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Peninsula Community Health Central Venous Catheter (CVC) Management Guidance (Excludes Dialysis Catheter)

Title: Procedural Document Type: Reference: CQC Outcome: Version: Approved by: Ratified by: Date ratified: Freedom of Information: Name of originator/author: Name of responsible team: Review Frequency: Review Date: Target Audience: Executive Signature (Hard Copy Only):

Guidelines for Central Venous Catheter Management Guidelines CG-MM-G02 Outcome 4 & Outcome 9 Version 1 IV Training Meeting Clinical Quality and Safety Committee 19th June 2012 This document can be released Andy Shaw Clinical Governance 3 Years or dependent on change in practice 19th June 2015 All Clinical Staff

Contents
1 2 3 4 5 6 7 8 Introduction ........................................................................................................ 3 Definitions .......................................................................................................... 3 Duties ................................................................................................................. 3 Central Venous Catheters .................................................................................. 5 Indications for a Central Venous Catheter.......................................................... 5 Staff Who Can Manage / Access CVCs ............................................................ 6 Insertion of CVCs .............................................................................................. 6 Care of Central Venous Catheters ..................................................................... 6 8.1 Dressings (i.e PICC & Hickman style) (refer to appendix 1)......................... 6 8.2 Flushing CVC Lines (Appendix 11 SOP 1, 2, 4)........................................... 7 8.3 Open and closed valve systems: ................................................................. 7 8.4 Locking......................................................................................................... 8 Blood Sampling from a Central Venous Catheter (SOP 3)................................. 8 CVC problems.................................................................................................... 8 10.1 Occlusions.................................................................................................. 8 Removing CVCs ................................................................................................ 9 11.1 Indications for Catheter Removal ............................................................... 9 11.2 PICC line removal ...................................................................................... 9 11.3 Documentation of line removal must include:........................................... 10 CVC Infections ................................................................................................. 10 12.1 Suspected Insertion Site Infections .......................................................... 10 12.2 Blood Cultures.......................................................................................... 10 Education ......................................................................................................... 10 13.1 Staff.......................................................................................................... 10 13.2 Patients .................................................................................................... 11 Risk Management Strategy Implementation..................................................... 11 14.1 Implementation & Dissemination ........................................................ 11 14.2 Training and Support .......................................................................... 11 14.3 Document Control & Archiving Arrangements .................................... 11 14.4 Equality Impact Assessment............................................................... 12 Process for Monitoring Effective Implementation ............................................. 12 Associated Documentation............................................................................... 12 References....................................................................................................... 12

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Please Note the Intention of this Document These guidelines have been developed to ensure that registered staff have correct and clear guidance with regards to the care, maintenance and removal of these lines.

Review and Amendment Log Version No Type of Change Date Description of change

1 Introduction
As central lines become more common place in the Cornish community it has been deemed essential that registered staff have correct and clear guidance with the care, maintenance and removal of these lines regardless from which hospital they originate. Cornwall is serviced by three main District General Hospitals (DGH) and the central venous catheter (CVC) policies/guidelines from each have been considered in the preparation of this guideline. In addition to the existing DGH policies, guidance from the Royal Marsden Manual for Clinical Nursing Procedure (2011) and EPIC2: National Evidence- Based Guidelines for Preventing Healthcare-Associated Infections have been used to establish best practice. It is applicable to all registered practitioners undertaking management of these lines.

2 Definitions
Central Vascular Catheter (CVC): Invasive catheter inserted into a large vessel ending at the superior vena cava. Flush: Method of clearing or keeping patent a CVC Lock: The amount of solution that is to be kept in the length of the line in millitres (mLs) after flushing. Clamp: A device situated on the external part of a CVC to close the line. Open system CVC: A CVC that has no internal non return valve system Closed system CVC: A CVC that has an internal device (port) that stops flash back into the line. These systems often lack the need and therefore a clamp. MVTR: Moisture Vapour Transmission rate. Term applied to occlusive transparent dressings to denote the amount of moisture that can move away from the wound/entry site reducing bacterial build up. CCAT: Central Catheter Assessment Tool used by Derriford Hospital (PHNT) to assess central lines for possible infection (similar to VIP). Clave: Proximal end catheter device to help maintain closed sterile system. Has septum and luer attachment for accepting syringes. Vacutainer: A device that allows a blood bottle to be inserted to obtain blood from lines/needles. VIP score: Visual Infusion Phlebitis score used to assess whether a CVC or peripheral invasive line is causing phlebitis.

3 Duties
The Director of Nursing and Professional Practice is ultimately responsible for the content of this policy and its implementation. PCH Directors are responsible for the implementation of this policy across all clinical services. The policy when ratified will be posted on the intranet.

