BASINGSTOKE AND NORTH HAMPSHIRE NHS FOUNDATION TRUST Clinical Policy for Peripheral Venous Cannula Insertion and Management (Adults) Reviewed in accordance with The Health and Social Care Act 2008: Code of Practice for health and adult social care on the prevention and control of infections and related guidance as published 16 December 2009. Summary This policy will provide information about the correct technique for peripherally cannulating a vein aseptically and the subsequent care of the peripheral venous cannulae. By using this policy the user will act to reduce the risks to patients and staff associated with peripheral venous cannulation. These include thrombosis, pain, local or systemic infection; occupational sharps injury and inappropriate cannula insertion. Aseptic peripheral venous cannulation is undertaken to provide venous access for either diagnostic or therapeutic purposes: a) Short-term intravenous fluid therapy of usually less than 3-4 days (if intravenous access is needed for longer periods, other options should be considered). Page 1 of 11
b) Administration of bolus injections in outpatients or in day case surgery c) Vascular access for fluids or drugs at time of particular procedure e.g. surgery, endoscopy The implementation of this policy will be monitored using clinical audit (Appendix B) Implementation Plan There will be a week long launch of the Policy, including teaching sessions for staff. Managers and Link Personnel to disseminate Policy to non- attenders of teaching sessions. Information regarding the new Policy will be issued in PULSE. Posters will be displayed in all clinical areas, outlining the basis of Peripheral Vascular Catheter care, and assessment tools. Implementation of Peripheral Venous Catheter Care plans. Regular Audits of Peripheral Venous Catheter care (including documentation) Summary of changes This is a new policy therefore there are no changes. Action needed and owner of action Staff are required to adhere to new Trust Guidelines. In order to ensure staff comply: Table of Contents Page No 1. Purpose 3 2. Responsibilities 3 3. Definitions 3 4. Clinical Practice 4 5. Training 6 6. References 7 7. Contributors 7 Appendix A: Abbreviated guide to peripheral venous cannulation 8 Appendix B: Cannula Insertion and Management form 10 1. Purpose Page 2 of 11
To inform best practice on the aseptic insertion of peripheral venous cannulation of adults. The implementation of this policy will reduce the risks associated with this procedure including thrombosis, pain, local or systemic infection; occupational sharps injury and inappropriate cannula insertion. 2. Responsibilities Supervisors of clinical practice will be responsible for monitoring compliance with the policies on an ongoing basis. The IV therapy Nurse will audit compliance as part of the infection control clinical practice audit process. A snapshot audit to monitor clinical practice during cannula insertion and subsequent care will be undertaken annually. Please refer to Paediatric Policy for cannulation in paediatric areas, 3. Definitions Aseptic Technique Clinical practices used to protect the patient from micro-organisms by preventing contamination of wounds, manipulated devices and other susceptible sites. Aseptic technique involves the use of appropriate hand hygiene, use of sterile equipment, no touch technique and robust patient skin / site disinfection. Venous Cannulation Procedure for insertion of a hollow fine bore tube into the venous system Health care professional A registered or trained member of staff, including but not exclusively nurses, doctors and operating department practitioners. Infection Entry of a harmful microbe into the body and its multiplication in the tissues Peripheral cannula A specifically-designed flexible tube designed for insertion into a blood vessel, with a proximal connector to allow injection or infusion of liquids. Sizes range from Yellow 24g Blue 22g Pink 20g Green 18g Grey 16g Orange 14g 22-20g are optimal for administration of intermittent medications. 16-14g are routinely used to administer fluids in acute situations i.e. haemorrhage. Phlebitis Inflammation of a vein Thrombosis Formation, development or existence of a blood clot within the vascular system Page 3 of 11
4. CLINICAL PRACTICE Action Rationale Identify clinical need for cannula insertion To prevent inappropriate insertion and exposure to associated risks. Collect equipment needed including: To ensure procedure is performed without disruption Dressing trolley (Cleaned) White tray (cleaned) Gauze Single use tourniquet Clean gloves Sharps box 2% Chlorhexidine and 70% alcohol (Sanicloth CHG 2%) Local anaesthetic (1% Lidocaine) orange needle and Choice of cannula must be based on clinical need 2ml syringe but the smallest cannula should be chosen to reduce Cannulae - IV dressing risk of complications associated with larger bores. Saline flush Identify patient by surname, first name and date of birth To ensure correct identification of the patient Wash hands with soap and water as per the Trust Hand Hygiene Policy Place White tray onto clean dressing trolley. Open To ensure patient is informed of procedure and the equipment into the clean