IV POLICY – INTRAVENOUS (IV) MEDICATION AND FLUID THERAPY ADMINISTRATION THROUGH A CENTRAL VENOUS ACCESS DEVICE (CVAD)

POLICY Reference CPG-TW-CVAD Approving Body Drugs & Therapeutics/Medicines Optimisation Committee Date Approved 13th July 2018 Issue Date 21st September 2018 Version 1.0 Summary of Changes from Previous Not applicable Version Supersedes Not applicable Document Category  Policy Consultation Undertaken Tracy Smith: Ward Leader Meeting 1:1 Welcome Treatment Centre 16/5/18 25/5/18 14/08/18 Email: 1/6/18 Meeting: 4/9/18 Meeting 11/9/18 Tom Bell: Divisional Lead Meeting 1:1 Pharmacist for Surgery Division and 5/8/18 Women & Children’s Division Email:16/8/18 Critical Care Lead Pharmacist Mandy Coggon: Clinical Educator Meeting 1:1 ICCU 10/5/18 Email:10/4/18 Emaill:1/6/18 Hazel Saddington: Nutritional Nurse Meeting 1:1 Specialist Email:10/4/18 Email:1/6/18 Helen Hume: Training and Email:1/6/18 Development Meeting 29/8/18 Meeting 11/9/18 Elwin Masih: Training and Meeting Development Email:10/4/18 Email: 1/6/18 Justin Wyatt: Ward Leader WD 43 Meeting Email:10/4/18 Email: 1/6/18 Christopher Smith: Emergency Meeting ODP Team Leader Email:10/4/18 Email:1/6/18 Rosie Dixon: Nurse consultant Email:10/4/18 infection Prevention and Control Email:1/6/18 Email : 7/9/18 Steve May: Chief Pharmacist. Email: 10/4/18 Email:1/6/18

Title: IV Policy - Intravenous (IV) Medication and Fluid Therapy Administration Through a Central Venous Access Device Version: 1.0 Issued: September 2018 Page 1 of 73

Carl Miller: Superintendent Email: 8/6/18 Radiographer Joanna Freeman: Highly specialist Email: 26/6/18 Pharmacist Nursing, Midwifery and Allied Meeting: 15/6/18 Health Professional Board Kelly Mitchell: Training and Email:10/4/18 Development Paediatric Governance Group Email Kerry Morris PDM Meeting Michael Yanney Consultant 28/08/2018 Paediatrician 2/8/18 & Bernadette Barlow Paediatric- 22/8/18 Respiratory Specialist Nurse 23/8/18 Andrea Rumsby (Deputy Sister) 22/8/18 TIVAD Robert Gullett-Smith (Deputy element only Charge Nurse) Carol Hind (Acting 23/8/18 Deputy Sister) Diane Parsons (Deputy Sister) 24/8/18 Verbal consultation/review Sarah Limb (Sister) 25/8/18 Meetings with corporate Matrons: 26/8/18

28/8/18.

2/5/18 (RH) 9/6/18 (RH) 23/6/18 (RH) 6/7/18 (RH) 28/8/18 (AD)

Janice Mighten,(Children’s Email 30/8/18 Respiratory Nurse) Nottingham Children’s Hospital 7/9/2018 Final email sent for final comments Date of Completion of Equality Impact 18/8/2018 Assessment Date of Environmental Impact Not applicable Assessment (if applicable) Legal and/or Accreditation Not applicable Implications Target Audience Registered Nurses and Midwives, Operating Department Practitioners, Medical Staff , Allied Health Professionals Review Date July 2021 Sponsor (Position) Suzanne Banks, Chief Nurse Andy Haynes, Medical Director Author (Position & Name) Yvonne Christley (Head of Professional Practice Development) Rebecca Herring (Practice Development Matron) Alison Davidson (Practice Development Matron) Kerry Morris (Paediatric Practice Development Matron) Kate Rodgers (Neonatal Practice Development Matron)

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Lead Division/ Directorate Corporate Lead Specialty/ Service/ Department Nursing/ Practice Development Team Position of Person able to provide Practice Development Team Further Guidance/Information Associated Documents/ Information Date Associated Documents were reviewed

Not Applicable Not Applicable

CONTENTS

Item Title Page

1.0 INTRODUCTION 6 2.0 POLICY STATEMENT 7 3.0 DEFINITIONS/ ABBREVIATIONS 7-8 4.0 ROLES AND RESPONSIBILITIES 8-9 5.0 APPROVAL 9 6.0 DOCUMENT REQUIREMENTS 10-14 7.0 MONITORING COMPLIANCE AND EFFECTIVENESS 15 8.0 TRAINING AND IMPLEMENTATION 16 9.0 IMPACT ASSESSMENTS 16-18 10.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) and 19-22 RELATED SFHFT DOCUMENTS APPENDICES AS LISTED BELOW

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APPENDICIES

11.0 APPENDIX ONE: (ADULT PROCEDURAL GUIDANCE) 23-43 Central Venous Catheters (CVC). 11.0 Dressing change for a CVC 11.1 Changing needle free access devices for a CVC 11.2 Administration of intermittent/bolus Intravenous Medication via a CVC 11.3 Administration of Continuous Infusions via a CVC 11.4 Disconnecting an intravenous infusion from a CVC Adult Procedural Guidance for PICC Lines 11.5 Dressing Change for a PICC Line 11.6 Changing the Needle Free Access Device via a PICC line 11.7 Administration of intermittent/bolus Intravenous medication via a PICC Line 11.8 Administration of Continuous Infusions via PICC Line 11.9 Disconnecting an Intravenous Infusion from a PICC Line Adult Procedural Guidance for Hickman Lines (skin tunneled catheters) 11.10 Dressing Change for a Hickman Line 11.11 Changing the Needle Free access Device for a Hickman Line 11.12 Administration of intermittent/bolus Medication via a Hickman 11.13 Administration of Continuous Infusions via a Hickman Line 11.14 Disconnecting an Intravenous Infusion from a Hickman Line Adult Procedural Guidance for Port Access Device (Portacath) 11.15 Insertion of a Gripper Needle/non –coring needle 11.16 Changing the Needle Free Access Device for an Implanted Port 11.17Administration of intermittent/bolus Intravenous Medication for an Implanted Port 11.18 Administration of Continuous Infusions via an Implanted Port 11.19 Disconnecting an Intravenous Infusion from an Implanted Port 11.20 Removal of a Gripper Needle(non –coring) needle from an Implanted Port Adult Procedural Guidance for Midline Catheters (Midline) 11.21 Dressing Changes for a Midline catheter 11.22 Changing the Needle Free Access Device on a Midline 11.23 Administration of intermittent/bolus Intravenous medication via a Midline 11.24 Administration of Continuous Infusions via a Midline 11.25 Disconnecting an Intravenous Infusion from a Midline

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12.0 APPENDIX TWO: (PAEDIATRICS PROCEDURAL GUIDANCE) 44-60 Paediatric Procedural Guidance for PICC (Lines also known as long lines) 12.0 Dressing Change for a PICC 12.1 Changing the Needle Free Access Device for a PICC 12.2 Administration of intermittent/bolus Intravenous Medication via a PICC 12.3 Administration of Continuous Infusions via a PICC 12.4 Disconnecting an Intravenous Infusion from a PICC Paediatric Procedural Guidance for a Hickman Line 12.5 Dressing Change for a Hickman Line 12.6 Changing the Needle Free Device for a Hickman Line 12.7 Administration of intermittent/bolus Intravenous Medication via a Hickman 12.8 Administration of Continuous Infusions via a Hickman Line 12.9 Disconnecting an Intravenous Infusion from a Hickman Line Paediatric Procedural Guidance for Port Access Device (Portacath) 12.10 Insertion of a Gripper Needle/ non-coring needle 12.11 Changing the Needle Free Access Device for an Implanted Port 12.12 Administration of intermittent/bolus Intravenous Medication for an Implanted Port 12.13 Administration of Continuous Infusions via an Implanted Port 12.14 Disconnecting an Intravenous Infusion for an Implanted Port 12.15 Removal of a Gripper Needle for an Implanted Port 13.0 APPENDIX THREE: (NEONATES PROCEDURAL GUIDANCE) 61-69 13.0 Care of a Baby with a Central Line (Umbilical Venous/ Umbilical Arterial Catheters / Long Lines) 13.1 General Care of Neonate with a Central Line 13.2 Dressing changes 13.3 Changing the Needle Free Access Device for umbilical Venous / Umbilical Arterial Catheters / Long Lines 13.4 Administration of intermittent/bolus Intravenous Medication for Umbilical Venous/ Umbilical Arterial Catheters / Long Lines 13.5 Administration of Continuous Infusion for Umbilical Venous/ Umbilical Arterial Catheters / Long Lines 13.6 Disconnecting an Intravenous Infusion For Umbilical Venous / Umbilical Arterial Catheters / Long Lines 14.0 APPENDIX FOUR : 70-71 Risks associated with CVADs 15.0 APPENDIX FIVE : 72 Types/Common Insertion sites/ Use and longevity of Central venous Access devices 16.0 APPENDIX SIX : 73 Quick guide to heparin flushes Parenteral Access Devices 17.0 APPENDIX SEVEN : Hyperlinked to intranet  Central Venous Access Device Monitoring Record

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1.0 INTRODUCTION

This policy refers to the administration of intravenous medication and fluid therapy (including dressing changes) via a Central Venous Access Device (CVAD)

The Trust uses a number of Central Venous Access Devices (CVAD) to provide either therapeutic (administration of medications, fluids and/or blood products) or diagnostic (blood sampling, central venous pressure [CVP] reading) purposes.

CVADs are increasingly used within acute and community settings to deliver substances into large central veins and in direct continuity with the right atrium. Insertion is commonly sited to deliver substances into the superior vena cava (SVC) or less frequently, the inferior vena cava (IVC) or the right atrium. The internal tip of the catheter lies within a large central vein. There are various different types of CVAD but common to all is the concept that the tip of the catheter should float freely within the bloodstream in a large vein and parallel to the vein wall. Blood flow around the catheter is maximised, and physical and chemical damage to the internal walls of the vein are minimised as a result (Royal Marsden Manual of Clinical Procedures, 2015)

CVADs are used mainly for:  Fluid resuscitation where high volumes of fluids are infused. (Large volumes of blood products however, should be given through a blood warming device to prevent cardiac arrhythmias and hypothermia)  Short term administration of intravenous medications when peripheral access is not obtainable or appropriate e.g. perioperatively and in acute illness. Medications should not be administered any faster than recommended due to the risk of ‘speed shock’  Access issues, e.g. patients with poor peripheral venous access for example those in shock or who have significant peripheral venous access issues- may require a CVAD and in these situations blood may be taken from a lumen for sampling.  Short term access for haemofiltration in critical care units. Medicines are not normally administered via this device.  The provision of long term medications e.g. chemotherapy, antibiotics etc.  Administration of irritant, vesicant or hyperosmolar medicines / fluids e.g. concentrated potassium, 20 % and 50% Dextrose, parenteral nutrition, chemotherapy, sodium bicarbonate etc. which could potentially damage the peripheral veins.  Measuring and monitoring central venous pressure.

Regardless of the type on CVAD, the principles of care remain the same:  To maintain a patent functional access device  To maintain a closed sterile system and reduce the risk of infection by minimal handling / disconnections  To monitor the device whilst in situ at least 4-6hourly for signs of inflammation / infection  To remove the device at the earliest convenience when it is no longer required

There are now a comprehensive range of CVADs available which allow for selection based on the device, therapy and the quality‐of‐life needs of the patient (Royal College of Nursing, 2016). For details see section 6.0.

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2.0 POLICY STATEMENT

This policy is designed as an evidence based resource for the multi-disciplinary team in order to standardise practice and reduce complications occurring when caring for patients with a CVAD.

Venous access devices are one of the main causes of healthcare-associated infections (Loveday et al, 2014), and bloodstream infections associated with device insertion are a major cause of morbidity. In the most recent national prevalence survey, the Health Protection Agency reported that the prevalence of blood stream infections (BSI) was 0.5%, accounting for 7.3% of the healthcare-associated infections (HCAI) detected; 64% of BSI occurred in patients with a vascular access device.