Individual Matrons, Clinical Managers, Professional and Clinical Leads are responsible for ensuring staff are working to the guidance of the policy and monitoring its implementation. Clinical staff are responsible for ensuring they work within the guidance of the policy. Peninsula Community Health are responsible in partnership with the medical physics teams to ensure that all intravenous pumps are appropriately serviced annually and an audit trail is available. Peninsula Community Health are responsible for providing and ensuring that all staff using medical devices are appropriately trained (MDA 2006). All staff have a responsibility to prevent and manage healthcare acquired infection as part of The Health Act Code of Practice for the Prevention and Control of Health Care Associated Infections (Department of Health, 2006). All Healthcare Professionals have a duty of care to their patients. This is a legal and professional requirement of state registration that cannot be delegated. It is the responsibility of the healthcare professional to ensure any IV access or therapy (including delegation to another Practitioner) is performed as per PCH policy and procedures. Pharmacists are responsible for monitoring both the prescribing and the administration of Medicine therapies and alerting prescribers and other health care professionals to potential problems. Responsibilities of Registered Nurses All Registered Nursing Staff administering intravenous drugs must have current Nursing and Midwifery Council registration. Nurses are accountable for their own professional practice and must work within this policy and respective professional codes and any associated legislation. All Registered Nursing Staff are personally responsible and accountable to ensure they receive training in the safe use and observation of any medical devices they need to use (MDA2006). Nurses who have undertaken the PCH training (or satisfy the criteria for employees originating from outside the PCH). and competency may manage Central and midline catheters Nurses can administer IV medication to adult patients only, unless they have undertaken additional training and assessment. Cytotoxic IV drugs are NOT to be administered by nurses unless they have undertaken additional training and assessment. Controlled drugs must not be administered Intravenously by nursing staff in any circumstance. IV drugs can only be administered by a nurse if the procedure is within that individuals knowledge and scope of practice. All administrations must comply with the Community Health Services Policy for the Safe Ordering Prescribing and Administration of Drugs in Community Hospitals and Minor Injury Units, (April 2010) and the NMC (2008) Standards for Medicines Management. Healthcare Assistants who have completed appropriate PCH training and been assessed as competent can undertake Venepuncture. Healthcare Assistants must not administer IV medication or cannulate a patient. Healthcare Assistants are not authorised to manage any aspect of Central or midline catheters

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Band 4 Practitioners who have completed PCH training and been assessed as competent can undertake venepuncture and cannulate patients. They can administer the initial flush when the cannula is inserted, if it has been prescribed and checked by a registered healthcare professional, but are not authorised to administer any other flush or IV medication. Band 4 practitioners are not authorised to manage any aspect of Central or midline catheters Responsibilities of the medical staff Doctors must provide a clear, legal, complete and unambiguous prescription, in accordance with Community Health Services Policy for the Safe Ordering Prescribing and Administration of Drugs in Community Hospitals and Minor Injury Units, (April 2010), to guide the person involved in IV administration. Peninsula Community Health staff are not authorised to prescribe or administer controlled drugs intravenously but may act as a second checker. A Medical Practitioner may administer controlled drugs intravenously in an emergency. It is recommended that complex IV drug calculations are checked by a second person (either a medical practitioner or a registered nurse) before administration (NMC, 2008) Nominated Community Health Services Dental Practitioners may prescribe and administer IV Midazolam for conscious sedation, following General Dental Council guidance. Two registered dental nurses must be in attendance, one of whom must hold a post qualification certificate in conscious sedation (NEBDN). NB: The use or continuation of the IV route is justified only where there is a clear benefit to the patient. Therefore, reassessment every 48 hours and documentation of the decision should be completed and alternative administration routes should be considered if necessary. Students Students are not permitted to administer any Intravenous medication or fluids and as such are not permitted to access CVCs. They may act as a second checker for medication where calculations are not required.

4 Central Venous Catheters


A central venous catheter is threaded into the central vasculature. A CVC tip will always be in the superior vena cava (SVC) or right atrium (Dougherty & Lister, 2011). Due to the location of the tip, a closed system is used and strict asepsis is required. Three way taps are not to be used in a community setting and if present should be removed immediately and replaced with a non return valve and reported on Datix Incident reporting system.

5 Indications for a Central Venous Catheter


In the case of poor peripheral access, a midline must be considered before a central venous catheter. Indications for a central venous catheter include:

To provide long-term access (greater than 4 weeks) for repeated transfusions of blood, blood products (as indicated by consultant) Parenteral nutrition Cytotoxic or antibiotic therapy or where a midline is clinically inappropriate. To provide reliable access for: Hydration or electrolyte maintenance Administration of drugs harmful to peripheral veins, such as potassium chloride

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Repeated specimen collection

6 Staff Who Can Manage / Access CVCs


Staff managing CVCs in the PCH must fulfil the following criteria: Are a registered healthcare professional Have successfully completed PCH Intravenous Drug (I.V.) therapy course and fulfilled the PCH competency assessment Must have completed further training in the management of central lines Have been assessed as competent in the management of these devices

7 Insertion of CVCs
A CVC line will only be inserted in an acute setting unless specific arrangements have been made with the acute care team for insertion in a community hospital. In the case of the latter X-ray facilities must be available on site. A detailed care plan must support the insertion for care and maintenance of the device.

