Peripheral Intravenous Devices

SH CP 140 Peripheral Intravenous Devices Procedures for Peripheral intravenous cannula and Midline intravenous catheters Summary: Keywords (minimum of 5): (To assist policy search engine) Target Audience: Trust procedures for the care and management of Peripheral intravenous cannulae and Midline peripheral intravenous catheters. Includes: Insertion of peripheral cannula Administration of intravenous medication (including flush) via a peripheral device Ongoing care and removal. Intravenous therapy, IV, IV therapy devices, Vascular access device ( VAD) Peripheral intravenous device, PICC, skin tunnelled, implanted port, cannulation, peripheral cannula, midline, insertion, maintenance, removal, flush, diluent, reconstitution, infiltration, extravasation, VIP score, vesicant, phlebitis, thrombosis, thrombophlebitis infusion. All clinical staff Next Review Date: July 2020 Approved and ratified by: Medicines Management Committee Date of meeting: 19/07/17 Date issued: Author: Sponsor: Sharon Guy, Clinical Educator & Mandy Lyons, Clinical Educator Julie Dawes, Director of Nursing and AHP 1

Version Control Change Record Date Author Version Page Reason for Change August 2014 April 2017 Jane Byrnell 1 All Replace ANTT terminology with Aseptic Technique Sharon Guy & Mandy Lyons 1 All Title change Reviewed in response to updated Royal College of Nursing Standards for Infusion Therapy and a Safeguard alert regarding NICE guidance on chlorhexidine allergy. Reviewers/contributors Name Position Version Reviewed & Date Theresa Lewis Head of Infection Prevention and Control 1 2 ( May 2017) David Jones Chief Pharmacist 1 Steve Mennear Senior Clinical Pharmacist 1 Zoe Denyer Inwood Day unit Sister 1 Steve Coopey Practice Development Specialist Nurse 1 2 ( April 2017) Claire Hollywell Clinical Educator 1 2

Contents Section Title Page 1. Introduction 4 2. Insertion of a peripheral cannula 4 3. Routine flush to maintain patency of peripheral device. 8 4. Administration of intravenous medication 11 5. Ongoing routine care, including observations and dressing 13 6. Removal of peripheral cannula 14 3

Peripheral Intravenous Devices Procedures for Peripheral intravenous cannula and Midline intravenous catheters 1. Introduction 1.1 These procedures should be read in conjunction with the following Southern Health policies for further information: SH CP 137: Intravenous Therapy and Peripheral cannulation SH CP 13: Aseptic Technique and Clean Technique procedure SH CP 1: Medicines Control, Administration and Prescribing Policy (MCAPP) SH CP 30: Medical Emergencies and Resuscitation Policy 1.2 All Peripheral Cannulation and Intravenous (IV) Therapy administration via a Peripheral Intravenous Device, including flush, requires the use of an aseptic technique, observation of standard precautions and product sterility. 1.3 Aseptic technique (AT): requires individual risk assessment to determine the use of sterile or non-sterile gloves. Sterile gloves are not always required for AT. If there is a likelihood of the Registered Nurse/ Clinician touching the key parts of the system then sterile gloves must be worn. If however you can carry out the procedure without touching the key part with your hands, non-sterile clean gloves may be worn. If the procedure is complex/ technically difficult, or the patient is immuno-compromised, sterile gloves must be worn. 1.4 Gloves: The use of gloves should follow a risk assessment that identifies exposure to blood/ bodily fluids as a risk to the healthcare professional. Well-fitting gloves should be worn to protect hands from contamination from blood, body fluids, secretions and excretions, and to reduce the risk of Cross-contamination to both patient and staff (RCN Therapy, 2016.) 1.4 Aprons: It is recommended that single-use disposable plastic aprons should be worn whilst carrying out ALL infusion procedures, including routine flush, due to the risk of contact with blood/ bodily fluids or contamination of uniform/clothing (RCN Standards for Infusion Therapy, 2016) 2. Insertion of a Peripheral Intravenous Cannula Action Identify clinical need for peripheral cannula insertion. Decontaminate hands as per Southern Health Hand Hygiene Procedure Identify patient by surname, first name and date of birth using open questions checking against NHS/ hospital number. Explain the procedure to the patient; discuss the need for a peripheral cannula, obtaining informed consent for procedure. Establish whether patient has any known or suspected allergies- in particular check for allergy to chlorhexidine. Refer to the Mental Capacity Act 2005 if inserting a peripheral cannula in the Rationale To prevent inappropriate insertion and exposure to associated risks. To reduce the risk of infection. To ensure correct identification of the patient. To ensure patient is informed of procedure. To reduce risk of generalised allergic reaction or anaphylaxis To ensure appropriate insertion is considered. 4