The risk of infection is greatly reduced by complying with all parts of the process for safe insertion, maintenance of the device and its removal as soon as it is no longer needed (National Institute for Clinical Excellence, 2014)

3.0 DEFINITIONS / ABBREVIATIONS

CVAD Central venous access devices (overarching term) IVC Inferior Vena cava SVC Superior Vena Cava ANTT Aseptic non – touch technique CVC Central Venous Catheters – the tip is either placed in the SVC or the IVC PICC Peripherally Inserted Central Catheter. Skin Tunnelled CVAD Skin Tunnelled CVAD with an external clamp E.g., Hickman Line Totally Implantable Implanted Central Venous Access Device with a self-sealing Venous Access Device injection port. (TiVAD) E.g. Portacath Midlines Venous access devices NOT centrally placed these are typically inserted into the larger vessels of the upper arm and finish at the level of the subclavian vein. These should be cared for as per CVCs due to the proximity of the tips to the central venous circulation Push-pause flushing A push – pause approach to flushing a CVAD that creates turbulence in the line that breaks down particulate matter- fibrin and medicine precipitation and prevents occlusion. Gripper Needle /Non – A hollow needle specifically designed to access an implantable coring needle port membrane without removing any of the device material. When removed the membrane re-seals itself. Air Embolus Embolus within a large vessel created by the entry of air via the CVAD – can be fatal. Pinch off When the Catheter of the CVAD is trapped between the clavicle and first rib causing an intermittent occlusion. More likely to occur in subclavian CVADs

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Phlebitis Localised inflammation of the tunica intima of the veins – 3 types  Mechanical – more common in PICCs and Midlines and occurs within the first week of insertion – caused by friction of the CVAD irritating the vessel wall  Chemical – Irritation of the vein caused by irritant medications – unlikely to occur in patients with a CVC in situ although it may become damaged  Infective – Bacterial - has the potential to develop into sepsis Haemorrhage Bleeding may occur when catheter inserted – or from /around exit site when used, however it is most likely to occur if Luer lock connections become disconnected. Cardiac Arrhythmias When the tip of the CVAD irritates the cardiac tissue. Most common on/after insertion. Catheter tip must be confirmed radiologically before use Pneumothorax Presence of air pleural cavity, causing partial or total collapse of the lungs – potentially life threatening. Commonly occurs on insertion Catheter Migration When the line either moves in or out of original placement – determined by measuring the external exposed length of catheter and comparing with original measurement from insertion Needle Free Access Connections to CVADs that minimise the risk of infection/ device contamination due to multiple uses / sharps

4.0 ROLES AND RESPONSIBILITIES

The Chief Nurse and Executive Medical Director are responsible for the content and implementation of this policy.

Divisional nurses and heads of department are responsible for ensuring that necessary measures are in place to support the safe implementation and monitoring of the use of the policy in practice. They will need to take measures where practice has been deemed potentially unsafe.

Matrons, department managers and service line directors are responsible for ensuring that all staff accountable to them are aware of this policy and adhere to its statement. It is the manager’s responsibility to investigate and rectify any discrepancies identified.

Ward Sister/Charge Nurses/Departmental Leaders will act as excellent role models and are responsible and accountable for the policy implementation among staff in practice, and the monitoring of standards and best practice associated with it. They will ensure that all staff in the sphere of their responsibility have access to training to develop the skills and competence. This includes the completion of the associated work books, medical equipment competency documents and study sessions in a timely manner.

All registered healthcare professionals have a duty of care to their patients. This is a legal and professional requirement of state registration that cannot be delegated. All registered healthcare professionals are personally responsible and professionally accountable in ensuring

Title: IV Policy - Intravenous (IV) Medication and Fluid Therapy Administration Through a Central Venous Access Device Version: 1.0 Issued: September 2018 Page 8 of 73 that they receive training in the safe use and observation of any medical device used in the delivery of intravenous therapy (MHRA, 2010). It is the responsibility of the healthcare professional to ensure that any intravenous access or intravenous therapy is appropriately prescribed for the patient and that the patient and therapy delivery are monitored according to associated policies and procedures.

Professional Education and Training Team (PETT)

The PETT will be responsible for the delivery of training and training materials associated with all aspects of venous access and care. They will coordinate the process of online and classroom based training and ward based assessment for:  Central Intravenous Therapy  Care and Maintenance of CVAD

The PETT team will coordinate the timely completion and return of all associated competency documents and subsequent recording of achievement of an individuals practice on the Oracle Learning Module (OLM).

Infection Control Team

The Infection Control Team will act as the expert group who will provide guidance, interpretation and support on infection prevention and control issues relating to CVADs.

To improve patient outcomes and reduce healthcare costs, it is essential that everyone involved in caring for patients with a CVAD are educated about infection prevention. Clinical staff MUST be confident and proficient in infection prevention practices, and be aware of the signs and symptoms of clinical infection. (Epic3 Guidelines, 2014)

All staff are required to prevent and manage healthcare acquired infection as part of The Health and Social Care Act 2008: Code of Practice on the prevention and control of infections and related guidance (Department of Health, 2015).

Pharmacists

Pharmacists will provide guidance as to suitability of substances for administration via a CVAD; this will direct the type of device used /length of use/number of lumen selected.

5.0 APPROVAL

This document has been produced under the direction of a multi- disciplinary working task group. The document has been sent out via the consultation process and agreed at the relevant forums:  Infection Prevention and Control  Critical Care Clinical Educator  Nutritional Nurse Specialist  Paediatric Governance  Professional Education and Training Team  Drugs & Therapeutics, Medicines Optimisation Committee  Nursing, Midwifery and Allied Health Professional Board

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6.0 DOCUMENT REQUIREMENTS

 See Appendices for procedural information

Types of Central Venous Access Devices

Central Venous Catheters (CVC):

CVCs are percutaneous catheters which should ideally be placed under ultrasound guidance. (However, those entering the body via the subclavian route cannot be inserted with ultrasound assistance). They are inserted by appropriately trained practitioners through the internal jugular, subclavian or femoral veins. The tip will be in either the inferior or superior vena cava. They may have multiple lumens. Tip placement is verified by radiology imaging.

Key principles for the management of a CVC include:  An aseptic approach should always be used when accessing the system / caring for the CVAD.  Infusions via the catheter should be given in a closed system, using a needle free Luer lock system.  The catheter should have the minimum number of lumens and ports necessary (HICPAC, 2011).  A dedicated lumen(s) should be used for short term parental nutrition and / or inotropes  Some medications should not be mixed (i.e. using the same lumen) due to the risk of precipitation in the lumen. Local pharmacy departments can offer advice regarding compatibility risks.

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PICC Lines (Peripherally Inserted Central Catheter)

The Peripherally Inserted Central Catheter is inserted in to the brachial or basilic vein (usually above the antecubital fossa); where as in paediatric and neonates insertion is approached from the long saphenous, femoral or dorsal vein with the catheter advanced into to the SVC. They are inserted under local anaesthetic and advanced into the central veins; the tip is located in the SVC. Tip placement is verified by radiology imaging and/or electrocardiogram (ECG) recording.

Advantages of a PICC:  They eliminate the mechanical complications associated with placement of a central venous catheter, particularly with CVCs. (Dougherty and Gull, 2015)  PICCs help to preserve peripheral veins  PICCs reduce discomfort for the patient; provide a reliable source of access; and are cost effective when compared to other short term and long term catheters (Dougherty and Gull, 2015)

PICC lines are commonly referred to as long lines within the paediatric division.

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Hickman Lines (Skin Tunnelled Catheter)

Hickman lines are usually inserted under ultrasound guidance via a percutaneous puncture and Seldinger technique to access the internal jugular vein. Following insertion into a central vein the catheter is tunnelled several centimetres under the skin and brought out through a suitable exit site (anterior chest wall between sternum and nipple). The catheter tip lies within the SVC or the right atrium. The catheter provides long term central venous access for medication, parental nutrition and blood sampling. They can come with single, double or triple lumens (Ives, 2009).

Skin tunnelled catheters have a Dacron cuff that sits within the skin tunnel approximately 3-5 cm from the exit site to help secure placement. The cuff also helps to impede the migration of bacteria by creating a barrier along the subcutaneous tract thus reducing the rate of catheter related infections (Dougherty and Gull, 2015: Ives, 2009: Weinstein, 2007)

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Totally Implantable Venous Access Device (TiVAD / PORTACATH)

A Port Access Device (Portacath) / Totally Implantable Venous Access Device (TiVAD) is similar to a tunnelled CVC but instead of protruding from the patient’s chest, the catheter terminates in a self‐sealing injection port which is implanted under the skin. There are therefore no external parts. The port is accessed through the skin using a dedicated gripper/ non‐coring needle. They are normally cited within the chest or the arm.

Advantages of TiVAD:

 Due to the port being situated under the skin, little care is required when the port is not in use.  Ports only require flushing once a month  Ports provide long term central venous access.

Disadvantages of TiVAD:

 Patients may feel discomfort when the port is accessed.  Ports are more difficult to treat should they become infected

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Midline Catheters

Midlines are not centrally placed lines as they sit within the axillary veins, A midline catheter is 3 inches (7.5 cm) to 8 inches (20 cm) in length, and would be inserted via the veins near the antecubital fossa into the basilic, cephalic, or brachial veins. The tip is advanced no further than the distal axillary vein in the upper arm. Midlines are included in this policy as they should be cared for in the same manner as a PICC line. Midlines are inserted using an aseptic technique and maximum sterile barrier precautions to reduce the risk of infection. They are inserted by registered medical/ nursing practitioners who will have completed specialist training and associated competencies – ultrasound guidance should be used to support insertion and to confirm vein placement.

Midlines catheters can be left in place for extended periods but Ives (2009) recommends that placement should be limited to 2-4 weeks. However, dwell times should also be assessed against treatment, assessment of insertion site and patient condition.

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7.0 MONITORING COMPLIANCE AND EFFECTIVENESS

Minimum Responsible Process Frequency Responsible Individual or Requirement Individual for Monitoring of Committee/Group for Review of to be Monitored e.g. Audit Monitoring Results

(WHAT – element of (WHO – is going to monitor (HOW – will this element be (WHEN – will this (WHERE – Which individual/ committee or compliance or this element) monitored (method used)) element be monitored group will this be reported to, in what effectiveness within the (frequency/ how often)) format (e.g. verbal, formal report etc.) and document will be by who) monitored)

Completion of Training Ward and department Oracle learning module Ongoing Training and development and associated Leaders/ matrons and competency packages Professional Education and Training Team

Incidence of device Infection prevention and DATIX incident reporting Ongoing Infection prevention and control related blood borne control team / Sepsis committee infections /sepsis Nurse

Incidents related to Ward and department DATIX incident reporting Monthly Divisional Governance care and management Leaders/ matrons of CVADs Patient experience team

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8.0 TRAINING AND IMPLEMENTATION

Prior to accessing CVADs, all practitioners must demonstrate that they have read this policy and be able to evidence this as part of their training.

All practitioners accessing CVADs to administer medication, flushes and fluids are required to have:

1. Accessed training, complete and return self-assessment competency forms for the Trust infusion pumps relevant to role and practice. 2. Completed an Accountability Assessment Pack (non-medical staff only) if not previously completed. The single completion of the pack, within a three year period, covers all training. 3. Successfully completed the peripheral intravenous therapy assessment pack. 4. Completed the total parenteral nutrition training package (if this is appropriate to the individual’s area of practice). 5. Attended training and completed competency packs in relation to CVADs ensuring they have completed a minimum of four supervised practices to administer medication, flushes and fluids; maintenance and removal of a CVAD. 6. Ensure all relevant competency packages are completed within three month of their training. 7. Provide ward level documented evidence of all the above, using the correct assessment packs, and send the signed record to the PETT in the Training, Education and Development Department. The return of this document and achievement of competency will be recorded on the Trust’s Oracle Learning Module (OLM)

9.0 IMPACT ASSESSMENTS

Delete/ amend as applicable:  This document has been subject to an Equality Impact Assessment, see completed form below  This document is not subject to an Environmental Impact Assessment

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Equality Impact Assessment.

Name of service/policy/procedure being reviewed: POLICY FOR THE ADMINISTRATION OF INTRAVENOUS MEDICATION AND FLUID THERAPY VIA A CENTRAL VENOUS ACCESS DEVICE. New policy Date of Assessment: 8/6/2018 For the policy and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) a) Using data and supporting b) What is already in place in c) Please state any barriers Protected information, what issues, needs or the policy or its implementation that still need to be addressed Characteristic barriers could the protected to address any inequalities or and any proposed actions to characteristic groups’ experience? barriers to access including eliminate inequality For example, are there any known under representation at clinics, health inequality or access issues to screening? consider? The area of policy or its implementation being assessed:

Race and Ethnicity NONE N/A NONE Gender NONE N/A NONE Age Patient group specific. Specific guidance within the policy NONE has been provided for procedural guidance for Adults, Paediatrics and Neonates. Religion NONE N/A NONE

Disability NONE N/A NONE Sexuality NONE N/A NONE Pregnancy and Consideration as to type of medicines Refer to medicines information NONE Maternity prescribed in terms of any potential centre for information regarding teratogenic effect during preparation, medicines classified as cytotoxic administration and receiving of or cytostatic. medicine.