8 Care of Central Venous Catheters


8.1 Dressings (i.e PICC & Hickman style) (refer to appendix 1)
The central venous catheter (CVC) / central venous access device (CVAD) must be carefully observed to assess if the dressing is intact and to detect any early signs of infection e.g. redness and warmth. No antimicrobial ointments should be used on the catheter site ANTT with sterile gloves must be used for all CVC dressings and procedures (see Appendix ). A Chloraprep applicator of 3mL Chlorhexidine 2% in Alcohol 70% must be used to clean the skin area before new dressing is applied. The dressing of choice is the Central Line I.V. 3000. This dressing has a high Moisture Vapour Transmission Rate (MVTR) which helps remove moisture build up and therefore reducing the ideal environment for bacteria. The site must be observed for erythema or inflammation and the Visual Infusion Phlebitis (VIP) or Central Catheter Assessment Tool (CCAT) (Appendix 1-1/2) score should be indicated in the care plan each time the device is accessed or at minimum daily or as condition dictates. In the community an appropriate person to monitor the site may be the patient or carer. Peripherally Inserted Central Catheters (PICC) are not stitched in place and require securing. Devices used for this range from the clear occlusive dressing and in addition a grip lock below.

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Grip-Lok is a flexible low profile PICC and Midline catheter securement device specifically designed for maximum patient comfort, compatible with most PICC and Midlines.

8.2 Flushing CVC Lines (Appendix 11 Standing Operating Procedures 1, 2, 4)


Before accessing the line a visual check of the site must be undertaken and the VIP/ CCAT score documented in patient care plan. All lumens must be flushed with 10-20mL sterile Sodium Chloride 0.9% before and following each drug administration and following blood sampling. Heparin should not be used as an end lock unless otherwise indicated by the Acute Trust and as a double precaution to catheter blockage. Where there is directive in the care plan requiring Heparin a rationale must be supplied with a full prescription of the exact amount of Hepsal/Heparin required in strength and amount in mLs. Where Heparin lock is prescribed this should initially be prescribed and supplied by the acute trust Implanted Ports (Portacaths) are the only central lines where Heparin is regularly prescribed from NDDH/RCHT/PHNT as a lock. On occasions a needle can be left in situ, When the needle is taken out a Heparin 100iu/mL is used and when needle is left in 10iu/mL is used. All Flushes to a CVC must be prescribed. A 10mL (or larger) luer lock syringe must be used with a pulsated push-pause (startstop) technique and maintain positive pressure on the syringe when closing the clamp and before removing the syringe. Maintaining a positive pressure is essential to stop clots forming in the tip of the catheter. Ensuring the clamp remains closed before attaching the luer lock syringe into the septum of the clave will ensure a closed system is maintained. This will reduce the risk of air emboli in the system.

8.3 Open and closed valve systems:


Some central lines have a non return valve in the system and it can be at either the proximal or distal end of the catheter.

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In these cases where there is a valve there may be some lag when drawing back and testing for patency, so be patient. Some closed systems lack a clamp as it is not required. So therefore an open system may require a Heparin lock which must be prescribed as above.

8.4 Locking
The lock is what is intentionally left in the line to keep it patent. Sometimes this is done with Heparin. It is important to note that Heparin is never to be used to flush the line and the amount of lock should only be that of the line in mLs. This amount depends on line length and if indicated this should be in the care plan and prescribed Always attempt to aspirate any Heparin lock before use of the line, discuss with consultant whether Heparin can be flushed into patient when aspiration is not possible. The rationale for Heparin use should come from a consultant who would have considered the risk of Heparin Induced Thrombocytopenia (HIT). A flush will clear the line. When using a saline flush only, this acts as the lock providing the clamp is applied during the last 1-2mLs under positive pressure.

9 Blood Sampling from a Central Venous Catheter (SOP 3)


Blood collection procedure applies for all sampling and the PCH policy must be adhered to whether peripheral or CVC. Sampling from a central line must only be performed when no other access is available or appropriate. This must only be undertaken by practitioners who have been assessed as competent to undertake the procedure. In adults, the Vacutainer system must be used using ANTT. All infusions via the line to be used must be stopped for 15 minutes before sampling. The first 5mLs of blood must be withdrawn (using blood bottle) and discarded (except for blood cultures). The adapter needle (blue) must be attached for Vacutainer use. On completion flush with at least 10mL Sodium Chloride 0.9% (unless specified otherwise) is required to keep the line patent using the previous technique. (Refer to SOP3 in this document)

10 CVC problems
10.1 Occlusions
Occlusion rates within CVCs are low, but it is still the most common non-infectious complication. Signs of a catheter occlusion include: Inability to flush Inability to aspirate lock or withdraw blood although flushing may be possible Sluggish or intermittent free flow of fluids If the CVC is occluded try: Un-kink the line

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Undo the clamp Get patient to cough Try to aspirate and clamp. Flush the line after unclamping Get patient to move position Use a push pull technique with the flush Urokinase is not to be used in a home situation. In a community hospital discuss use with the doctor and if indicated administer using method described in the Royal Marsden Manual.

Occlusions can be described as either partial or complete; in either case it is important to ascertain the cause of the occlusion before taking appropriate action. In situation where there is a total blockage discuss with relevant doctor and consider removal.