patient s best interests. Explain to the patient the importance of keeping the site clean and dry post insertion and discuss risks and signs of infection. If required apply prescribed topical local anaesthetic cream as per manufacturer s instructions for approximately 30-60 minutes prior to cannulation. Position the patient and make comfortable with appropriate limb positioned below the level of the heart. Collect required equipment: Essential equipment Clinically clean area: tray/ trolley Sterile pack Single use disposable tourniquet Well-fitting disposable gloves Sharps box 2% Chlorhexidine gluconate and 70% alcohol skin preparation wipe, or suitable alternative if allergy or sensitivity to chlorhexidine known or suspected ( ie: povidone iodine in 70% alcohol ) 10 ml Luer lock syringe(s) 1x 10ml 0.9% Sodium Chloride for injection flush Or: 1x prefilled flush ( eg: Posiflush) Cannula:WITH INTEGRAL EXTENSION SET( eg: Tipro One) preferable to ensure closed system Cannula: WITHOUT INTEGRAL EXTENSION SET WILL REQUIRE ADDITION OF A PRIMED EXTENSION SET ( also known as an octopus) 1x Extension set ( also known as an Octopus) primed with 0.9% normal saline for injection ( or compatible alternative) Optional equipment: Topical local anaesthetic Securing device eg: Statlock To educate the patient and reduce risk of infection. To ensure patient comfort. To allow dependent veins to fill with blood. To ensure procedure is performed without disruption to maintain patient safety. Choice of needle safe peripheral cannula must be based on clinical need but the smallest should be chosen to reduce risk of complications associated with larger bores e.g. phlebitis. Maintaining a closed system is recommended to reduce the risk of infection Check all packaging intact before opening Clean identified working area with a Clinell Universal sanitising wipe. In both inpatient and outpatient setting ensure the correct lighting, ventilation, privacy and position of the patient. Support the chosen limb on a pillow To reduce the risk of infection. To ensure comfort and safety of patient and health care professional To ensure patient comfort and ease of access 5

Encourage patient to keep limb warm as this increases blood flow, gentle palpation will encourage veins to distend. Assess and select vein; where possible use the non-dominant forearm and avoid areas of flexion. Apply single use disposable tourniquet 10cm above insertion site to aid vein selection Once vein selected release tourniquet and prepare equipment. Select cannula based on vein size Decontaminate hands as per Southern Health Hand Hygiene Procedure Open dressing pack to create aseptic field on cleaned working area. Open equipment onto the aseptic field taking care that any sodium chloride ampoules remain on the cleaned working area, or clean with a single use 2% chlorhexidine gluconate in 70% isopropyl alcohol wipe( or suitable alternative ie: povidone in alcohol, if patient has known or suspected allergy) if placing on the aseptic field. If using a cannula without an integral extension set prime extension set with sodium chloride for injection 0.9% using aseptic technique. If infusion is not to be commenced immediately, prepare 0.9% sodium chloride 10 mls for flush. Clean the patient s skin at the insertion site. Use a grid motion from the proposed puncture site outwards with a single use 2% chlorhexidine gluconate in 70% isopropyl alcohol wipe ( or povidone in alcohol if patient sensitive to chlorhexidine) for 30 seconds and then allow to dry for 30 seconds. Put on gloves and single use disposable apron Reapply single use disposable tourniquet Remove needle guard and inspect device for any faults Anchor the vein with the non-dominant hand by gently pulling on skin a few centimetres below the proposed site of insertion. Grip the cannula as preferred in the dominant hand, ensuring To identify where veins are of adequate size and straight enough to accommodate the cannula. To reduce risk of cannula displacement or mechanical phlebitis To dilate the veins by obstructing venous return. Tourniquet time should be a maximum of 60 seconds to prevent and haemoconcentration and false blood chemistry results. To ensure the patient does not feel discomfort while equipment is prepared. To reduce damage or trauma to vein and reduce risk of phlebitis To reduce the risk of infection. To create a clean working area and reduce infection risk. To remove air from the set prior to connection and reduce the risk of air embolism and infection To maintain patency of cannula To remove skin flora and reduce risk of infection. To prevent contamination of the health care professional from any blood spill To promote venous filling To detect faulty equipment and preserve patient safety To immobilise the vein and provide counter tension, which will facilitate smooth needle entry and a successful pain free cannulation 6