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Gender NONE N/A NONE Reassignment Marriage and Civil NONE N/A NONE Partnership Socio-Economic NONE N/A NONE Factors (i.e. living in a poorer neighbourhood / social deprivation)

What consultation with protected characteristic groups including patient groups have you carried out?  None – referred to existing policies

What data or information did you use in support of this EqIA? 

As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments?  No

Level of impact

From the information provided above and following EQIA guidance document Guidance on how to complete an EIA (click here), please indicate the perceived level of impact:

Low Level of Impact

For high or medium levels of impact, please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting.

Name of Responsible Person undertaking this assessment: Alison Davidson

Signature: Alison Davidson

Date: 18/8/2108

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10.0 EVIDENCE BASE (Relevant Legislation/ National Guidance) and RELATED SFHFT DOCUMENTS

BARD ACCESS SYSTEMS™– Instructions for use BARDPORT™ implantable Ports, SLIMPORT™, XPORT™ implantable ports with open ended and Groshong Catheters (manufacturers guidance) no date

Conn, C. (1993) The importance of syringe size when using implanted vascular access devices. The Journal of Vascular Access Networks (3) 11.13

Department of Health (2015) The Health and Social care Act 2008 code of practice on the prevention and control of infections and related guidance (accessed 25/04/20118 at :- https://www.gov.uk/government/publications/the-health-and-social-care-act-2008-code-of- practice-on-the-prevention-and-control-of-infections-and-related-guidance

Department of Health (2010). Clean Safe Care High Impact Intervention Central Venous Catheter Care Bundle and Peripheral IV Cannula Care Bundle. London. Department of Health.

Dougherty, L. (2008) Obtaining Peripheral Access. In: Dougherty, L and Lamb, J. (eds) Intravenous Therapy in Nursing Practice. 2nd Edition. Oxford. Blackwell Publishing.

Dougherty L, Gull K. (2015) Vascular access devices: insertion and management. In: The Royal Marsden Hospital Manual of Clinical Nursing Procedures (9th edition). Oxford, UK: Wiley-Blackwell, pp. 861-933

Dougherty, L and Lister S (2015) Vascular access devices: insertion and management: The Royal Marsden manual of Clinical Nursing Procedures (accessed 21/02/2018) at:- http://www.rmmonline.co.uk/manual/c14-sec-0031#c14-fea-0053

GAIN (Guideline Audit and Implementation Network (2014) Guidelines for insertion and maintenance of central venous access devices in children and young people. GAIN

Great Ormond Street Hospital for Children (2017) clinical guidelines. Neonatal Long lines (PICCS); nursing management. https://www.gosh.nhs.uk/health-professionals/clinical- guidelines/neonatal-long lines-piccs-nursing-management. Accessed 07/05/2018

Great Ormond Street Hospital for Children (2015) Central Venous Access Devices – long term (accessed on line 23/08/2018)

Hadaway. L. (1998) Catheter connection The Journal of Vascular Access Devices 3 (3) 129-145

Healthcare Infection Control Practices Advisory Committee (HICPAC). (2011) Guidelines for the prevention of intravascular catheter-related infections, 2011. Atlanta, USA: Centers for Disease Control and Prevention. https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html

Infusion Nursing Standards (2011). Journal of Infusion Nursing, supplement. 34(15), S1- S110

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Ives F. (2009) “Catheter design and materials.” In: Hamilton H, Bodenham A (eds). Central Venous Catheters. Oxford: Wiley Blackwell, pp. 57–77.

Lloreda-García J M. Lorente-Nicolas A. Bermejo-Costa F and Fernandez-Fructuoso J R (2016) Catheter tip position and risk of mechanical complications in a neonatal unit. Anales de Pediatría 85 (2) 77-85

Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A , Bak, A, Browne J, Prieto J and Wilcox. M. (2014) epic3:National Evidence- Based Guidelines for Preventing Healthcare- Associated Infections in NHS Hospitals in England (accessed 21/02/2018) at :- http://www.journalofhospitalinfection.com/article/S0195-6701(13)60012-2/pdf

McQueen. S, Bruce. E A, Gibson. F (2012) , The Great Ormond Street Hospital Manual of Children’s Nursing Practices. GOSH NHS Foundation Trust. Blackwell. London

MHRA (2010) Device Bulletin: infusion Systems DB2003(02) V2.0. London: Medicines and Healthcare Products Regulatory Agency. Available at www.mhra.gov.uk/home/groups/dts/iac/documents/publication/con0077322

National Institute for Clinical Excellence (2011) Infection Prevention and Control Quality Standard 5; Vascular Access Devices: (accessed 21/02/18) at :- https://www.nice.org.uk/guidance/qs61/chapter/quality-statement-5-vascular-access- devices#rationale-5

NICE Infection Prevention and Control Quality Standard 5; Vascular Access Devices: (accessed 21/02/18) at :- https://www.nice.org.uk/guidance/qs61/chapter/quality-statement-5-vascular-access- devices#rationale-5

Nottingham Children’s Hospital (2013) Central Venous Access Device Policy. Nottingham University Hospitals NHS Foundation Trust.

Nottingham Children’s Hospital (2014) PO7 Care and management of children with a totally implantable Venous access device (Portacath) Nottingham University Hospitals NHS Foundation Trust.

Petit J and Wyckoff, M M (2007) Peripherally inserted central catheters. Guidelines for practice, 2nd edition.

Royal College of Nursing. (2010) Standards for Infusion therapy. London, Royal College of Nursing

Royal College of Nursing (2016) Standards for Infusion Therapy.4th Edition. London.

Title: IV Policy - Intravenous (IV) Medication and Fluid Therapy Administration Through a Central Venous Access Device Version: 1.0 Issued: September 2018 Page 20 of 73

Royal Marsden NHS Foundation Trust Policy (2016) Central Venous Access Devices (CVAD) - Policy for Insertion and Care in Hospital https://www.nice.org.uk/guidance/mtg34/resources/policy-for-the-insertion-and-care-of- central-venous-access-devices-cvad-in-hospital-royal-marsden-nhs-ft-pdf-4481503169 accessed 5/4/2018

Sharpe E, (2014) Neonatal peripherally inserted central catheter practices and their association with demographics, training and radiographic monitoring. Results from a national survey. Advances in Neonatal Care. 14 (5)329-335.

Sharpe E and Pettit J (2013) A National Survey of Neonatal Peripherally Inserted Central Catheter (PICC) Practices. Advances in Neonatal care. 13 (1) 55-74.

Soe A (2007) Central venous catheterisation in newborn infants. Infants. 3 (5) 172-175.

Weinstein S. (2007) Plumer’s Principles and Practices of Intravenous Therapy (8th edn). Philadelphia: Lippincott.

Related SFHFT Documents: All Current Versions available on the Intranet  Hand Hygiene Policy ICP 17  Prevention and Control Operating Policy ICP1  Infection Invasive Procedure Policy  IV Policy - for Managing Intravenous Fluid Therapy in Adult Patients in Hospital  IV Policy - for the Care of the Patient Undergoing Bolus, Continuous and Intermittent IV Therapy  Medical Equipment User Training Policy  Medical Device Management Policy  Medicines Policy  Mental Capacity Act (MCA) Policy  Nutrition and Hydration Policy  Personal Protective Equipment Policy (PPE) ICP 9  Policy for Consent to Examination, Treatment and Care  Policy and Procedure for the Positive Identification of Patients  Role and Specialist Role development Policy  Sharps, Needle stick and PEP Policy  Transfusion Policy, Procedures & Guidelines  Vascular Access Assistance Policy

Related guidelines and procedures  Aseptic technique A1 (ANTT)  Removal of peripheral cannula C26  Procedure for changing an intravenous patient controlled analgesia (PCA) Syringe / bag  Procedure for administration of intravenous opioids (theatre recovery only) P12  Flushing a central venous catheter C16  Administration of IV drugs via a central venous catheter C15  Multidisciplinary guideline for the administration of parenteral nutrition

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 Management of a central venous line – neonates C5  Changing the dressing of a central venous catheter line (adults) C14  Clinical guideline for the treatment of suspected sepsis

Related role development standards for practice:  Care and management of a child with a totally implantable venous access device (Port-a- Cath)  RD04 Administration of peripheral Intravenous drugs  RD04.4 Overview administration of drugs and intravenous fluids via a silastic long line  RD05 Administration of drugs and Infusions via intravenous Central Lines  RD06 Fluid management via intravenous peripheral infusion  RD08 Administration of a saline flush to ensure a cannula is patent

APPENDICES:

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APPENDIX ONE: ADULT PROCEDURAL GUIDANCE

Central Venous Catheters (CVC)

11.0 Adult: Dressing Change for a CVC

 Frequency of dressing change: If sterile gauze is applied post insertion the dressing must be changed within 24 hours and then every 7 days, using a transparent, high moisture vapour permeable dressing.  Any dressing should be changed if it has become loose, damp or soiled.  Sutures should be used to secure the CVC in addition to the transparent, high moisture vapour permeable dressing - sutures would only be removed on removal of the line.  Measure catheter length to check for migration. This measurement should be from the exit site to the CVC hub and the length documented on the central venous access device observation record.

Equipment

 Sterile dressing-pack including sterile gloves.  Apron  Non sterile gloves  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or Povidone Iodine cleaning solution if chlorhexidine sensitivity  High moisture vapour permeable transparent dressing.

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Using the principles of ANTT prepare the equipment and assemble on a clean dressing trolley or tray. 3. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 4. Put on non- sterile gloves and loosen the dressing, removing it without touching the catheter and exit site 5. Measure the catheter length to check for migration. 6. Use effective hand hygiene and put on sterile gloves. 7. Clean catheter site with 2% Chlorhexidine gluconate and 70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected 10% aqueous Povidone iodine cleansing solution. Using a cleansing technique for 30 seconds, start from the exit site, extending out to the area that will be covered by the dressing. 8. Allow to air dry for minimum of 30 seconds (DOH 2010, INS, 2011) 9. Apply a transparent high moisture vapour permeable dressing over the top. 10. Leave extension set / injection port visible and accessible 11. Dispose of all waste as per guidelines and use effective hand hygiene. 12. Document using the central venous access device observation record:  Date/time of dressing change  Insertion site score

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 Evidence of catheter migration  Any nursing intervention as per individual area practices  Document the Date/time of dressing change upon the dressing surface

11.1 Adult: Changing Needle Free access device for a CVC.

 The needle free connector is a self-sealing bung that must not be pierced by a needle.  It does not have to be removed to attach a syringe or giving set tube to the CVC.  The device must always be changed every 7 days. The device must also be changed if it becomes contaminated, or if it is suspected that blood may have collected inside. The device will usually be changed at the same time as the dressing change.  The device must be changed after blood cultures are taken.

Equipment

 Sterile dressing pack including sterile gloves  Apron  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected 10% aqueous Povidone Iodine cleansing solution  Primed needle free access device

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 4. Ensuring line is clamped, holding a sterile piece of gauze, one in each hand, hold the line and with the other hand remove the existing needle free access device and discard. 5. Clean catheter hub end with 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds (DOH 2010; INS, 2011). Using ANTT attach the new needle free access device to the catheter hub. 6. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 7. Record procedure and any variances in the patient's clinical record

11.2 Adult: Administration of Intermittent /Bolus Intravenous Medication via a CVC

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol cleansing solution.  syringes as required  Blunt fill needle (for drawing up) filter needle from glass ampoules  10ml of Sodium chloride 0.9% as required (for flushing)  Sterile gloves

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Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe, 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry (DOH 2010, INS, 2011) 4. Check the patency of the catheter by attaching a syringe containing 10ml sodium chloride 0.9% to the needle free access device. Check for flash back of blood by gently withdrawing syringe 5. As soon as a trace of blood is seen in the catheter or syringe, flush the sodium chloride into the line using a push-pause flush technique. 6. It is not necessary to routinely withdraw and discard blood from the catheter before flushing. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. 7. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 8. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner. 9. Administer medication 10. Follow procedure and administration as per Medicine Prescription and Administration Record and manufacturer’s instructions. 11. Attach new needle free access device (if required). Needle free devices must be changed every 7 days. 12. Flush the sodium chloride 0.9% into the line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation 13. Remove and dispose of waste equipment correctly. 14. Record the procedure and any variances in the patient’s clinical record.

11.3 Adult: Administration of Continuous Infusions via a CVC

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol  syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required (for flushing)  Administration set  Fluid/medicine for administration  Volumetric infusion pump

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray.