11 Removing CVCs
11.1 Indications for Catheter Removal
The catheter should only be removed in the following circumstances after Consultant opinion has been sought: Patient preference Short term catheter Suspicion of complicated infections e.g. Septic thrombosis, endocarditis, osteomyelitis or possible metastatic seeding Confirmed staphylococcus aureus infection Confirmed fungal infection

11.2 PICC line removal


When instructed or a clinical need is assessed by a Consultant a registered Practitioner who has been deemed competent can remove a PICC line in a community hospital. Due to possible complications this is not to be done in a home setting. This procedure is done using ANTT. Determine the patients clotting status/INR If possible lie patient down or position entry site so that it is lower than the heart Using ANTT expose line and prepare sterile field Measure line and compare to care plan Clamp the line (avoids air emboli) Using ANTT gently remove line using a steady and constant motion until line is completely removed Apply digital pressure to the site for approximately 2-5 minutes to stop bleeding and air entry Check length of line is the same length as when inserted by measuring Apply sterile dressing and observe for further bleeding If infection is suspected remove 5cm of tip using sterile scissors and send to microbiology for investigation If resistance is felt stop. Apply warm towel to arm and attempt after approx 20 mins. If thrombus or a broken line is suspected stop, seek medical assistance. Patient will have to be thrombolised before removal.
*Tunnelled lines / implanted ports require surgical removal at an appropriate location. Multiple lumen lines in the Internal Jugular should not be in the community but are removed using a Val Salva technique refer to Royal Marsden. Advice from Acute Trust should be sought.

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11.3 Documentation of line removal must include:


Reason for removal Length of catheter removed (which must be checked against insertion information) Confirm if the catheter tip has been sent for culture Technique used

12 CVC Infections
Infection is one of the most frequently reported complications of CVCs. If a catheter related blood stream infection is suspected or confirmed, alternative vascular access should be sought until the issue is resolved. The following guidance represents current best practice however; practitioners should seek guidance from appropriate medical staff, Infection prevention & control team, microbiology team and pharmacist. Practitioners need to audit their own practice as part of infection prevention measures by completing a Central catheter form, Each time a port is accessed there is a risk of infection. This guideline mandates ANTT when accessing a CVC which will further reduce the risks of bacteraemia in lines. The method of cleaning ports and hubs prior to access is the same as all vascular access devices. A Chlorhexidine 2% and Alcohol 70% (PDI or Clinell wipe is to be used. For patients where there is an allergy/reaction likely to Chlorhexidine, a Povidine Iodine 10% aqueous solution should be used.

12.1 Suspected Insertion Site Infections


A swab must be taken from the insertion site before commencing systemic antibiotic therapy. If a swab is taken the result must be followed up within 48 hours and discussed with the Medical Management Team. A daily assessment including VIP, Temperature, Pulse, Respirations and dressing change to be initiated.

12.2 Blood Cultures


Where a catheter related blood stream infection is suspected a minimum of two blood culture samples are required. The cultures must be taken using a closed system. One set of cultures must be taken from the CVC (or a sample from each lumen) and the other taken peripherally before commencing antibiotic therapy. This is a procedure to be undertaken by medics only.

13 Education
13.1 Staff
All registered practitioners accessing CVCs should be fully trained in intravenous infusions, be deemed competent to PCH standards and have had additional teaching

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and local assessment by a registered healthcare practitioner who themselves have experience in caring for CVCs. Staff should also have completed the PCH infection control and ANTT training and be fully up to date with Anaphylaxis training. Training for CVC management will be provided by the IV link trainers Additional training may be required when accessing implanted ports and where an opportunity arises to gain this from an acute setting prior to discharge the staff should be encouraged to take the opportunity.

13.2 Patients
If patients/carers are deemed able to self manage the CVC they should be made fully aware of the risks involved. They must be given advice and taught how to care for the line safely during their hospital stay and following discharge. The patient (and carer/other if appropriate) must be given advice verbally and this should be supported by written information in a format they understand. Contact details for 24 hour advice must be provided in case the patient has any concerns regarding line care. A full care plan/information pack must accompany the patient on discharge and the Community Teams must be included in the discharge planning. Dressing change must be done by the District Nurses/Community Matron when a patient is outside the hospital environment due to the risk of potential infection or displacement.

14 Risk Management Strategy Implementation


14.1 Implementation & Dissemination

Via professional practice group, Intravenous therapy link nurses, educators, clinical leads, matrons, ward managers and through training department

14.2

Training and Support

Refer to section 13 for further details

14.3

Document Control & Archiving Arrangements

Once ratified, these guidelines will be loaded to the documents library. Any previous versions will be electronically archived by the Policy Administrator in the electronic Policy Drive Archive Folder. A signed hard copy of the guidelines will be forwarded to the Policy Administrator and an electronic copy will be saved by the Policy Administrator in the electronic Policy Drive. Further copies of current and archived policies can be obtained from the Policy Administrator including versions in large print, Braille and other languages.

