation are trained and competent in the skill. Regular ongoing review of cannulation insertion related incidents/complaints Evidence for Selfassessment Sections 8.4; 9.0;11-15 Section 14.0 Process for Monitoring Review of competency documentation at appraisal The number of incidents/ complaints reported via safeguard. Responsible Individual / Group Line managers carrying out the appraisal CHS PSEG Frequency of monitoring Annually Reported as required and as exception.

17 Stakeholders and Consultation Appendix 4 Key individuals involved in developing the document Name Designation Original document developed by Unnamed Senior Nurses LCRCHS David Leeson Clinical Education Lead Circulated to the following individuals for comment Name Designation Julie Neville Clinical Trainer CHS Caroline Barclay Nurse Consultant CHS Amanda Hemsley Senior Nurse Advisor IP&C Emma Wallis Lead Nurse Community Hospitals Vic Peach Head of Professional Practice and Education LPT Sue Swanson Clinical Trainer CHS

18 Due Regard Screening Appendix 5 Section 1 Name of activity/proposal Clinical Guidelines for Peripheral Cannulation Date Screening commenced Directorate / Service carrying out the CHS Clinical Education assessment Name and role of person undertaking David Leeson Clinical Education Lead this Due Regard (Equality Analysis) Give an overview of the aims, objectives and purpose of the proposal: AIMS: Ensure that peripheral cannulation is performed to accepted national standards OBJECTIVES: Include process for staff to adhere to in order to maintain patient safety. Section 2 Protected Characteristic Age Disability Gender reassignment Marriage & Civil Partnership Pregnancy & Maternity Race Religion and Belief Sex Sexual Orientation Other equality groups? If the proposal/s have a positive or negative impact please give brief details No Impact No impact No impact No impact No impact No impact No impact No impact No impact No impact Section 3 Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? Please tick appropriate box below. Yes High risk: Complete a full EIA starting click here to proceed to Part B No Low risk: Go to Section 4. Section 4 If this proposal is low risk please give evidence or justification for how you reached this decision: Carrying out this procedure does not impact on any protected characteristics Signed by reviewer/assessor D. Leeson Date Sign off that this proposal is low risk and does not require a full Equality Analysis Head of Service Signed Date