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3. Using the principles of ANTT clean the needle free access device with recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry (DOH 2010, INS, 2011). 4. Withdraw 5-10 mls of blood from the catheter and discard before flushing. Flush the line with 10ml sodium chloride 0.9% via the needle free access device. 5. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. 6. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 7. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner. 8. Administer the medication. Follow procedure and administration as per Medicine Prescription and Administration Chart and manufacturer’s instructions. 9. Using ANTT attach the primed line by connecting to the cleaned needle free access device. 10. Place newly primed set in pump (if pump required). Commence infusion at prescribed rate. 11. Use of pumps should be considered in accordance with parenteral therapy guidelines. Ensure that all lines are labelled as per hospital guidelines. 12. Remove and dispose of waste equipment correctly. 13. Record procedure and any variance in the patient’s clinical record.

11.4 Adult: Disconnecting an Intravenous Infusion from CVC

Equipment

 Syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium Chloride 0.9% as required (for flushing)  Needle free access device (if required)  Sterile gloves and dressing towel

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Use ANTT throughout the procedure. 4. Clamp both the lumen and the infusion line. 5. Disconnect the infusion. 6. Release clamp and flush the sodium chloride 0.9% into the line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. Care should be taken following a potent medicine infusion such as potassium or noradrenaline. After the infusion is no longer needed- the lumen must be aspirated (and blood discarded) prior to flushing with saline. 7. Remove and dispose of waste equipment correctly. 8. Record procedure and any variances in the patient's clinical record.

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ADULT PROCEDURAL GUIDANCE FOR PICC LINES

11.5 Adult: Dressing Change for a PICC Line

 Frequency of dressing change: within 24 hours of insertion and then every 7-10 days using transparent, high moisture vapour permeable dressing.  Any dressing should be changed if it has becomes loose, damp or soiled.  Mechanical phlebitis is more likely to occur within the first 7 days following insertion of the PICC. It can usually be resolved within 48 hours by the application of heat to the upper arm for 10-20 minutes, 3 times a day.  PICC lines should be secured with their anchoring device (e.g. Stat-Lock™) and not sutured

Equipment

 Sterile dressing-pack including sterile gloves.  Apron  Non sterile gloves  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected use sterile water.  Anchoring device (e.g. Stat-Lock™).  Sterile high moisture vapour permeable transparent dressing.

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Assess the need to carry out additional procedures e.g. change of needle free access device every 7 days. 3. Using the principles of ANTT prepare the equipment and assemble on a clean dressing trolley or tray. 4. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 5. Put on non-sterile gloves and loosen the dressing, removing it without touching the catheter and exit site. 6. Use effective hand hygiene and put on sterile gloves. 7. Clean catheter site with the cleansing solution and using the spiral cleansing technique start from the exit site, extending out to the area that will be covered by the dressing. Allow to air dry (DOH, 2010. RCN, 2010. Dougherty, 2008) 8. Secure line with the Stat-Lock™ and apply a transparent high moisture vapour permeable transparent dressing over the top. Lines can be looped over the dressing and dressed in gauze for extra security. Leave extension set / injection port covered to prevent. Apply tubular bandage over the top. 9. Dispose of all waste as per guidelines and use effective hand hygiene. 10. Document using the central venous access device observation record:  Date/time of dressing change  Insertion site score  Evidence of catheter migration  Any nursing intervention as per individual area practices

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11.6 Adult: Changing the Needle Free Access Device for a PICC Line

 The needle free access device is a bung that must not be pierced by a needle.  It does not have to be removed to attach a syringe or giving set tube to the PICC.  The device must always be changed at least weekly.  The device must also be changed if it becomes contaminated, or if it is suspected that blood may have collected inside.  The device will usually be changed at the same time as the dressing change.

Equipment

 Sterile dressing pack including sterile gloves  Apron  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected use sterile water.  Needle free access device

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis or migration. If any concerns inform clinician. 4. Ensuring line is clamped, holding a sterile piece of gauze, one in each hand, hold the line and with the other hand remove the existing needle free access device and discard. 5. Clean catheter site with the cleansing solution using the spiral cleansing technique start from the exit site, extending out to the area that will be covered by the dressing. Allow to air dry. 6. Using ANTT attach the new needle free access device to the catheter hub. 7. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene 8. Record procedure and any variances in the patient's clinical record

11.7 Adult: Administration of Intermittent/Bolus Medication via PICC Line Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/ 70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected 10% aqueous iodine cleansing solution  syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required (for flushing)  Needle free access device (if required)  Sterile gloves and dressing towel (if breaking line)

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Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe, 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry 4. Withdraw 5-10ml of blood and discard syringe. Flush the line with 10ml sodium chloride 0.9% via the needle free access device. If any signs of catheter occlusion, whether partial or complete you will require early action to restore patency of the device. 5. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 6. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner. 7. Administer medication. 8. Follow procedure and administration of medication as per prescription. 9. Attach new needle free access device (if required). Needle free devices must be changed within 7 days. 10. Flush the sodium chloride 0.9% into the line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. This prevents backflow of blood into the catheter and promotes positive pressure. 11. Remove & dispose of waste equipment correctly. 12. Undertake effective hand hygiene. 13. Record procedure and any variances in the patient’s clinical record.

11.8 Adult: Administration of Continuous Infusions via a PICC Line

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate / 70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected use sterile water.  syringes as required  Blunt fill syringe (for drawing up)  10ml of Sodium Chloride 0.9% as required  Administration set  Fluid / medicine for administration  Volumetric infusion pump

Procedure 1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry until hub appears dry.

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4. Withdraw 5-10ml of blood and discard syringe. Flush the line with 10ml sodium chloride 0.9% via the needle free access device. If any signs of catheter occlusion, whether partial or complete you will require early action to restore patency of the device. 5. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 6. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner. 7. Administer medication. Follow procedure and administration as per Medicine Prescription and Administration Chart and manufacturer’s instructions. 8. Using ANTT attach the primed line by connecting to the cleaned needle free access device. 9. Place newly primed set in pump (if pump required). Commence infusion at prescribed rate. 10. Ensure that all lines are labelled as per hospital guidelines. 11. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 12. Record procedure and any variance in the patient’s clinical record.

11.9 Adult: Disconnecting an Intravenous Infusion from a PICC Line Equipment  Syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required (for flushing)  Needle free access device (if required)  Sterile gloves and dressing towel (if breaking line)

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Explain the procedure to the patient. 3. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 4. Use ANTT throughout the procedure. 5. Clamp both the catheter and the infusion line 6. Disconnect the infusion. 7. Unclamp the catheter and flush the sodium chloride 0.9% into the line using a push- pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 8. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 9. Record procedure and any variances in the patient's clinical record

ADULT PROCEDURAL GUIDANCE FOR HICKMAN LINES (SKIN-TUNNELLED CATHETERS).

11.10 Adult: Dressing Change for a Hickman Line

 Frequency of dressing change: within 24 hours of insertion and then every 7 days using transparent, high moisture vapour permeable dressing.  Any dressing should be changed if it has become loose, damp or soiled.  Sutures should be used to secure the Hickman line in addition to the transparent, high

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moisture vapour permeable dressing.  Measure catheter length to check for migration. This measurement should be from the exit site to the hub and the length documented on the central venous access device observation record.

Equipment

 Sterile dressing-pack including sterile gloves.  Apron  Non sterile gloves  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected use sterile water.  Sterile high moisture vapour permeable transparent dressing.

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Assess the need to carry out additional procedures e.g. change of needle free access device every 7 days. 3. Using the principles of ANTT prepare the equipment and assemble on a clean dressing trolley or tray. 4. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 5. Put on non-sterile gloves and loosen the dressing, removing it without touching the catheter and exit site. 6. Use effective hand hygiene and put on sterile gloves. 7. Clean catheter site with solution and using the spiral cleansing technique start from the exit site, extending out to the area that will be covered by the dressing. The up, down, Left to right technique can also be used. Allow to air dry (DOH, 2010. RCN, 2010. Dougherty, 2008) 8. Apply a transparent high moisture vapour permeable transparent dressing over the top. Lines can be looped over the dressing in gauze to protect skin integrity. Ensure the clamp and ports are dressed in gauze to maintain skin integrity and prevent any pressure damage. 9. Dispose of all waste as per guidelines and use effective hand hygiene. 10. Document using the central venous access device observation record:  Date/time of dressing change  Insertion site score  Any nursing intervention as per individual patient preference.

11.11 Adult: Changing the Needle Free Access Device for a Hickman Line

 The needle free access device is a self-sealing bung that must not be pierced by a needle.  It does not have to be removed to attach a syringe or giving set tube to the Hickman line.  The device must always be changed at least weekly.  The device must also be changed if it becomes contaminated, or if it is suspected that blood may have collected inside. Title: IV Policy - Intravenous (IV) Medication and Fluid Therapy Administration Through a Central Venous Access Device Version: 1.0 Issued: September 2018 Page 31 of 73

 The device will usually be changed at the same time as the dressing change.  Following sampling for blood cultures

Equipment

 Sterile dressing pack including sterile gloves  Apron  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected 10% aqueous iodine cleansing solution  Needle free access device

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 4. Ensuring line is clamped, holding a sterile piece of gauze, one in each hand, hold the line and with the other hand remove the existing needle free access device and discard. 5. Clean catheter hub end with recommended cleansing wipe 2% Chlorhexidine gluconate/ 70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds. 6. Using ANTT attach the new needle free access device to the catheter hub. 7. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 8. Record procedure and any variances in the patient's clinical record.

11.12 Adult: Administration of Intermittent/Bolus Intravenous Medication via a Hickman Line

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol wipe or if chlorhexidine sensitivity is suspected use sterile water.  Syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required  Needle free access device (if required)  Sterile gloves and dressing towel (if breaking line)  Heparin sodium flushing solution 50units /5ml

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe, and allow to air dry for a minimum of 30 seconds / hub appears dry. 4. Withdraw 5-10 mls of blood from the catheter and discard before flushing. Flush the line with 10ml sodium chloride 0.9% via the needle free access device.

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5. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 6. Follow procedure for a person check and administration as per prescription and manufacturer’s instructions. 7. Attach new needle free access device (if required). Needle free access devices must be changed within 7 days. 8. Flush the sodium chloride 0.9% into the line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. If the line is not going to be accessed within 8 hours, instil Heparin sodium solution 50units /5ml using positive pressure flush and clamp line as this prevents backflow of blood into the catheter and promotes positive pressure. 9. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 10. Record procedure and any variances in the patient’s clinical record

11.13 Adult: Administration of Continuous Infusions via a Hickman Line

Equipment  Recommended cleansing wipe 2% Chlorhexidine gluconate/ 70% Isopropyl alcohol wipe or if chlorhexidine sensitivity is suspected use sterile water.  Syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required  Administration set  Fluid/Medicine for administration  Volumetric infusion pump (if required)

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe and allow to air dry for a minimum of 30 seconds / hub appears dry. 3. Withdraw 5-10 mls of blood from the catheter and discard before flushing. Flush the line with 10ml sodium chloride 0.9% via the needle free access device. 4. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 5. Follow procedure and administration of medication as per Medicine Prescription and Administration Chart and manufacturer’s instructions. 6. Using ANTT attach the primed line by connecting to the cleaned needle free access device. 7. Place newly primed set in pump (if pump required). Commence infusion at prescribed rate. 8. Ensure that all lines are labelled as per hospital guidelines. 9. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 10. Record procedure and any variance in the patient’s clinical record.

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11.14 Adult: Disconnecting an Intravenous Infusion from a Hickman Line

Equipment

 Syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required  Heparin Sodium flushing solution 50 units /5ml  Needle free access device (if required)  Sterile gloves and dressing towel (if breaking line)

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Use ANTT throughout the procedure. 4. Clamp both the catheter and the infusion line. 5. Disconnect the infusion. 6. Unclamp the catheter and flush the sodium chloride 0.9% into the line using a push- pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 7. If the line is not going to be accessed within 8 hours. Instil Heparin sodium flushing solution 50 Units /5ml using positive pressure flush and clamp line which prevents backflow of blood into the catheter and promotes positive pressure. 8. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene 9. Record procedure and any variances in the patient's clinical record.