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14.4

Equality Impact Assessment

Peninsula Community Health aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. As part of its development, this strategy and its impact on equality have been assessed. The assessment is to minimise and if possible remove any disproportionate impact on employees on the grounds of race sex, disability, age, sexual orientation or religious belief. No detriment was identified.

15 Process for Monitoring Effective Implementation


By use of the annual audit of the infection prevention society audit tools. Results of these audits will be presented to Professional Practice forum.

16 Associated Documentation
This document references the following supporting documents which should be referred to in conjunction with the document being developed. PCH Intravenous drug Administration and Vascular Access Policy (2012) PCH Infection control Policy PCH Waste management Policy PCH Blood Transfusion Policy Safe Ordering Prescribing and Administration of Drugs in Community Hospitals and Minor Injury Units, (April 2010) All professional codes/ standards of practice All relevant Patient Group Directions

17 References
Department of Health (2001) Guidelines For Preventing Infections Associated With The Insertion And Maintenance Of Central Venous Catheters. Department of Health, London Department of Health (2006) The Health Act: Code for the Prevention of Hospital Acquired Infections. Department of Health, London Department of Health (2007) High Impact Intervention No. 1 Central Venous Catheter Care Bundle. Department of Health, London Department of Health (2007) Taking Blood Cultures. Department of Health, London Accessed at: http://www.cleansafcare.nhs.uk/toolfiles/105_283198BC_blood_cultures.pdf National Institute for Clinical Excellence (NICE) (2003) Infection Control Prevention of Healthcares Associated Infections in Primary and Community Care. NICE, London

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Pratt R.J. et al (2007) Epic 2. Guidelines for Preventing Health Care Associated Infections in NHS Hospitals. The Journal of Hospital Infection. 65s, S1-S64 Accessed at: http://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2-final.pdf Royal Marsden Hospital (2010) The Royal Marsden Manual of Clinical Nursing Procedures. London. 6th Edition. Published by Blackwell Science. Chapter 44. Royal College of Nursing (RCN) (2010) Standards for Infusion Therapy. Royal College of Nursing, London. Skills for Health (2007) CHS75: Insert a Central Venous Access Device. Skills for Health, London Accessed at: http://tools.skillsforhealth.org.uk/competence/show?code=CHS75 Rapid Response Report: Risks with Intravenous Heparin Flush Solutions (Reference: NPSA/2008/RRR02) issued on 24 April 2008 PHNT Intravenous Policy http://nww.picts.nhs.uk/PHNetLive/DesktopDefault.aspx?tabid=1731 http://www.plymouthhospitals.nhs.uk/ourservices/clinicaldepartments/Pages/VascularAccess Team.aspx PHNT Vascular access guidelines 2011 PHNT I.V. Policy PHNT Vascular Access Team- Information guides

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Appendix 1

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Appendix 2

Reference Guide for Peripherally Inserted Central Catheters (PICCs)


Indications: Securing the Line: Patient requiring regular central access for longer than 4 weeks Securing device e.g. Statlock/ Griplock, remain in place as long as the catheter is in situ. Securing devices are preferred to sutures due to infection risk 2,13,. These devices will need to be changed weekly in accordance with manufacturers instructions Site must be cleaned with a 3ml applicator of 2% Chlorhexidine in 70% alcohol e.g. Chloraprep and left to dry. (Povidine iodine 10% solution if patient Chlorhexidine General sensitive) A sterile dressings pack must be used for all line care Visual phlebitis (VIP) (CCAT) score must be documented within the patient record. Dressings: Post Insertion If wound oozing or bleeding, sterile gauze should be used. Dressing must be checked and replaced 24-48 hours post insertion or sooner if integrity compromised. Once oozing/bleeding stopped transparent permeable dressing can be used. Wound/ catheter site inspected daily in acute setting, weekly Continued Care in the community. Change dressing using sterile technique cleaning with a 3ml 2% Chlorhexidine in 70% applicator FLUSH LOCK 5-10mLs 0.9% w/v sodium Chloride (the last 1-2mLs being the lock) Once weekly as above if not in frequent use21.

Patency:

Manipulations of the line should be kept to a minimum Accessing the Line Sterile technique must be used. Needleless connectors to maintain closed system with a 10 ml syringe or larger Access points must be decontaminated with 2% Chlorhexidine in 70% alcohol e.g. Sanicloth All care (insertion, maintenance, access) must be documented within the patient record. A Documentation Contact Details visual phlebitis (VIP) or (CCAT) score must be recorded at each observation/ access of the line. Measure external line at each visit and document Designated consultant lead for the line/ vascular access team.