tray. risk of allergic reaction is minimised Explain to the patient the importance of keeping the site To ensure patient compliance and reduce risk of clean and dry and advise of risks of infection infection Decontaminate hands with alcohol gel or wash with soap and water Palpate potential sites these include: The hand - a lower risk of phlebitis The wrist or upper arm increasing risk The lower limb has a higher risk than the upper limb When potential site is identified position patient comfortably with appropriate limb below the level of the heart. Removing excess hair (shaving is not recommended clippers are better) Apply proximal single use tourniquet, without obstructing arterial flow Optimal time for application is 3 to 5 mins if additional time is needed release tourniquet as vein will tend to disappear. Encourage patient to exercise limb muscles (e.g. repeatedly making a fist and opening hand) Decontaminate hands with alcohol gel or wash with soap and water and don clean gloves Clean insertion site using a spiral motion from the proposed puncture site outwards with 2% chlorhexidine in 70% alcohol (from pre-soaked wipe Sani cloth CHG 2%) for 30 seconds and then allow to dry Administer local anaesthetic (1% Lidocaine) which should be encouraged in all but the most urgent of cases. Alternatively apply prescribed topical local anaesthetic cream 45mins prior to procedure To reduce risk of arterial rather than venous cannulation, and reduce risk of infection. To allow dependent veins to fill with blood Local trauma can be caused by shaving, increasing risk of infection To distend veins Muscle pump forces blood into veins to distend them further To reduce risk of infection To ensure patient comfort Page 4 of 11
Action Inserting the cannula: Gently pull on skin, distal and lateral to insertion site. Do not touch the cannula or the insertion site. Insert cannula (bevel uppermost) through the cleaned skin area at an angle of 20 degrees. Advance until just in the vein and then lower the cannula until it is parallel with the skin (a flashback of blood is usually but not always seen at this point) Then, either; a) Pull the needle back 1cm and push the cannula/needle into the vein up to the hilt Or; b) Hold the needle still and advance the cannula over the needle until the cannula is inserted up to the hilt In the event of unsuccessful cannulation of the vein withdraw the cannula from the puncture site and apply pressure with non woven swab Prior to subsequent attempts at cannulation it is the responsibility of the individual practitioner to risk assess the difficulty of further attempts against their own registered competence and experience. If the practitioner anticipates the difficulty level to be beyond their scope of practice, then referral to more experienced, competent practitioners should be made Remove the tourniquet and apply pressure on the proximal vein, close to the tip of the cannula a second person may be required for this Remove needle and dispose of immediately into sharps container, cap off cannula with a sterile cap or attach intravenous fluids as appropriate Secure cannula with a recognised, sterile cannula dressing, ensuring it is applied correctly (non-sterile, sticky-tape fixation or bandage is NOT acceptable). Place date for cannula review sticker to outside of dressing Flush cannula with 1-2 mls saline if not being attached to infusion. Document cannula insertion by completing a Cannula insertion and management form for each separate cannula inserted. Once cannula has been removed this document is filed in the patients medical notes. Rationale To fix the skin and the superficial veins underlying it. To use the sharpened needle to introduce the plastic cannula into the vein. To introduce the cannula fully into the vein To minimise haematoma formation and /or excessive bruising To ensure cannulation is always undertaken by competent practioners and minimise risks associated with failed attempts at gaining venous access To prevent excessive bleeding during needleremoval. To reduce risk of needle stick injury and prevent blood spillage To reduce risk of infection and secure cannula in position To ensure timely review To ensure cannula patency To establish an audit trail and monitor management of cannula Page 5 of 11
Action Ongoing cannula management: Decontaminate hands before and after each patient contact. Use correct hand hygiene procedure as per trust policy. Always access cannula by cleaning with 2% chlorhexidine and 70% isopropyl alcohol (Sani cloth CHG 2%), and allow to dry before administering fluid or injections. Needle free bungs should NOT be applied directly onto cannula; single or double lumen extensions should be applied. Cannula site should be inspected three times a day (8 hourly). Cannula dressing should be, intact, dry and adherent. A date and time of insertion must be applied at point of insertion. Remove cannula if there is no continuing clinical indication and document date and time of removal on cannula management form. Replace cannula in a new site after 72 hours (3 days), earlier if clinically indicated. Administration sets should be replaced immediately after blood and blood product administration, intermittent IV antibiotics and medicines. Heparin infusion lines should be replaced every 24 hours. All other fluid sets should be replaced after 72 hours. ALL giving sets should be labelled with date and time on commencement of use. All disconnected giving sets should be disposed of and cannot be reattached. Rationale To prevent unwanted movement of cannula in the vein. Thus causing phlebitis. Observe for signs of infection or phlebitis. To ensure that the cannula is replaced or removed on time, thus reducing the risk of infection. 