ADULT PROCEDURAL GUIDANCE FOR A PORT ACCESS DEVICE (PORTACATH)

11.15 Adult: Insertion of a Gripper Needle / Non – Coring Needle

Equipment  Sterile dressing pack – including sterile gloves  Recommended cleansing 2% Chlorhexidine gluconate / 70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected use sterile water  Heparin Sodium solution: 50 units /5ml  10ml syringes x 3  Blunt fill needle (for drawing up)  Needle free access device  Sterile IV high moisture vapour permeable transparent dressing.  Gripper needle (appropriate length for each individual patient)  10ml of Sodium Chloride 0.9%  Sharps bin

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Procedure 1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Using the principles of ANTT prepare the equipment and assemble on a clean dressing trolley or tray. 3. Prepare the patient and examine port site for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 4. If applicable apply local anaesthetic, refer to manufacturers recommendations. 5. Use effective hand hygiene and put on sterile gloves. 6. Prepare sodium chloride 0.9% and heparin solution. 7. Attach the needle free access device to end of gripper, prime gripper and needle free access device with pre-filled sodium chloride 0.9% and apply clamp. 8. If applicable remove local anaesthetic with sterile gauze. Clean skin at port site with cleansing solution using a left to right and up and down or spiral technique. Allow to air dry for minimum of 30 seconds. 9. Position patient in a comfortable position. 10. Place sterile towel under area needing to be accessed. 11. Locate the edges of the port and hold firmly to prevent from moving. Identify the centre of the port and push the gripper needle through the skin until it touches the back of the chamber. A good indication of correct placement will be identified by hearing a scratching sound from the needle against the port chamber. If in doubt of needle placement remove and start again with a new set 12. Check patency of port by attaching a syringe. Check for flash back of blood by gently withdrawing 5-10ml of blood and discard. 13. Attach the sodium chloride and flush into the line using a push-pause flush technique. 14. If the line is not going to be accessed within 8 hours. Instil heparin sodium solution 50units / 5ml solution using positive pressure flush and clamp line which prevents backflow of blood into the port and promotes positive pressure. 15. Remove wings and cover with a sterile IV high moisture vapour permeable transparent dressing. 16. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 17. Record procedure and any variances in the patient’s clinical record. 18. Change the needle free device weekly and record in nursing notes.

11.16 Adult: Changing the Needle Free Access Device for an Implanted Port

 The needle free access device is a self-sealing bung that must not be pierced by a needle.  It does not have to be removed to attach a syringe or giving set tube to the port.  The device but must always be changed at least weekly.  The device must also be changed if it becomes contaminated, or if it is suspected that blood may have collected inside.  The device will usually be changed at the same time as the dressing change.

Equipment

 Sterile dressing pack including sterile gloves  Apron

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 2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing wipe for needle free access device  Sharps bin

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Prepare the patient and observe for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 4. Ensuring extension line is clamped, holding a sterile piece of gauze, one in each hand, hold the line and with the other hand remove the existing needle free access device and discard. 5. Clean catheter hub end with 2% Chlorhexidine gluconate/70% Isopropyl alcohol wipe and allow to air dry for a minimum of 30 seconds / hub appears dry. 6. Using ANTT attach the new needle free access device to the catheter hub. 7. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 8. Record procedure and any variances in the patient's clinical record.

11.17 Adult: Administration of Intermittent/Bolus Intravenous Medication via an Implanted Port

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected use sterile water.  10 ml syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required  Heparin sodium flushing solution: 50 units /5ml  Needle free access device (if required)  Sterile gloves and dressing towel (if breaking line)  Sharps bin

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe, 2% Chlorhexidine gluconate/70% Isopropyl alcohol wipe and allow to air dry for a minimum of 30 seconds / hub appears dry. 4. Withdraw 5-10 mls of blood from the catheter and discard before flushing. Flush the line with 10ml sodium chloride 0.9% via the needle free access device. 5. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 6. Administration medication as per prescription and manufacturer’s instructions. 7. Flush the sodium chloride 0.9% into the extension line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. Title: IV Policy - Intravenous (IV) Medication and Fluid Therapy Administration Through a Central Venous Access Device Version: 1.0 Issued: September 2018 Page 36 of 73

8. If the line is not going to be accessed within 8 hours, instil Heparin sodium solution 50units / 5ml using positive pressure flush and clamp line which prevents backflow of blood into the port and promotes positive pressure. 9. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with policy. 10. Record procedure and any variances in the patient’s clinical record.

11.18 Adult: Administration of Continuous Infusions via an Implanted Port

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected use sterile water.  10ml syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required  Administration set  Fluid/medicine for administration  Volumetric infusion pump (if required)  Transparent high moisture vapour permeable dressing

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry 4. Withdraw 5-10ml of blood and discard. Flush with 10ml Sodium Chloride 0.9%. 5. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. 6. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 7. Administer medication 8. Follow procedure and administer medication as per Medicine Prescription and Administration Record and manufacturer’s instructions. 9. Using ANTT attach the primed IV line by connecting to the cleaned needle free access device. 10. Place newly primed set in pump (if pump required). Commence infusion at prescribed rate. 11. Ensure that all lines are labelled as per hospital guidelines. 12. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with policy. 13. Record procedure and any variance in the patient’s clinical record.

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11.19 Adult: Disconnecting an Intravenous Infusion from an Implanted Port

Equipment

 10ml syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required  Heparin Sodium solution 50 units/ 5ml  Needle free access device (if required)  Sterile gloves and dressing towel (if breaking line)

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Use ANTT throughout the procedure. 4. Clamp both the gripper line and the infusion line. 5. Disconnect the infusion. 6. Flush the sodium chloride 0.9% into the extension line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 7. If the line is not going to be accessed within 8 hours. Instil Heparin sodium 50units /5ml solution using positive pressure flush and clamp line which prevents backflow of blood into the port and promotes positive pressure. 8. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with policy. 9. Record procedure and any variances in the patient's clinical record

11.20 Adult: Removal of a Gripper Needle (non-coring needle) from an Implanted Port

Equipment

 Blue ANTT tray  Dressing pack  Apron  2% Chlorhexidine gluconate and 70% Isopropyl alcohol wipe or if chlorhexidine sensitivity is suspected use sterile water.  Blunt fill needle(for drawing up)  10ml syringes as required  10ml of Sodium chloride 0.9%  Heparin Sodium flushing solution 50 units /5ml  Sterile high moisture vapour permeable transparent dressing.  Sharps bin

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Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment as per ANTT and assemble on clean dressing trolley or tray. 3. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 4. Using the 2% Chlorhexidine gluconate and 70% Isopropyl alcohol wipe thoroughly clean the needle free device and allow to air dry. Ensure gripper line does not come into contact with anything else or place gripper line onto a sterile towel. 5. Withdraw 5-10ml of blood and discard blood from the catheter. 6. Attach a pre-filled syringe containing 10ml sodium chloride 0.9% to the needle free access device. Unclamp line and flush the sodium chloride into the line using a push- pause flush technique. 7. Unclamp line and instil Heparin sodium 50 units/ 5ml solution using positive pressure flush and clamp line which prevents backflow of blood into the catheter and promotes positive pressure. The heparin sodium will last for 4 weeks. 8. Hold port firmly with one hand whilst removing gripper from port. If applicable, apply gentle pressure with sterile gauze if site is bleeding, remove gauze and cover with a high moisture vapour permeable transparent dressing. 9. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with policy. 10. Record procedure and any variances in the patient's clinical record.

ADULT PROCEDURAL GUIDANCE FOR MIDLINE CATHETERS(Midline)

11.21 Adult: Dressing Changes for a Midline Catheter

 Frequency of dressing change: within 24 hours of insertion and then every 7 days using transparent, high moisture vapour permeable dressing.  Any dressing should be changed if it has become loose, damp or soiled.  A sterile anchoring device should be used to secure the Midline in addition to the transparent, high moisture vapour permeable dressing.  Mechanical phlebitis is more likely to occur within the first 7 days following insertion of the Midline. It can usually be resolved within 48 hours by the application of heat to the upper arm for 10-20 minutes, 3 times a day.

Equipment

 Sterile dressing-pack including sterile gloves.  Apron  Non sterile gloves  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected use sterile water  High moisture vapour permeable transparent dressing.  Sterile anchoring device

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Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Assess the need to carry out additional procedures e.g. change of access device. Explain and discuss the procedure with the patient. 3. Using the principles of ANTT prepare the equipment and assemble on a clean dressing trolley or tray. 4. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 5. Put on non- sterile gloves and loosen the dressing, removing it without touching the catheter and exit site 6. Use effective hand hygiene and put on sterile gloves. 7. Clean catheter site with cleansing solution. Cleanse area for 30 seconds using the start from the exit site, extending out to the area that will be covered by the dressing. Allow to air dry for minimum of 30 seconds (DOH 2010, INS, 2011) 8. Apply a sterile anchoring device to secure the Midline and then apply a transparent, high moisture vapour permeable dressing 9. Apply a transparent high moisture vapour permeable transparent dressing over the top. 10. Leave extension set / injection port visible and accessible. 11. Dispose of all waste as per guidelines and use effective hand hygiene. 12. Document using the central venous access device observation record:  Date/time of dressing change  Insertion site score  Any nursing intervention as per individual area practices  Document the Date/time of dressing change upon the dressing surface

11.22 Adult: Changing the Needle Free Device on a Midline

 The needle free access device is a self-sealing bung that must not be pierced by a needle. It does not have to be removed to attach a syringe or giving set tube to the Midline.  The device but must always be changed at least weekly.  The device must also be changed if it becomes contaminated, or if it is suspected that blood may have collected inside.  The device will usually be changed at the same time as the dressing change.

Equipment

 Sterile dressing pack including sterile gloves  Apron  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected use sterile water  Needle free access device

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. Title: IV Policy - Intravenous (IV) Medication and Fluid Therapy Administration Through a Central Venous Access Device Version: 1.0 Issued: September 2018 Page 40 of 73

3. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 4. Ensuring line is clamped, holding a sterile piece of gauze, one in each hand, hold the line and with the other hand remove the existing needle free access device and discard. 5. Clean catheter hub end with recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol wipe and allow to air dry for a minimum of 30 seconds / hub appears dry. 6. Using ANTT attach the new needle free access device to the catheter hub. 7. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with policy. 8. Record procedure and any variances in the patient's clinical record.

11.23 Adult: Administration of Intermittent/bolus Intravenous Medication via a Midline

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol  10 ml syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required  Needle free access device (if required)  Sterile gloves and dressing towel (if breaking line)

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe, 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry. 4. Withdraw 5-10ml of blood from each lumen and discard blood from the catheter before flushing unless a concentrated locking solution or above has been used previously. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. 5. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 6. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner. 7 Follow procedure and administer as per prescription and manufacturer’s instructions. 8 Attach new needle free access device (if required). Needle free devices must be changed within 7 days 9. Flush the sodium chloride 0.9% into the line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 10. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Trusts Hand Hygiene Policy. 11. Record procedure and any variances in the patient’s clinical record.

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11.24 Adult: Administration of Continuous Infusions via a Midline

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol wipe  10ml syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required  Administration set  Fluid/Medicine for administration  Volumetric infusion pump (if required)

Procedure

1. Explain and discuss the procedure with the patient and obtain verbal consent to proceed. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol wipe and allow to air dry for a minimum of 30 seconds / hub appears dry. 4. Withdraw 5-10ml of blood and discard syringe. Flush the line with 10ml sodium chloride 0.9% via the needle free access device. If any signs of catheter occlusion, whether partial or complete you will require early action to restore patency of the device. 5. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 6. Follow procedure and administer as per prescription and manufacturer’s instructions. 7. Using ANTT attach the primed line by connecting to the cleaned needle free access device. 8. Place newly primed set in pump (if pump required). Commence infusion at prescribed rate. 9. Ensure that all lines are labelled as per hospital guidelines. 10. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Trust’s Hand Hygiene Policy. 11. Record procedure and any variance in the patient’s clinical record.

11.25 Adult: Disconnecting an Intravenous Infusion from a Midline

Equipment  10ml syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required  Needle free access device (if required)  Sterile gloves and dressing towel (if breaking CVAD line)

Procedure

1. Explain the procedure to the patient. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Use ANTT throughout the procedure. 4. Clamp both the catheter and the infusion line. 5. Disconnect the infusion

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6. Unclamp the catheter and flush the sodium chloride 0.9% into the line using a push- pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 7. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with policy. 8. Record procedure and any variances in the patient's clinical record.

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APPENDIX TWO: PAEDIATRIC PROCEDURAL GUIDANCE

Children’s services within Sherwood Forest Hospitals NHS Foundation Trust provide care for children and young people with a broad spectrum of both acute and long term health needs. Central venous access may be required both in the short and long term dependent on the specific needs of the child or young person.

Short term central venous access device, PICC lines (peripherally inserted central catheters) commonly referred to as “long lines” must be inserted by skilled clinicians at SFH using a strict aseptic procedure. The placement of a “long line” in these circumstances could be to facilitate administration of a longer course of intravenous antibiotics, minimising the need for repeated cannulation.

Children and young people with long term health problems can also have central venous access devices placed surgically at neighbouring tertiary care centres to facilitate administration of medication and treatments to optimise their health.

CVADs offer an alternative to repeated cannulation which is advantageous where gaining venous access is problematic.