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2R2 Reference Guide for Tunnelled Central Lines

Indications:

Patient requiring regular central access for longer than 4 weeks Site must be cleaned with at least a 3ml applicator of 2% Chlorhexidine in 70% alcohol e.g. Chloraprep and left to dry. (Povidine iodine 10% solution if patient Chlorhexidine General sensitive) A sterile dressings pack must be used for all line care Visual phlebitis (VIP) or (CCAT)score must be documented within the patient record. If wound oozing or bleeding, sterile gauze should be used. Dressing must be checked and replaced 24-48 hours post insertion or sooner if integrity compromised. Once oozing/bleeding stopped transparent permeable dressing can be used. Wound inspected daily in acute setting, weekly in the community Dressing to be changed every 7 days (or sooner if required). Continued Care Tunnelled CVCs may not require a dressing once the exit sutures have been removed2; (the patient age, patient choice and the risk of infection must be considered before this decision is made). Open (un-valved) Systems FLUSH 10mLs of 0.9% w/v sodium chloride LOCK ONCE WEEKLY IF NOT IN FREQUENT USE WITH 2-3mLs Heparin Solution (Heparin 10units/mL) if indicated in care plan Using positive pressure cap FLUSH & LOCK 10-20mLs 0.9% w/v sodium chloride (lock= last 1-2mLs)

Dressings:

Post Insertion

Patency: Closed (valved) systems

Manipulations of the line should be kept to a minimum Accessing the Line Sterile technique must be used. Use needleless connectors to maintain closed system with a 10 mL syringe or larger Access points must be decontaminated with 2% Chlorhexidine in 70% alcohol e.g. Sanicloth Documentation All care (insertion, maintenance, access) must be documented within the patient record. A visual phlebitis score (VIP) or (CCAT) must be recorded at each observation/ access of the line. Designated consultant lead for the line.

Contact Details

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2R3 Reference Guide for Implanted Ports


Indications: Securing the Line: Site must be cleaned with 3ml applicator of 2% Chlorhexidine in 70% alcohol e.g. Chloraprep and left to dry. (Povidine iodine 10% solution if patient Chlorhexidine General sensitive) A sterile dressings pack must be used for all line care Visual phlebitis (VIP) or (CCAT) score must be documented within the patient record. Dressings: Post Insertion If wound oozing or bleeding, sterile gauze should be used. Dressing must be checked and replaced 24-48 hours post insertion or sooner if integrity compromised. Once oozing/bleeding stopped and area has healed, no further dressing is required. Continued Care Site inspection required when accessing the line. Patient requiring regular central access for longer than 4 weeks Fixed under the skin with dissolvable sutures.

FLUSH Patency: 4 WEEKLY LOCK IF NOT IN FREQUENT USE Accessing the Line Sterile technique must be used.

5-10mL of 0.9% w/v sodium chloride and use Heparin 10 units/mL If needle left in 4-6mLs of heparin solution (Heparin 100 units/mL) direct into port

Manipulations of the line should be kept to a minimum Access using specialised non-coring needles and extension sets (e.g. Huber) with a 10 mL syringe or larger Access points must be decontaminated with 2% Chlorhexidine in 70% alcohol Documentation Contact Details All care (insertion, maintenance, access) must be documented within the patient record. A visual phlebitis score (VIP) must be recorded at each observation/ access of the port. Designated consultant lead for the line.

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Appendix 3
Procedure Equipment and documentation:

Standard Operating Procedure for Flushing PICC line


Rationale To prepare for task

CVC SOP1

Sterile dressing pack, Hand cleanser, Non sterile gloves, 10ml luer lock syringe, drawing up needle,10-20mls 0.9%Sodium Chloride flush, 2% Chlorhexidine 70% Alcohol wipe x 2, sharps bin, secondary securing dressing, care plan, prescription chart 1. Wash hands apply gloves and apron and gain informed consent

2. Prepare sterile field and equipment 3. Expose line and switch off any infusion and observe VIP/CCAT score whilst measuring external length of line 4. Clamp line and using ANTT disconnect any infusion seal giving set end with sterile Bung 5. Remove gloves, wash hands and apply sterile gloves and apron. 6. Prepare flush using sterile gauze to open flush 7. Using sterile gauze pick up clave end and clean with wipe for 30 seconds and allow drying for at least 30 seconds. 8. Attach syringe using luer locking system unclamp line and using a push pause technique flush the line with 10mls 9. Toward the last 1-2 mls clamp line but continue to flush 10. Use second wipe to clean end as before 11. Apply secondary dressing (Loose Bandage, tube fast) 12. Dispose of all sharps and document action in care plan

To reduce risk of cross contamination and gain patient co-operation with the knowledge they or their carer understand the rationale for the task Advanced preparation for task and reduce risk of contamination To allow easy access when sterile and reduce risk of infusion drips on sterile field. Note early signs of phlebitis. Determine if line has moved Allow access to port and reduce risk of contamination Reduce risk of contamination Reduce risk of contamination Reduce risk of contamination Maintain a closed system and keep line patent by creating turbulence in order to flush line thoroughly To lock the system under positive pressure reduce risk of backflow and clot formation Reduce risk of contamination To protect from snags Reduce risk of contamination to others and maintain continuous record

*PHNT and Royal Marsden guidelines

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Standard Operating Procedure for Flushing Tunnelled Line (Hickman)