bevel is uppermost. Insert the cannula through the skin at an angle of 15 degrees in to the vein. Advance until just in the vein then lower the cannula until it is parallel with the skin ( depending on cannula type a flashback of blood may be seen at this point) Advance the device a further 2-3mm in to the lumen of the vein. As the cannula advances simultaneously pull the needle back using preferred technique ( either 1 or 2 handed) (At this point blood should fill the extension line if a cannula with an integral extension set is used, or blood will be seen along the shaft of the cannula) Release the tourniquet Pull the needle back until the safety device is activated. If using a cannula without an integral extension set apply pressure on the proximal vein, close to the tip of the cannula (a second person may be required for this.) Remove the needle and dispose of it immediately in to a sharps container. If using a cannula without an integral extension set it is now necessary to attach sterile extension set ( octopus ), ensuring it has been previously primed with sterile 0.9% Sodium chloride for injection. Secure cannula with a sterile, transparent, vapour permeable IV dressing. Secure the Y connection with luer lock cap/ bung if required ( depending on cannula type).secure the extension tubing Place date for cannula review sticker to outside of dressing. Flush cannula with 10mL 0.9% sodium chloride for injection (or recommended compatible alternative) using push pause /positive pressure techniques. Never force the solution into the device Following successful insertion ensure patient is comfortable. Dispose of equipment as per the disposal and handling of waste policy. Remove apron and gloves. Decontaminate hands as per Hand Hygiene procedure. Documentation should include: Name, date, time and reason for cannula insertion VIP score (and any removal if cannula is being re sited). To indicate that the needle has entered the vein To stabilise the device To decrease the pressure within the vein To prevent needlestick injury To prevent excessive bleeding during needle-removal. To reduce risk of needle stick injury and prevent blood spillage. To reduce risk of air embolus or mechanical phlebitis To reduce risk of infection and secure cannula in position To prevent pulling/ accidental removal of device and reduce risk of mechanical phlebitis. To ensure timely review. To create turbulent flow that will remove debris from the sides of the lumen and to create positive pressure to maintain patency To prevent damage to the device To ensure patient comfort. To ensure patient and staff safety. To establish an audit trail and monitor management of cannula. 7

Details of site preparation and where located. Type and size of vascular access device, Patient response to placement. Complete a Peripheral Cannula Insertion and Management chart (see IV policy) A chart needs to be completed for each separate cannula inserted. Once cannula has been removed this document is filed in the patients notes. In the event of unsuccessful cannulation of the vein, withdraw the peripheral cannula from the puncture site and apply pressure with sterile non-woven swab. Prior to any subsequent attempts at cannulation it is the responsibility of the individual health care professional (HCP) to risk assess the difficulty of further attempts against their own registered competence and experience. If the HCP anticipates the difficulty level to be beyond their scope of practice, then referral to more experienced, competent practitioners should be made. Maximum of two attempts before contacting senior staff. A new cannula is required for each insertion. DAY CASE: A cannula insertion and management chart is not required; details of insertion and removal of the patient s cannula need only be documented fully in the notes. To minimise haematoma formation and /or excessive bruising. To ensure cannulation is always undertaken by competent registered nurses and minimise risks associated with failed attempts at gaining venous access. Cannula inserted for procedure only and in situ for less than six hours and then removed. 3. Routine flush to maintain patency of peripheral intravenous device 3.1 For Peripheral Cannulae and Midline Catheters10mls 0.9% sodium chloride for injection (or recommended compatible alternative) should be used to flush before, between medicines and after medicine administration, or at least once daily to maintain patency 3.2 Syringes for medicine administration and flushing must be Luer lock with a minimum size of 10mL. 3.3 The principles of administration of flush for a Midline peripheral intravenous catheter are the same as that of a Central venous catheter. However, the tip of the Midline catheter rests in the axillary region and therefore does not need X-ray to confirm placement unless difficulties with flushing. 3.4 Do not attempt blood withdrawal or collection from a Peripheral cannula, except at time of insertion. 8