5.Training Prior to undertaking any cannulation procedure, all staff must be able to demonstrate clinical competence and a clear understanding of the underlying principles of practice. This will be achieved by: Nursing and other health care staff a) complete the Trust venous cannulation competency pack b) attend a cannulation study day c) complete a period of supervised clinical practice (Staff who have been trained and practised in a previous post may be allowed to demonstrate an equivalent level of competence through a period of supervised practice only). Medical staff Post registration house officer (PRHO) induction will include training by Trust trainers on local Policies and principles of practice. Senior House Officer s and Registrars will be assumed competent unless identified otherwise by their supervisor. If problems are identified, the staff member will be required to: Page 6 of 11
a) complete the Trust venous cannulation competency pack b) attend a cannulation study day c) complete a period of supervised clinical practice 6. References Department of Health (2001) The epic Project: Developing National Evidence based Policys for Preventing healthcare associated Infections Journal of Hospital Infection (2001) 47 (supplement) Donaldson I. (1999) Intravenous therapy in critically ill adults: developing a clinically and cost- effective approach Intensive and Critical Care Nursing No 15, 338-345 Dougherty L, Mallett J (2001) The Royal Marsden Hospital Manual of Clinical Nursing Procedures Fifth edition. Blackwell Science Fletcher SJ; Bodenham A (1999) Catheter related sepsis: an overview Part 1 British Journal of Intensive Care. March/April Infection Control Nurses Association (2001) Policys for preventing intravascular catheter related infection NICE (2003) (No. 4) Care of patients with central venous catheters Clinical policy 2 Infection control, June 2003 Polderman KH; Girbes AR (2002) Central venous catheter use. Part 2: infectious complications Intensive Care medicine 2002, Jan; 28(1): 18-28 RCN (March 2004) Good practice in infection control Guidance for nursing staff RCN (Oct 2003) Standards for infusion therapy DoH ( July 2006) Winning ways high impact working together to reduce healthcare associated infection in England-intervention 2b 7. Contributors Sandy Kirk, IV Nurse Specialist Appendix A Abbreviated guide to peripheral venous cannulation (adult) Page 7 of 11
Clinical Practice Policy (abbreviated) Action Identify clinical need for cannula insertion Collect equipment needed including: Dressing trolley White Tray Single use tourniquet Clean gloves Sharps box 2% Chlorhexidine and 70% alcohol skin preparation (Sanicloth CHG 2%) Local anaesthetic (1% Lidocaine) orange needle and 2ml syringe Cannulae - IV dressing Saline flush Identify patient by surname, first name and date of birth Wash hands with soap and water as per the Trust Hand Hygiene Policy Place White tray onto clean dressing trolley. Open equipment into the clean tray. Explain the procedure to the patient, discuss the need for a cannula, obtaining verbal consent for procedure establishing whether patient has any known allergies Explain to the patient the importance of keeping the site clean and dry and advise of risks of infection Decontaminate hands with alcohol gel or wash with soap and water Palpate potential sites these include: The hand - a lower risk of phlebitis The wrist or upper arm increasing risk The lower limb has a higher risk than the upper limb When potential site is identified position patient comfortably with appropriate limb below the level of the heart. Removing excess hair (shaving is not recommended clippers are better) Apply proximal single use tourniquet, without obstructing arterial flow Optimal time for application is 3 to 5 mins if additional time is needed release tourniquet as vein will tend to disappear. Encourage patient to exercise limb muscles (e.g. repeatedly making a fist and opening hand) Decontaminate hands with alcohol gel or wash with soap and water and don sterile gloves Clean insertion site using a spiral motion from the proposed puncture site outwards with 2% chlorhexidine in 70% alcohol (from a pre-soaked wipe Sani cloth CHG 2%)) for 30 seconds and then allow to dry Administer local anaesthetic (1% Lidocaine) which should be encouraged in all but the most urgent of cases. Alternatively apply prescribed topical local anaesthetic cream 45mins prior to procedure Inserting the cannula: Gently pull on skin, distal and lateral to insertion site. Do not touch the cannula or the insertion site. Insert cannula (bevel uppermost) through the cleaned skin area at an angle of 20 degrees. Advance until just in the vein and then lower the cannula until it is parallel with the skin (a flashback of blood is usual but not always seen at this point) Page 8 of 11