Procedure Equipment: Sterile dressing pack, Hand cleanser, Non sterile gloves, 10ml luer lock syringe, 10-20mls 0.9%Sodium Chloride flush, 2% Chlorhexidine 70% Alcohol wipe x 2, sharps bin, secondary securing dressing, care plan, prescription chart 1. Wash hands apply gloves and apron 2. Prepare sterile field and equipment 3. Expose line and switch off any infusion and observe VIP/CCAT score 4. Clamp line and using ANTT disconnect any infusion, seal giving set end with sterile Bung 5. Remove gloves, wash hands and apply sterile gloves and apron. 6. Prepare flush using sterile gauze to open flush 7. Using sterile gauze pick up clave end and clean with wipe for 30 seconds and allow drying for at least 30 seconds. 8. Attach syringe using luer locking system unclamp line. Draw back if possible to test and using a push pause technique flush the line with 10mls 9. Toward the last 1-2 mls clamp line but continue to flush 10. If Heparin is used, use only required amount to lock e.g. 2-3mls 11. Use second wipe to clean end as before 12. Apply secondary dressing if required 13. Dispose of all sharps and document action in care plan Rationale To prepare for task

CVC SOP2

To reduce risk of cross contamination Advanced preparation for task and reduce risk of contamination To allow easy access when sterile and reduce risk of infusion drips on sterile field. Note early signs of phlebitis. Allow access to port and reduce risk of contamination Reduce risk of contamination Reduce risk of contamination and maintain sterile filed Reduce risk of contamination

Maintain a closed system and keep line patent by creating turbulence in order to flush line thoroughly (if line contains Heparin, dispose of amount drawn back) To lock the system under positive pressure reduce risk of backflow and clot formation To ensure line remains patent and Heparin is not used as a flush Reduce risk of contamination Comfort Reduce risk of contamination to others and maintain continuous records

*PHNT and Royal Marsden guidelines

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Standard Operating Procedure for Taking blood via CVC (Discard Method)
Procedure Equipment: Sterile dressing pack, Hand cleanser, Non sterile gloves, Vacutainer, Blue needle adaptor, spare 5ml blood bottle for discarding or 10ml luer lock syringe, required blood bottles, x 2 10 ml 0.9%Sodium Chloride flush, 2% Chlorhexidine 70% Alcohol wipe x 2, sharps bin, care plan, prescription chart 1. Wash hands apply gloves and apron 2. Prepare sterile field and equipment 3. Expose line and switch off any infusion and observe VIP/CCAT score 4. Clamp line and using ANTT disconnect any infusion, seal giving set end with sterile Bung 5. Remove gloves, wash hands and apply sterile gloves and apron. 6. Prepare flush using sterile gauze to open flush 7. Place sterile towel under port/s 8. Using sterile gauze pick up clave end and clean with wipe for 30 seconds and allow drying for at least 30 seconds. 9. For Vacuum sampling: Attach Vacutainer system to port unclamp line. Place 5ml blood bottle into Vacutainer and fill with blood then discard properly 10. Attach sample bottles for requested samples in correct order and label as soon as possible, clamp on completion 11. Remove Vacutainer system and discard appropriately 12. Attach 2nd flush syringe, unclamp and flush with a full 10mls using a push pause technique clamping on final 1-2mls 13. Use second wipe to clean end as before. 14. Dispose of all sharps and document action in care plan 15. Ensure blood labels are done at bedside as soon as possible following action *Royal Marsden Guidelines Rationale To prepare for task

CVC SOP3

To reduce risk of cross contamination Advanced preparation for task and reduce risk of contamination To allow easy access when sterile and reduce risk of infusion drips on sterile field. Note early signs of phlebitis. Allow access to port and reduce risk of contamination Reduce risk of contamination Reduce risk of contamination and maintain sterile filed Reduce risk of contamination and maintain sterile filed Reduce risk of contamination Maintain a closed system and remove any Heparin/Saline from line which can cause result inaccuracies To obtain sample. It is not necessary to clamp between samples, clamping at end maintains closed system To prevent loss of blood and reduce risk to others Maintain line patency and obtain a positive pressure in line Reduce risk of contamination Reduce risk of contamination to others and maintain continuous records Reduce risk of wrong patient labelling

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Standard Operating Procedure for Flushing Implanted Ports (Portacaths) CVC SOP4
Procedure Rationale To prepare for task Equipment: Open and prepare; Sterile dressing pack, Hand cleanser, Non sterile gloves, x2 10ml luer lock syringe, 10-20mls 0.9%Sodium Chloride flush, 2% Chlorhexidine 70% Applicator 3 ml, sharps bin, non coring Huber needle with extension set, care plan, cover dressing if required, prescription chart 1. Wash hands apply gloves and apron To reduce risk of cross contamination 2. Prepare sterile field and equipment Advanced preparation for task and reduce risk of contamination 3. Expose port area and observe for any redness or To allow easy access and note any signs of infection swelling in area 4. Apply topical anaesthetic solution if patient requires 30- To reduce feeling of pain on insertion of needle 60 minutes prior to access 5. Locate port and septum and assess thickness of skin. To select correct length of Huber needle to insert Refer to care plan 6. Wash hands and put on sterile gloves Reduce risk of contamination and maintain sterile filed 7. Flush port needle and extension set Check patency of needle and set 8. Clean port area of skin with applicator in a cross hatch To minimize risk of contamination and destroy skin flora fashion 9. Ready the patient and explain you are about to insert Prepare patient and ensure needle is well inserted into portal needle and push needle into port through the skin until it touches back plate 10. Draw back on the syringe and check for blood return 2- To check needle is correctly placed 3mls . Dispose of Heparin mix blood solution. 11. Flush and observes any sign of swelling Check fro patency and correct positioning 12. If needle is not to remain in place monthly To maintain patency over long periods of time (PHNT Guidelines for flushing and locking central maintenance flushes should be done with 0.9% saline and lines) locked with Heparinised saline 100iu/ml . When needle is to remain in place flush with saline then lock with (See guidelines for explanation of lock) appropriate volume of 10iu/ml heparin. 13. Maintain pressure on plunger as syringe is To prevent backflow of blood and possible clot formation disconnected from injection cap 14. Remove needle and discard. Document needle size Reduce risk of contamination to others and maintain continuous records and number of attempts on care plan 15. No dressing is required but a small plaster may be To prevent oozing from site used *The Royal Marsden Manual of Clinical Nursing Procedures 2010