Procedure for flushing a peripheral intravenous device (Peripheral cannula and Midline intravenous catheter) Action Identify clinical need for procedure Decontaminate hands as per Hands Hygiene Procedure. Identify patient by surname, first name and date of birth using open questions checking against NHS/ hospital number. Explain the procedure to the patient obtaining informed consent for procedure. Establish whether patient has any known or suspected allergies- in particular check for allergy to chlorhexidine. Refer to the Mental Capacity Act 2005 when appropriate and consider if intervention is in the patients best interests. Inspect the peripheral cannula site or midline catheter insertion site for signs of skin discolouration or infection using a Visual Infusion Phlebitis Score (VIPS) and document accordingly. Ascertain whether the patient has experienced any new symptoms of pain, discomfort or swelling; whether the cannula or midline catheter has been pulled or caught and whether the exterior length of the midline device remains constant. Identify a working area (eg: clean, plastic, re-usable wipe-clean tray) and clean with a Clinell Universal sanitising wipe. In both inpatient and outpatient setting ensure the correct lighting, ventilation, privacy and position of the patient. Collect required equipment: Aseptic field Gloves Apron Sharps box 2% chlorhexidine gluconate in 70% Isopropyl alcohol e.g. Clinell Single Use Device wipes or suitable alternative ( povidone iodine in alcohol if suspected or known allergy. 10 ml Luer lock syringe Needle to draw up flush solution 0.9% sodium chloride for injection ( or compatible alternative) NB: There are pre-prepared 10mL syringes containing 0.9%sodium chloride for injection available (e.g. BD Posiflush) which remove the need to Rationale To prevent inappropriate intervention and exposure to associated risks. To prevent infection. To ensure correct identification of the patient. To ensure patient is informed of procedure. To reduce risk of generalised allergic reaction or anaphylaxis To ensure consent for insertion is obtained, and that the insertion of the device is appropriate for the patient. To assess for risk of infection being present. To assess whether the peripheral cannula or midline catheter may be malpositioned or displaced To reduce the risk of infection. To ensure comfort and safety of patient and health care professional To reduce risk of interruption during procedure. 9

use needles to draw up the solution from an ampoule. Decontaminate and dry hands and put on clean gloves and apron Prepare aseptic field with equipment required to carry out flush procedure. Using a suitable cleansing agent, wipe clean ampoules containing flush if required using aseptic technique for at least 30 seconds and place on edge of aseptic field and allow to air dry for at least 30 seconds and draw up flush solution in to syringe. Using a suitable cleansing agent and aseptic technique, thoroughly clean the site and the clamp and port for minimum 30 seconds to and place onto sterile paper towel to allow to air dry for 30 seconds. Swanlocks (bungs) should NOT be applied directly onto the peripheral cannula; primed single or double lumen extensions must be used if the cannula does not have an integral extension set. NB : The HCP should aspirate MIDLINES to check blood return prior to administration of medications and/ or solutions. In the absence of a blood return for midlines an attempt should be made to flush the device; if resistance is met force should not be applied ( RCN, 2016). Flush the peripheral intravenous device using an intermittent push pause and positive pressure technique. Never force the solution into the device For peripheral cannulae it may be necessary to remove the device if patency cannot be established Remove the syringe and discard into sharps container as per Sharps Safety and Management Procedure. Replace the hub if visibly contaminated, or every 7 days for a midline device Remove dressing towel and discard. Ensure the patient is comfortable. Remove gloves aprons. Decontaminate hands. Dispose of all waste correctly following Handling & Disposal of Healthcare Waste Policy. Document in patient s records medications administered, any problems encountered and action taken. To prevent infection. To reduce infection risk To render aseptic. To prevent cross infection. To prevent unwanted movement of cannula in the vein as this can cause mechanical phlebitis. To confirm patency, assess catheter function and prevent complications To create turbulent flow that will remove debris from the sides of the lumen and to create positive pressure to maintain patency To prevent damage to the device To prevent unnecessary sharps injury To reduce risk of infection and promote patency of the venous access device. To prevent infection. To ensure patient and staff safety. To comply with Record Keeping Policy, promote continuity of care and patient safety. 10