Children and young people who require insertion of a Portacath (totally implantable venous access device) to enable treatment of long term health problems are routinely cared for locally at SFH, but have their devices surgically placed at neighbouring tertiary care centres.

In terms of the management of complications associated with the use of these devices, liaison with specialist clinicians at the appropriate tertiary care centre would always be recommended.

Peripherally Inserted Central Catheter (PICC also known as long lines)

Prior to undertaking any procedure with a child/young person, the responsible nurse must ensure that age/developmentally appropriate explanations are provided to encourage cooperation and to allay fears and anxieties. This should be undertaken in partnership with the child/young person’s parents/carers.

Children and young people may require play and distraction techniques prior to procedures (McQueen, 2012). The play therapy team should always be involved in pre-procedural preparation.

12.0 Paediatric: Dressing Change for a PICC

1. Frequency of dressing change: within 24 hours of insertion and then every 7 days using transparent, high moisture vapour permeable dressing unless manufactures recommend otherwise.

In certain circumstances, where a dressing is intact, visibly clean with no indications of infection, subject to discussion with the MDT team it may be appropriate to leave a dressing in situ if there is a risk compromising access. This should not be routinely

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2. Any dressing should be changed if it has becomes loose, damp or soiled. 3. Sterile steri-strips should be used to secure the PICC in addition to the transparent, high moisture vapour permeable dressing. 4. Observe the catheter insertion site through the transparent dressing for any obvious signs of migration (loosening of steri-strips, loosening of dressing or obvious change of line external line length). 5. Some PICC lines will be secured with their anchoring device (supplied with device) and will not be sutured in place. Please refer manufactures guidelines for use of anchoring device.

Equipment

 Sterile dressing-pack including sterile gloves.  Apron  Non sterile gloves  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected liaise with pharmacy. Use with caution in children under 2months.  Sterile steri-strips.  Sterile high moisture vapour permeable transparent dressing.

Procedure

1. Ensure the child/young person is provided with clear, age/developmentally appropriate explanations regarding the proposed procedure, and ensure that the parents/carers are provided with appropriate information 2. It is advisable that a dressing change should be a two person procedure to ensure the limb is supported and to minimise the risk of accidental dislodgement. 3. Assess the need to carry out additional procedures e.g. change of needle free access device. 4. Using the principles of ANTT prepare the required equipment and assemble on a clean dressing trolley or tray. 5. Prepare the patient and examine catheter for signs of infection/damage, dislodgement or phlebitis. If any concerns inform clinician and ensure the patient records are updated accordingly. 6. Apply non-sterile gloves and loosen the dressing, removing it without touching the catheter and exit site. (Appeel ™) could be used to ensure the dressing adhesive is dissolved, to minimise patient distress, but should be used with caution if there is a risk of loosening the steri-strips. Patient sensitivities should also be clarified before use. 7. Observe catheter length to check for migration. 8. Use effective hand hygiene and apply sterile gloves. 9. Clean the catheter site using the cleaning solution and the spiral technique start from the exit site, extending out to the area that will be covered by the dressing. Allow to air dry (DOH, 2010. RCN, 2010. Dougherty, 2008. Nottingham Children’s Hospital: 2013)

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10. Secure line with steri-strips placing them in an “H” style and apply a transparent high moisture vapour permeable transparent dressing over the top. Lines can be looped under the dressing For extra security; however DO NOT loop the line over the top of itself. Leave extension set/ injection port exposed. 11. Dispose of all waste as per guidelines and use effective hand hygiene. 12. Document using the central venous access device observation record:  Date/time of dressing change  Insertion site score  Evidence of catheter migration  Any nursing intervention as per individual area practices

12.1 Paediatric: Changing the Needle Free Access Device for a PICC

 The needle free access device is a bung that must not be pierced by a needle.  It does not have to be removed to attach a syringe or giving set to the PICC.  The device must always be changed at least weekly.  The device must also be changed if it becomes contaminated, or if it is suspected that blood may have collected inside.  The device will usually be changed at the same time as the dressing change. Equipment

 Sterile dressing pack including sterile gloves  Apron.  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution/ wipe or if chlorhexidine sensitivity is suspected liaise with pharmacy.  Needle free access device.

Procedure

1. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 2. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 3. Ensuring line is clamped, holding a sterile piece of gauze, one in each hand, hold the line and with the other hand remove the existing needle free access device and discard. 4. Clean catheter hub end with 2% Chlorhexidine gluconate/70% Isopropyl alcohol and 5. allow to air dry for a minimum of 30 seconds / hub appears dry. 6. Using ANTT attach the new needle free access device to the catheter hub. 7. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene 8. Record procedure and any variances in the patient's clinical record.

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12.2 Paediatric: Administration of Intermittent/Bolus Intravenous Medication via a PICC

 10 ml Luer-lock syringes or larger will need to be used when first accessing any CVAD. The back pressure from an occlusion may not be felt when using a smaller syringe when damage to a catheter has occurred (Conn, 1993). Smaller sized syringes can be used once catheter patency has first been established using a 10ml syringe (Hadaway, 1998, GOSH, 2015,) The exception to this being when accessing a Portacath or Hickman line as nothing less than a 10 ml syringe must be used throughout as high intra -luminal pressures can be generated which may result in catheter rupture (Nottingham Children’s Hospital: 2013, GAIN, 2014). Syringes with Luer-Lock connections should always be used to avoid accidental disconnection (Nottingham Children’s Hospital: 2013).  It is not necessary to routinely withdraw and discard blood from the catheter before flushing unless a larger concentrated solution of heparin or in certain circumstances: antibiotics have been used to lock the catheter line (an example of this may be line occlusion or line infection)

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/ 70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected liaise with pharmacy.  10 ml Luer-lock syringes as required  Blunt fill needle (for drawing up)  Sodium chloride 0.9% as required (for flushing)  Heparin Sodium flushing solution 50 units /5mls  Needle free access device (if required)  Sterile gloves and dressing pack.  Apron

Procedure

1 Explain the procedure to the patient 2 Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3 If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe, and allow to air dry for a minimum of 30 seconds / hub appears dry. 4. Check patency of catheter by attaching a syringe containing 10ml sodium chloride 0.9% to the needle free access device. Flush the sodium chloride into the line using a push- pause flush technique. 5. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. If concerned discuss with a clinician. 6. Do not force as forcing may result in emboli or catheter rupture. However, if met with resistance, smaller sized syringes may be used to administer medication following initial assessment of patency using a 10ml syringe. If concerned discuss with clinician. 7. Prior to administration ensure that medication, dose and rate are second checked by an

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appropriate practitioner – 2 Nurse check in accordance with SFH policy. 8. Administer medication. 9. Follow procedure and administration as per Medicine Prescription and Administration Record and manufacturer’s instructions. 10. Attach new needle free access device (if required). Needle free devices must be changed weekly. 11. Flush the sodium chloride 0.9% into the line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 12. Instil Heparin sodium 50 units /5mls solution using positive pressure flush and clamp line which prevents backflow of blood into the catheter and promotes positive pressure. The Volume of heparin solution will be dependent on the size of device in situ. This is determined by the prescribing clinician. 13. Remove & dispose of waste equipment correctly. Undertake effective hand hygiene. 14. Record procedure and any variances in the patient’s clinical record 15. Update the visual inflammation phlebitis score (VIPS) chart

12.3 Paediatric: Administration of Continuous Infusions via a PICC

 It is not necessary to routinely withdraw and discard blood from the catheter before flushing unless a larger concentrated solution of heparin or in certain circumstances: antibiotics have been used to lock the catheter line (an example of this may be line occlusion or line infection)

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate / 70% Isopropyl alcohol wipe or if chlorhexidine sensitivity is suspected liaise with pharmacy.  10ml Luer-lock syringes as required  Sterile dressing pack including sterile gloves  Apron  Blunt fill needle (for drawing up)  Sodium Chloride 0.9% as required (for flushing)  Administration set  Fluid / medicine for administration  Volumetric infusion pump (paediatrics - a pressure sensor device should always be used)

Procedure

1. Explain the procedure to the patient. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT, clean the needle free access device with the recommended cleansing wipe and allow to air dry until hub appears dry. 4. Check patency of catheter by attaching a syringe containing sodium chloride 0.9% to the needle free access device. Flush the sodium chloride into the line using a push- pause flush technique.

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5. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. If concerned discuss with a clinician. 6. Do not force as forcing may result in emboli or catheter rupture. However, if met with resistance, smaller sized syringes may be used to administer medication following initial assessment of patency using a 10ml syringe. If concerned discuss with a clinician. 7. Using ANTT attach the primed line by connecting to the cleaned needle free access device . 8. Place newly primed set in the appropriate infusion device, which must be appropriate for paediatric use and have an integral pressure sensor device. 9. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner. 10. Administer medication/ intravenous fluids / Intravenous infusion and follow procedure and administration as per Medicine Prescription and Administration Chart and manufacturer’s instructions. 11. Ensure that all lines are labelled as per hospital guidelines. 12. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 13. Record the procedure and any variances in the patient’s clinical record.

12.4 Paediatrics: Disconnecting an Intravenous Infusion for a PICC

 It is not necessary to routinely withdraw and discard blood from the catheter before flushing unless a larger concentrated solution of heparin or in certain circumstances: antibiotics have been used to lock the catheter line (an example of this may be line occlusion or line infection)

Equipment

 10ml Luer-lock syringes as required  Blunt fill needle (for drawing up)  Sodium chloride 0.9% as required (for flushing)  Heparin Sodium flushing solution 50 units /5mls  Needle free access device (if required)  Sterile dressing pack including sterile gloves  Apron

Procedure

1. Explain the procedure to the patient. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Use ANTT throughout the procedure. 4. Clamp both the catheter and the infusion line 5. Disconnect the infusion. 6. NB: Dependant on the medication/fluid being infused, it may be necessary to administer the flush at the same rate of infusion as the medication/fluid being infused, to ensure that any medication remaining in the line is not administered too quickly. Local pharmacological guidance should be sought.

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7. Unclamp the catheter and flush the sodium chloride 0.9% into the line using a push- pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 8. Repeat above process using the Heparin sodium 50 units /5ml solution. The Volume of heparin solution will be dependent on the size of device in situ. This is determined by the prescribing clinician. 9. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 10. Record procedure and any variances in the patient's clinical record

PAEDIATRIC: PROCEDURAL GUIDANCE FOR HICKMAN LINES.

For children and young persons who are cared for at Sherwood Forest Hospitals Foundation Trust, their Hickman lines will be cited within specialist centres. Please familiarise yourself with any devices before undertaking a procedure relating to that device.

12.5 Paediatric: Dressing Change for a Hickman Line

 Frequency of dressing change: within 24 hours of insertion and then every 7 days using transparent, high moisture vapour permeable dressing. However, once the Hickman line has become established dressings are not routinely required (Nottingham Children’s Hospital: 2013)  Any dressing should be changed if it has become loose, damp or soiled.  Sutures should be used to secure the Hickman line in addition to the transparent, high moisture vapour permeable dressing.  Measure the catheter length to check for migration. This measurement should be from the exit site to the hub and the length documented on the central venous access device observation record.

Equipment

 Sterile dressing-pack including sterile gloves.  Apron  Non sterile gloves  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected liaise with pharmacy. Use with caution in children under 2 months  Sterile high moisture vapour permeable transparent dressing.

Procedure

1 Ensure the child/young person is provided with clear, age/developmentally appropriate explanations regarding the proposed procedure, and ensure that the parents/carers are provided with appropriate information. 2 A second person may be required to support during the procedure to minimise the risk of accidentally dislodging the catheter. 3 Assess the need to carry out additional procedures e.g. change of needle free access device. 4 Using the principles of ANTT prepare the equipment and assemble on a clean dressing

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trolley or tray. 5 Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If concerned inform clinician and ensure the patient records are updated accordingly. 6 Put on non-sterile gloves and loosen the dressing, removing it without touching the catheter and exit site. 7 Measure catheter length to check for migration. 8 Use effective hand hygiene and put on sterile gloves. 9 Clean catheter site with cleaning solution. Start from the exit site (spiral technique), extending out to the area that will be covered by the dressing. Allow to air dry for minimum of 30 seconds. 10 Lines can be looped under the dressing for extra security; however DO NOT loop line over the top of itself. Leave extension set / injection port exposed. 11 Dispose of all waste as per guidelines and use effective hand hygiene. 12 Document using the central venous access device observation record:  Date/time of dressing change  Insertion site score  Evidence of catheter migration  Any nursing intervention as per individual area practices

12.6 Paediatrics: Changing the Needle Free Access Device for a Hickman Line

 The needle free access device is a self-sealing bung that must not be pierced by a needle.  It does not have to be removed to attach a syringe or giving set tube to the Hickman line.  The device must always be changed at least weekly.  The device must also be changed if it becomes contaminated, or if it is suspected that blood may have collected inside.  The device will usually be changed at the same time as the dressing change.