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Appendix 4

Central Catheter Care & Audit Form

This form acts as an ongoing care and audit form. On completion copy this form and send it to the infection control team and file the original into the patients notes.

Patient Name.NHS/Hospital No.D.O.B. Type of central lineReason Location on body .. Name of Hospital Line inserted at Care plan from insertion clinician/wardY/N
Date Time Patient Temp VIP score Primary dressing changed using a sterile technique Clave changed For PICC lines: Measurement out of arm @ exit Access port cleaned with Chlorhexidine wipe Sterile Procedure Used for Flush Y/N Heparin used as lock & Strength Positive pressure on completion of flush Clinician Name

*Now send a copy of this form to Infection control and file original in patients notes.

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Appendix 5

Types of Central Venous Catheters

CVC Device

Use
Inserted via the antecubital veins in the arm and advanced into central veins until the tip is in the superior vena cava. Its position must be checked by chest Xray Inserted directly into the vein, these devices are mainly used in theatres and intensive care units for therapies of less than 3 weeks duration. It has a lifespan of 5-7 days but can remain insitu for up to 14 days (check manufacturers instructions). Not placed directly into vein but are tunnelled through the skin for approx 5cm, the tunnel reduces the risk of infection.

Picture

Location

Advantages
1.Ease of insertion and removal 2.Fewer insertion complications 3.Low incidence of related infection/thrombosis 4. Can be used in home setting 1.Can be inserted at bedside 2. Good access, several lumens 3. High flow continuous access

Disadvantages
1. Smaller lumen/flow 2. Mechanical Phlebitis at insertion site 3. Problems with kinking

Peripherally inserted central catheter (PICC)

Non tunnelled central venous catheter e.g. Hohn catheter, Triple Iumen catheter

1. Highest rate of all CVC infections 2. Requires external sutures 3. Uncomfortable for patients 4. Requires frequent changing 5-7 days 5. Difficulty maintaining exit/dressing site

Tunnelled central venous catheter e.g. Hickman, Groshong and Broviac line

1.Low infection rate 2.Patient comfort 3. No external fixation 4. Long term

1. Surgical incision 2. Requires surgical removal 3. External portion of catheter visible

Error!
Totally implanted vascular access device that is inserted into the chest wall, lower ribcage or antecubital area. The port is accessed via a noncoring (huber point) needle.

Subcutaneous Port e.g. Port-a-cath

1. Patient comfort no external sutures 2. No exit dressing required 3. Requires less maintenance

1. Use of needle to access port 2. Local skin ulceration through repeated use 3. Shorter life span than a tunnelled CVC 4. Requires surgical removal

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Competency for Managing a Central Venous Catheter for I.V. trained staff
Competency Understands the vascular system in relation to a CVC Outcome Remarks

Appendix 6

Can identify and use all equipment required for accessing a CVC

Understands and explains the difference between ANTT non sterile and sterile Can identify and explain the different types of CVC Has read the PCH CVC guidelines Understands the rationale for using a CVC Using the Standing operational procure in the PCH guidelines, can manage a CVC in a safe and sterile way

Uses a CVC correctly and understands the term Flush and Lock Uses the care/audit plan effectively Can exp[lain and safely remove non tunnelled CVC line Has changed CVC dressing using a sterile technique Disposes of waste safely and appropriately

*These competencies can only be fulfilled if the registered staff member has shown they are competent to manage peripheral I.V. catheters, completed ANTT training and fully read and understood the CVC guidelines.

Name of person being assessedGrade Assessor NameGrade.. Date.

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Equality Impact Assessment Tool


To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Yes No X
1. Does the document/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay, transgender and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems (including gypsies and X X X X X X X X X

Comments

2. 3.

Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? Is the impact of the document/guidance likely to be negative? If so, can the impact be avoided? What alternative is there to achieving the document/guidance without the impact? Can we reduce the impact by taking different action?

X X

4. 5. 6. 7.

X N/A N/A N/A

If you have identified a potential discriminatory impact of this procedural document, please refer it to the Equality and Diversity lead, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact the Equality and Diversity lead.

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