4. Administration of Intravenous Medicines via a Peripheral Device Key Principles: 4.1 Peripheral cannulae and midline peripheral catheters are not suitable for vesicant (caustic) medications, cytotoxic drugs, hyperosmolar solutions, parenteral nutrition, solutions or medications with a ph of less than 5 or greater than 9. 4.2 The principles of administration of medication for a Midline peripheral catheter are the same as that of a Central catheter. However, the tip of the Midline catheter rests in the axillary region and therefore does not need X-ray to confirm placement, unless difficulties arise with administration or flushing. 4.3 All IV medicines, including diluents and flushes, must be prescribed by a Registered Medical practitioner or Non-Medical Prescriber responsible for the patient s care, either on an in-patient prescription chart or a community administration authorisation sheet and FP10. 4.4 Any adjustments to the patient s treatment plan will require a new prescription to be completed. Verbal messages will not be accepted for change in an Intravenous Drug Treatment Plan Procedure for administration of Intravenous Medicines via a peripheral device Action Place the final syringe or infusion and the empty ampoule (s) /vials (s) into a clean, wipe-clean plastic tray, with the prescription, for taking to the patient for administration. Assemble everything required including any flush solution(s). Identify patient by surname, first name and date of birth using open questions checking against NHS number/ hospital number. Explain the procedure to the patient obtaining informed consent for procedure. Establish whether patient has any known or suspected allergies- in particular check for allergy to chlorhexidine. Refer to the Mental Capacity Act 2005 when appropriate and consider if intervention is in the patients best interests. Decontaminate hands as per Hands Hygiene Procedure and apply gloves & apron. Inspect the cannula site or midline catheter insertion site for signs of skin discolouration or infection using a Visual Infusions Phlebitis Score (VIPS) and document accordingly. Ascertain whether the patient has experienced any new symptoms of pain, discomfort or swelling; whether the Rationale To prevent infection and aid administration. To ensure correct identification of the patient. To ensure patient is informed of procedure. To reduce risk of generalised allergic reaction or anaphylaxis To ensure consent for insertion is obtained, and that the insertion of the device is appropriate for the patient. To prevent infection. To assess for risk of infection being present. To assess whether the cannula or midline catheter may be malpositioned or displaced 11

cannula or catheter has been pulled or caught since previous therapy, whether the exterior length of the midline peripheral device remains constant. Having checked that an appropriate access device is in place and patent, it is necessary to flush immediately before and after administration of a medicine, and between doses of different medicines administered consecutively. After administration advise the patient to report promptly any soreness at the injection site or any discomfort. Re-check the administration site for signs of leakage, infection or inflammation and continue to monitor the patient. Discard the empty ampoules/vials from which the injection was prepared and any unused medicine in accordance with local waste disposal policy. Ampoules or vials should never be used to prepare more than one injection unless specifically labelled by the manufacturer for multidose use. Make a detailed record of administration in the patient records. All documents and record keeping to be maintained as per Record Keeping Policies, Standards and Standard Operating Procedures. NB: A signed Trust prescription card must be held for all medicines administered by authorised community team members. This includes medicines obtained on FP10HNC/FP10MDA/FP10SS forms. The registered nurse must ensure all medication administered to patients is regularly reviewed by discussion with the patient/carer and the prescriber. Review should be in response to individual patient needs but at least 3 monthly. Report any adverse reactions to Prescriber, Medicine Management and Medicines and Medicine Health care Regulatory Agency MHRA via a Safeguard Incident Form. To adhere to local policy and reduce risk of adverse reaction and maintain patency of device To reduce risk of harm to patients and staff. To comply with Record Keeping Policy, promote continuity of care and patient safety. 12