Equipment

 Sterile dressing pack including sterile gloves  Apron  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or if chlorhexidine sensitivity is suspected liaise with pharmacy.  Needle free access device

Procedure

1. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 2. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 3. Ensuring line is clamped, holding a sterile piece of gauze, one in each hand, hold the line and with the other hand remove the existing needle free access device and discard 4. Clean catheter hub end with recommended cleansing wipe 2% Chlorhexidine

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gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds. 5. Using an ANTT attach the new needle free access device to the catheter hub.

6. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 7. Record procedure and any variances in the patient's clinical record.

12.7 Paediatric: Administration of Intermittent/Bolus Intravenous Medication via a Hickman Line

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected liaise with Pharmacy  10ml Luer-lock syringes as required  Blunt fill needle (for drawing up)  Sodium chloride 0.9% as required (for flushing)  Heparin sodium flushing solution 50 units /5mls  Needle free access device (if required)  Sterile dressing pack including sterile gloves  Apron

Procedure

1. Explain the procedure to the patient. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe, 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry. 4. Attach 10ml Luer-lock syringe, unclamp line and gently draw back to ensure blood is obtained. Clamp line and check blood sample for clots and if clear connect saline syringe, unclamp line and instil the saline flush and then clamp line. (Nottingham Children’s Hospital: 2013) 5. If blood cannot be withdrawn discuss with a clinician. 6. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. 7. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 8. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner 9. Administer medication 10. Follow procedure for administration as per Medicine Prescription and Administration Record and manufacturer’s instructions. 11. Attach new needle free access device if required. Needle free devices must be changed within 7 days 12. Flush the sodium chloride 0.9% into the line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 13. Instil Heparin sodium 50 units /5mls solution using positive pressure flush and clamp line which prevents backflow of blood into the catheter and promotes positive pressure.

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The volume of heparin solution will be dependent on the size of device in situ. This is determined by the prescribing clinician and manufacturing guidance. 14. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 15. Record procedure and any variances in the patient’s clinical record

12.8 Paediatric: Administration of Continuous Infusions via a Hickman Line

Equipment  Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected liaise with pharmacy. Use with caution in children under 2 months.  Sterile dressing pack including sterile gloves  10ml Luer-lock syringes as required  Blunt fill needle (for drawing up)  Sodium chloride 0.9% as required (for flushing)  Administration set  Fluid/ medicine for administration  Volumetric infusion pump (if required)

Procedure

1. Explain the procedure to the patient. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry. 4. Attach 10ml Luer-lock syringe, unclamp line and gently draw back to ensure blood is obtained. Clamp line and check blood sample for clots and if clear connect saline syringe, unclamp line and instil the saline flush and then clamp line (Nottingham Children’s Hospital: 2013) 5. If blood cannot be withdrawn discuss with a clinician. 6. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. 7. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 8. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner. 9. Administer medication by following procedure and administration as per Medicine Prescription and Administration Record and manufacturer’s instructions. 10. Using ANTT attach the primed line by connecting to the cleaned needle free access device. Place newly primed set infusion device. Commence infusion at prescribed rate. 11. Ensure that all lines are labelled as per hospital guidelines. 12. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 13. Record procedure and any variance in the patient’s clinical record.

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12.9 Paediatric: Disconnecting an Intravenous Infusion from a Hickman Line

Equipment

 10ml Luer-lock syringes as required  Blunt fill needle (for drawing up)  Sodium chloride 0.9% as required (for flushing)  Heparin Sodium flushing solution 50 units /5ml  Needle free access device (if required)  Sterile dressing pack including sterile gloves  Apron

Procedure

1. Explain the procedure to the patient. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Use ANTT throughout the procedure. 4. Clamp both the catheter and the infusion line. 5. Disconnect the infusion. 6. NB: Dependant on the medication/fluid being infused, it may be necessary to administer the sodium chloride 0.9% flush at the same rate of infusion as the medication/fluid being infused, to ensure that any medication remaining in the line is not administered too quickly. Local pharmacological guidance should be sought 7. Unclamp the catheter and flush the sodium chloride 0.9% into the line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 8. Instil Heparin sodium 50 units /5mls solution using positive pressure flush and clamp line which prevents backflow of blood into the catheter and promotes positive pressure. The volume of heparin solution will be dependent on the size of device in situ. This is determined by the prescribing clinician and manufacturing guidance. 9. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene 10. Record procedure and any variances in the patient's clinical record.

PAEDIATRIC PROCEDURAL GUIDANCE FOR PORT ACCESS DEVICE (PORTACATH)

12.10 Paediatric: Insertion of a Gripper Needle/ Non-coring needle  The port should always be accessed using a non-coring needle. If needles that are not designed for implanted ports are used this will result in damage to the septum and will require removal of the port itself.  Different lengths and gauges of port needles are available. The length of the port needle will depend on the amount of subcutaneous tissue over the port and the depth of the reservoir.  Please refer to the patients’ health records where gripper needle size should be clearly documented.  The needle length should be assessed each the port is accessed as the child or young person could gain or lose weight (GOSH, 2015).

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Equipment

 Sterile dressing pack – including sterile gloves  Recommended cleansing solution: 2% Chlorhexidine gluconate/ 70% Isopropyl alcohol (Chloroprep ™ Sponges) or if chlorhexidine sensitivity is suspected liaise with pharmacy. Use with caution in children under 2 months of age.  Heparin sodium flushing solution: 100 units/ 1ml. 2ml for children aged 5 and under and 4ml for children over the age of 5.  10ml Luer-lock syringes  Blunt fill needle (for drawing up)  Needle free access device or Bionector  Sterile IV high moisture vapour permeable transparent dressing.  Gripper needle (appropriate length for each individual patient)  10ml of Sodium chloride 0.9%  Apron

Procedure

1. Prior to commencing procedure it is advised to palpate the port to assess the stability and mobility of port. Some ports may be mobile in children and young people. Establishing port location, prior to attempting to insert the gripper needle will aid insertion. 2. If applicable apply topical anaesthetic as prescribed. Refer to manufacturer’s recommendations. Remove topical anaesthetic after the recommended time. 3. Using the principles of ANTT prepare the equipment and assemble on a clean dressing trolley or tray. 4. Prepare flushing solutions – ensuring two nurse checks throughout in accordance with trust policy 5. Attach the needle free access device to the end of gripper needle. Prime the gripper and needle free access device with sodium chloride 0.9% and apply clamp. 6. Prepare the patient and examine port site for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 7. Position the patient in a comfortable position. 8. Use effective hand hygiene and apply sterile gloves. 9. Place sterile towel under area needing to be accessed. 10. Clean area with the appropriate cleaning solution “Chloraprep ™ ” for 30 seconds using the spiral technique. Start from the exit site (spiral technique), extending out to the area that will be covered by the dressing (Nottingham Children’s Hospital: 2014). Allow to air dry for minimum of 30 seconds. Allow to air dry. 11. Locate the edges of the port and hold firmly to prevent from moving. Identify the centre of the port and push the gripper needle through the skin at a 90 degree angle and advance until the base of the port is felt. 12. Assess patency by attaching 10ml syringe filled with 0.9% Sodium Chloride to flush; withdraw the plunger to observe for a “flashback” of blood to ensure correct position. Then instil 10ml Sodium Chloride0.9% slowly. During the flushing observe for any swelling pain and redness – if present do not use the port and inform a paediatric doctor. If in doubt remove needle.

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13 Attach syringe and instil the heparin sodium solution (heparin sodium flushing solution: 100 units / 1ml. 2ml for children aged 5 and under and 4ml for children over the age of 5). 14 Remove wings and cover with a sterile IV high moisture vapour permeable transparent dressing. 15 Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Hand Hygiene policy. 16 Record procedure and any variances in the patient’s clinical record. 17 Change the needle free device weekly and record in nursing notes.

12.11 Paediatric: Changing the Needle Free Access Device for an Implanted Port

 The needle free access device is a self-sealing bung that must not be pierced by a needle.  It does not have to be removed to attach a syringe or giving set to the port.  The device must always be changed at least weekly.  The device must also be changed if it becomes contaminated, or if it is suspected that blood may have collected inside.  The device will usually be changed at the same time as the dressing change.

Equipment

 Sterile dressing pack including sterile gloves  Apron  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution for needle free access device

Procedure

1. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 2. Prepare the patient and observe for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 3. Ensuring extension line is clamped, holding a sterile piece of gauze, one in each hand, hold the line and with the other hand remove the existing needle free access device and discard. 4. Clean catheter hub end with 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry. 5. Using ANTT attach the new needle free access device to the catheter hub. 6. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Hand Hygiene Policy 7. Record procedure and any variances in the patient's clinical record.

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12.12 Paediatric: Administration of Intermittent/bolus Intravenous Medication via an Implanted Port

 10ml Luer–lock syringes must always be used for implanted ports.

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected liaise with pharmacy. Use with caution in children under the age of 2 months.  10 ml Luer-lock syringes as required  Blunt fill needle (for drawing up)  Sodium chloride 0.9% as required (for flushing)  Heparin sodium flushing solution: 100 unit /1ml. 2ml for children aged 5 and under and 4ml for children over the age of 5  Needle free access device (if required)  Sterile dressing pack including sterile gloves  Apron

Procedure

1. Explain the procedure to the patient. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe, 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry. 3. Check patency of port by attaching a syringe containing 10ml sodium chloride 0.9% to the needle free access device. Check for flash back of blood by gently withdrawing syringe .As soon as a trace of blood is seen in the catheter or syringe, flush the sodium chloride into the line using a push-pause flush technique. 4. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. Do not force if resistance is met as forcing may result in emboli or catheter rupture 5. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner. 6. Administer medication. 7. Follow procedure for administration as per Medicine Prescription and Administration Record and manufacturer’s instructions. 8. Prime and attach new needle free access device (if required). Needle free devices must be changed every 7 days. 9. Flush the sodium chloride 0.9% into the extension line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 10. Attach syringe and instil the heparin sodium solution (Heparin Sodium flushing solution: 100 units /1ml. 2ml for children aged 5 and under and 4ml for children over the age of 5)

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11. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Hand Hygiene Policy. 12. Record procedure and any variances in the patient’s clinical record.

12.13 Paediatric: Administration of Continuous Infusions via an Implanted Port

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol or if chlorhexidine sensitivity is suspected liaise with pharmacy.  10ml Luer-lock syringes as required  Blunt fill needle (for drawing up)  10ml of Sodium chloride 0.9% as required (for flushing)  Administration set  Sterile dressing pack including sterile gloves  Apron  Fluid/medication for administration  Volumetric infusion device

Procedure

1. Explain the procedure to the patient. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry. 4. Check patency of port by attaching a syringe containing 10ml sodium chloride 0.9% to the needle free access device. Check for flash back of blood by gently withdrawing the plunger of the syringe. As soon as a trace of blood is seen in the line, flush with sodium chloride using a push-pause technique. 5. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. If concerned discuss with a clinician. 6. Do not force if resistance is met as forcing may result in emboli or catheter rupture. 7. Using ANTT attach the primed line by connecting to the cleaned needle free access device.Place the newly primed set into the infusion device. Prior to administration ensure that medication, dose and rate are second checked by a registered practitioner. Follow procedure and administration as per the Trust’s Medicine Prescription and Administration Record and manufacturer’s instructions. 8. Ensure that all lines are labelled as per hospital guidelines. 9. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Hand Hygiene Policy. 10. Record procedure and any variance in the patient’s clinical record.

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12.14 Paediatric: Disconnecting an Intravenous Infusion from an Implanted Port

Equipment

 10ml luer-lock syringes as required  Blunt fill needle (for drawing up)

 10ml of Sodium chloride 0.9% as required (for flushing)  Heparin sodium flushing solution 100units /1ml. 2ml for children aged 5 and under 4ml for children above the age of 5 years.  Needle free access device (if required)  Sterile dressing pack including sterile gloves  Apron

Procedure

1. Explain the procedure to the patient. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Use ANTT throughout the procedure. 4. Clamp both the gripper line and the infusion line. 5. Disconnect the infusion. NB: Dependant on the medication/fluid being infused, it may be necessary to administer the flush at the same rate of infusion as the medication being infused, to ensure that any medication remaining in the line is not administered too quickly. Local pharmacological guidance should be sought. 6. Flush the sodium chloride 0.9% into the extension line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. 7. Attach syringe and instil the heparin sodium solution (heparin sodium flushing solution: 100 units /1ml. 2ml for children aged 5 and under and 4ml for children over the age of 5). 8. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Hand Hygiene Policy. 9. Record procedure and any variances in the patient's clinical record.