Then, either; b) Pull the needle back 1cm and push the cannula/needle into the vein up to the hilt Or; b) Hold the needle still and advance the cannula over the needle until the cannula is inserted up to the hilt In the event of unsuccessful cannulation of the vein withdraw the cannula from the puncture site and apply pressure with non woven swab Prior to subsequent attempts at cannulation it is the responsibility of the individual practitioner to risk assess the difficulty of further attempts against their own registered competence and experience. If the practitioner anticipates the difficulty level to be beyond their scope of practice, then referral to more experienced, competent practitioners should be made Remove the tourniquet and apply pressure on the proximal vein, close to the tip of the cannula a second person may be required for this Remove needle and dispose of immediately into sharps container, cap off cannula with a sterile cap or attach intravenous fluids as appropriate Secure cannula with a recognised, sterile cannula dressing, ensuring it is applied correctly (non-sterile, sticky-tape fixation or bandage is NOT acceptable). Place date for cannula review sticker to outside of dressing Flush cannula with 1-2 mls saline if not being attached to infusion. Document cannula insertion by completing a Cannula insertion and management form for each separate cannula inserted. Once cannula has been removed this document is filed in the patients medical notes. Ongoing cannula management: Decontaminate hands before and after each patient contact. Use correct hand hygiene procedure as per trust policy. Always access cannula by cleaning with 2% chlorhexidine and 70% isopropyl alcohol, and allow to dry before administering fluid or injections. Needle free bungs should NOT be applied directly; single or double lumen extensions should be applied. Cannula site should be inspected at least three times a day. (8 Hourly) Cannula dressing should be, intact, dry and adherent. A date and time of insertion must be applied at point of insertion. Remove cannula if there is no continuing clinical indication. Replace cannula in a new site after 72 hours, earlier if clinically indicated. Administration sets should be replaced immediately after blood and blood product administration, intermittent IV antibiotics and medicines. Heparin infusion lines should be replaced every 24 hours. All other fluid sets should be replaced after 72 hours. ALL giving sets should be labelled with date and time on commencement of use. Page 9 of 11
Appendix B Patient Hospital Number Cannula Insertion and Management Form Date of Birth Ward WARD Consultant GAUGE Observation Shift What is the continuing clinical Indication? SJK/07/2009 INSERTION 24 22 20 18 16 14 Lot No CONSENT Informed Implied Unable INSERTION REASON IV Fluids IV Antibiotics Blood Chemotherapy Surgery Other ADHERED TO Aseptic Technique Skin Prep IV 3000 Dressing Extension Single Double Local Anaesthetic used? Yes No Cannula Timed & Dated Yes No Day 1 Early Late Night Day 2 Early Late Night Day 3 Early Late Night Date and Time Inserted---------------- BY----------------------- Signature---------------- Status--------- Date and Time Removed----------------BY-----------------------Signature- ---------------Status--------Number of attempts- Standard: Hand Hygiene must be performed before and after accessing cannula. Is the dressing Intact? Administration set replacement needed? V.I.P. Score Action taken REMOVAL REASON Not Required Phlebitis Infiltration Extravasation By Patient V.I.P Score on removal Other COMMENTS Date and Signature
Visual Infusion Phlebitis Score (V.I.P) (Adapted with permission from: Jackson. A. 1999) Signs & Symptoms Score Action to be Taken IV cannula site healthy 0 One of the following is present: Slight pain Redness around IV site 1 No signs of phlebitis Observe and document cannula each shift First signs of phlebitis. Remove & replace cannula in alternative site. Observe both sites and document. Two of the following are present: Pain Redness Swelling All of the following are present: Pain along path of cannula Redness around site Swelling All of the following are present and extensive: Pain along path of cannula Redness around site Swelling Palpable venous cord All of the following are present and extensive: Pain along path of cannula Redness around site Swelling Palpable venous cord SJK/07/2009 Pyrexia 2 3 4 5 Early stage of phlebitis. Remove & replace cannula in alternative site. Observe both sites and document. Medium stage of phlebitis. Remove cannula, inform doctor. Document and complete Incident Form. Consider treatment. Inform IV Nurse Specialist Advanced stage of phlebitis or start of thrombophlebitis. If pyrexia present take blood cultures from alternative site. Inform doctor. Document and complete Incident Form. Inform IV Nurse Specialist Advanced stage of thrombophlebitis Remove and send tip for culture and sensitivity, swab site. Inform doctor. Resite cannula and initiate treatment. Complete Incident Form. Inform IV Nurse Specialist.