5. Ongoing routine care including observations and dressing Action A Peripheral Cannula Insertion and Monitoring Chart, including VIP Score, should be used for monitoring all intravenous access devices. For a peripheral cannula it needs to be updated at least once daily, or whenever being accessed for IV therapy. For a Midline peripheral catheter it needs to be updated at least once weekly, or whenever being accessed for IV therapy. A VIP score of 2 requires the removal of the device. The peripheral cannula should be replaced in a new site after 72 hours or earlier if clinically indicated. If the device is re-sited, record the new site and why (Licensed to stay in place for up to 96 hours if site is healthy and therapy due to be completed could consider leaving in situ for up to 96 hours). The transparent, IV dressing should be, intact, dry and adherent. If compromised the dressing will need to be changed using aseptic technique. Peripheral Cannula dressings should be changed if soiled or compromised, otherwise they can remain for the life of the cannula. Midline peripheral catheter dressings should be changed if soiled or compromised; otherwise they should be changed every 7 days. Cleansing of skin, should be undertaken using a Chlorhexidine Gluconate 2% with 70% isopropyl alcohol wipe for a minimum of 30 seconds and allowed to air dry for a minimum of 30 seconds. In the event of patient allergy to chlorhexidine, use povidone iodine (10% in aqueous solution) as an alternative cleanser, if compatible with equipment (see manufacturer s guidelines). Dressing: use a sterile, transparent, vapour permeable dressing. Physiological observation chart to be commenced and maintained for all patients receiving intravenous therapy. Fluid balance must be monitored and documented for all patients receiving any IV therapy. Frequency of observations to be decided upon according to individual patient Rationale To monitor the entry site to alert staff to the early signs of phlebitis. To prevent systemic infection. To reduce the risk of infection and promote patency and keep within manufactures licence. To reduce the risk of contamination thus reducing the risk of infection. To reduce the risk of contamination thus reducing the risk of infection. To reduce the risk of contamination thus reducing the risk of infection. To prevent allergic reaction To reduce the risk of contamination thus reducing the risk of infection. To enable early detection of any change in patients condition or signs of infection, complications, adverse reaction or deterioration. To reduce risk of sepsis. 13

assessment and therapy required and recorded in the patients care plan. 6. Peripheral Cannula Removal NB: Midline Peripheral Catheters can only be removed by specifically trained and competent staff in an appropriate setting. The risks associated with removal of a Midline include air embolism, and bleeding. Action The peripheral cannula should be removed if there is no continuing clinical indication. Always access peripheral cannula using aseptic technique. Collect equipment required for Peripheral cannula removal, for example a sterile pack or sterile dressing towel to create an aseptic field, gloves, disposable plastic apron, sterile gauze, hypoallergenic tape and a sharps box. Discuss removal with patient, gain consent and position patient comfortably with arm supported. D e c o n t a m in a t e hands before and after each patient contact as per hand hygiene procedure. Wearing gloves & apron gently remove dressing from site lifting the dressing up towards the cannula, and supporting the peripheral cannula throughout and dispose of used dressing into appropriate waste disposal bag. Gently pull peripheral cannula backwards and remove from the vein, using gauze for gentle pressure to the exit site. Dispose of used cannula immediately into sharps box. Apply dressing of gauze secured with hypoallergenic tape, gently but firmly over the site. Dispose of all equipment as per Handling and Disposal of waste policy Remove gloves and apron & decontaminate hands as per the Hand Hygiene Procedure. Document the removal of the peripheral cannula on the Peripheral Cannula insertion and management form, and VIP score, noting any problems encountered and their management. Rationale To reduce the risk of infection. To reduce the risk of infection. To reduce the risk of infection, and promote efficiency and reduce risk. To ensure patient is prepared and ready for procedure. To reduce the risk of infection. To avoid undue trauma. To prevent trauma and to prevent bleeding & risk of haematoma formation. To prevent cross infection and to prevent contamination by blood. To prevent infection and to prevent further bleeding. To ensure staff and patient safety and to prevent infection. To comply with Record keeping policy, promote continuity of care and patient safety. 14