12.15 Paediatric: Removal of a Gripper Needle/non- coring needle from an Implanted Port

Equipment

 Sterile dressing pack including sterile gloves  2% Chlorhexidine gluconate and 70% Isopropyl alcohol wipe or if chlorhexidine sensitivity is suspected 10% aqueous liaise with pharmacy  Blunt fill needle(for drawing up)  10ml Luer-lock syringes as required  10ml of Sodium Chloride 0.9% (for flushing)

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 Heparin Sodium flushing solution 100 units / ml: 2ml for children aged 5 and under: 4ml for children aged above 5 years.  Apron

Procedure

1. Prepare the equipment as per ANTT and assemble on clean dressing trolley or tray. 2. Prepare the patient and examine catheter for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 3. Using the 2% Chlorhexidine gluconate and 70% Isopropyl alcohol wipe thoroughly clean the needle free device and allow to air dry. Ensure gripper line does not come into contact with anything else or place gripper line onto a sterile towel 4. Check patency of catheter by attaching a syringe containing 0.9% Sodium Chloride for flushing , open line clamp, pull back on the syringe plunger until a flashback of blood is visible then administer flush. Clamp line. 5. Unclamp line and instil heparin sodium flushing solution using positive pressure flush and clamp line which prevents backflow of blood into the catheter and promotes positive pressure. The heparin sodium will last for 4-6 weeks (Nottingham Children’s Hospitals: 2014) 6. Hold port firmly with one hand, pressing down, whilst removing gripper from port. 7. If applicable, apply gentle pressure with sterile gauze if site is bleeding, remove gauze and cover with a high moisture vapour permeable transparent dressing. 8. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene. 9. Record procedure and any variances in the patient's clinical record.

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APPENDIX THREE: NEONATES PROCEDURAL GUIDANCE

13.0 Care of a Baby with a Central Line (Umbilical Venous / Umbilical Arterial Catheters / Long Lines)

Non-tunnelled, centrally inserted central venous catheters (CVCs) are lines positioned in a large central vein.

UVC

In neonates the route most frequently used at birth is the umbilical vein. This fine bore (UVC) catheter is aseptically inserted into the umbilical vein. It is advanced until the tip ideally lies in the inferior vena cava. It has a double lumen for infusion of simultaneous fluids.

UAC

The umbilical artery is used for placing a single lumen arterial catheter, used for blood sampling and blood pressure monitoring. Considerations affecting Umbilical Arterial lines (UAC):  Position the transducer at the approximate level of the neonates heart, mid axilla, to maintain an accurate reading  The transducer needs to be calibrated or zeroed at the commencement of monitoring, once per shift or if the transducer’s position or baby’s position is altered.  Never inject fluid boluses or medications into arterial lines. This may cause spasm severe enough to obstruct all blood flow through the artery.  Never forcefully irrigate the catheter. Released clots may obstruct the flow to distal arteries. If the line appears clotted, seek help from senior member of the team.  Do not allow air to enter the system. Air may result in an embolus in the distal arteries.

Long line (PICC)

Long lines are a type of central venous line, which are peripherally inserted central venous catheters (PICC), commonly used in neonates for central vascular access. They are peripherally inserted via an upper or lower limb vein, and then threaded to the superior vena cava (SVC) if an upper limb vein is used (e.g. brachial or cephalic veins), or to the inferior vena cava (IVC) if inserted via a lower limb vein (e.g. femoral or saphenous vein) (Lloreda-García et al 2016). They are used in neonates because of the small lumen size of the catheter and because they can remain in-situ for 4-6 weeks, making them ideal for long term use.

There are specific key points to highlight regarding care of neonatal long lines that differ from the care of other central venous access devices (CVAD). This is due to the small lumen size of the catheters (Size 1-2fr).

The Department of Health (UK) (DH 2001) recommend that the line tip is placed OUTSIDE the heart either the superior (SVC) or inferior (IVC) vena cava to avoid risks of cardiac tamponade. Cardiac tamponade can pose serious health risks and may result in death (Lloreda-García et al 2016). This may occur if the position of the long line is intra-atrial. The position can only be Title: IV Policy - Intravenous (IV) Medication and Fluid Therapy Administration Through a Central Venous Access Device Version: 1.0 Issued: September 2018 Page 61 of 73 confirmed by the medical team or specifically trained nurse practitioners. If the long line is in the incorrect position, the medical team or nurse practitioner team can pull it back by 1cm-2cm, however position complications will frequently require removal or replacement of the long line (Lloreda-García et al 2016, Sharpe 2014). Confirmation of Long line position can only be undertaken by performing a chest x-ray. As these Long lines cannot be aspirated, checking for blood return is NOT a means of assessing Long line position before use (Soe 2007).

Central Line Indications for use include:

 UVC – emergency venous access  Major gastrointestinal disease.  Prolonged intolerance to enteral feeds  Parental nutrition administration  Compromised peripheral venous access  Long term antibiotic therapy  Inotrope infusions/ irritant medicine use  Simultaneous infusions of multiple infusions  Blood sampling (UAC only)  Accurate blood pressure monitoring (UAC only)

13.1 General Care of Neonate with a Central Line.

 The baby should be nursed in an incubator or under a radiant heater. Especially important with UAC or UVC when baby is nursed exposed so that the insertion site can be easily observed  The baby should have ECG lead monitoring, to check for arrhythmias and general deterioration.  An x-ray must be undertaken following line placement to confirm the position. The position of the catheter tip should be documented in the medical notes. It is good practice to infuse 1ml/hr 0.9% sodium chloride through the CVC, to keep the line patent until the x-ray confirmation is obtained.  Platelets should not be infused through central lines. The line is too small and will break down the cells.  Long lines are for long term use (PN, Antibiotics, Prostin etc.) and may be left in for up to 14 days, as long as there is no evidence of line infection.  Never administer bolus fluids through the Long line - This may result in the catheter bursting due to the low pressure tolerance and burst strengths of the Long line  Never aspirate from a Long line - Due to the soft lumen, this may result in trauma or vessel irritation.  Always use a 10ml Luer lock syringe when accessing the Long line  Always have an infusion of minimum 0.5ml/hr running through the Long line (e.g. 0.9% sodium chloride). This can be via a syringe pump or infusion pump, to reduce the risk of the Long line occluding. N.B. Long lines may be flushed when assessing for patency if occlusion suspected. However due to the small lumen size, these long lines can run at extremely high pressures of between 100-300mmhg, and it is important not to make the mistake of assuming the long line is blocked.

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If flushing the Long line for assessment of patency, no more than 1ml volume should be used and a 10ml Luer lock syringe must be used so the optimal pressure is achieved. (Petit and Wyckoff 2007)

13.2 Dressing Changes

Long lines have low infection rates and low risks of complications, so it is recommended that dressing changes are not be performed routinely but only be changed on an ‘as required’ basis (Sharpe and Pettit 2013). The need to change a dressing should be determined from visually assessing the site and identifying that the line or skin integrity is at risk. The UAC/UVC should be stitched to the stump on insertion and then held in place by adequate fixation.

Assessment of insertion site  The insertion site must be assessed hourly for any signs of redness, swelling, oozing, phlebitis or tracking.  Document the outcome of the assessment on the intensive care chart  Record any signs of infection such as erythema, tenderness, and swelling and inform medical team immediately. Document any action taken.  The colour and warmth of the limb should also be checked hourly and the CVC may need to be removed if there is impaired circulation.  The limb should be observed for any signs of swelling or discolouration along the line of the catheter  The medical team must review the need for the CVC and document on a daily basis.  Babies with UAC or UVC should be nursed supine.  Keep site visible. No socks or covers and nappy should be unfastened for umbilical line.  Observe lower limbs and buttocks of neonate with an umbilical catheter for signs of blanching or discolouration.

Indications for dressing change include:  The dressing integrity appears affected or is lifting  If the hub or any part of the entrance site of the long line has become exposed  If the loop has become uncoiled or is pulling and the long line position may be compromised  If the Long line or skin is visibly dirty or oozing blood/ serous fluid where it is affecting the dressing integrity  If it appears to have any signs of infection such as redness, swelling, purulent ooze.

Equipment  New dressing (IV3000®)  Aprons and gloves  Chlorahexadine 0.05% solution for skin cleansing  Adhesive remover wipes (e.g. Appeel®)  Sterile wound closure strips (e.g. Steri-Strips®)  Pack of sterile gauze

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Dressing change procedure: 1. A two nurse technique should be used. One to perform the dressing change and one to assist. 2. Both nurses must don aprons and perform hand hygiene as per Trust Clinical Guideline ‘Hand Hygiene’ 3. The assisting nurse should clean and prepare surface of trolley being used for procedure using sanitizing wipes (e.g. Clinell® universal wipes) and allowing this to dry. Hand hygiene should again be performed. 4. Aseptic non-touch technique is to be used at all times as per ANTT clinical guideline, Gloves should be applied 5. Adhesive remover wipes (e.g. Appeel®) should be used to loosen the adhesive from the old dressing. The old dressing should be removed very carefully, while holding the stabilising wing on the catheter. It should be peeled from the outside towards the insertion site. 6. Remove the old steristrips 7. The insertion site should be closely observed and specific position of length of insertion noted, oozing or for signs of infection. 8. The site should be cleaned using a 0.05% Chlorhexidine gluconate in up and down motions beginning from the insertion site and moving outwards 9. The skin must be allowed to dry for a minimum of 30 seconds. 10. Proceed to loop or coil the long line and place on surface of skin 11. A small square of sterile gauze or Duoderm® should be placed under the stabilisation hub 12. Place a wound closure strip (e.g. steri-strip®) over loop and entrance site and place another strip over the stabilisation hub 13. Visually assess site to ensure the long line position has not moved by observing the markings on the Long line and ensure skin integrity remains intact . 14. Cover the long line including all of the thin segment and the stabilisation wing with a semipermeable transparent dressing (e.g. IV 3000®/ Tegaderm®), being careful not to encircle the limb 15. Remove apron and gloves. 16. Perform hand hygiene. 17. Document dressing change and observation of site in health care record 18. Dispose of all waste in accordance with the Trust Waste Management Policy

13.3 Changing the Needle Free Access Device For Umbilical Venous / Umbilical Arterial Catheters / Long Lines

 The needle free access device is a self-sealing bung that must not be pierced by a needle.  It does not have to be removed to attach a syringe or giving set tube to the UAC, UVC or Long Line.  The device can be used for up to 140 times, but must always be changed at least weekly for all neonates regardless of level.  The device must also be changed if it becomes contaminated, or if it is suspected that blood may have collected inside.

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Equipment

 ANTT Tray  2 pairs of non-sterile gloves  Apron  2% Chlorhexidine gluconate and 70% Isopropyl alcohol cleansing solution or wipe.  Needle free access device primed with 0.9% saline.

Procedure

1. Prepare the equipment using ANTT, don first pair of gloves and assemble on a clean dressing trolley or tray. 2. Prepare the patient and examine catheter and patient for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician. 3. Clean hands as per trust policy and change to the second pair of gloves. 4. Ensuring line is clamped, hold the line and with the other hand remove the existing needle free access device and discard. 5. Clean catheter hub end with recommended cleansing wipe, (2% Chlorhexidine gluconate/70% Isopropyl alcohol), and allow to air dry for a minimum of 30 seconds/ hub appears dry. 6. Using ANTT attach the new needle free access device to the catheter hub, protecting key parts at all times. 7. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Infection Control policy. 8. Record procedure and any variances in the patient's clinical record.

13.4 Administration of Intermittent Intravenous Medication For Umbilical Venous / Umbilical Arterial Catheters / Long Lines

 Do not give intermittent intravenous medication via a UAC, Intravenous medication should only be given via the UAC route under rare circumstances under specialist instruction.  Bolus and intermittent medicine administration should be kept to a minimum as repeated manipulation of line increases the risk of blood stream infections.  Bolus and intermittent medicine administration also increases the risk of line rupture.  Flush volumes should be equal to at least twice the volume of the catheter and add on devices (RCN 2010)

Equipment

 Recommended cleansing wipe 2% Chlorhexidine gluconate/70% Isopropyl alcohol  10ml syringes as required  Tray, apron, non-sterile gloves  Blunt filter needle (for drawing up medications)  10ml syringe of Sodium chloride 0.9% required for flushing volume  Needle free access device (if required)

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Procedure

1. Explain the procedure to the parents. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. If using an existing needle free device, use principles of ANTT clean the needle free access device with recommended cleansing wipe, 2% Chlorhexidine gluconate/70% Isopropyl alcohol and allow to air dry for a minimum of 30 seconds / hub appears dry. 4. Check patency of catheter by attaching a 10ml syringe containing 5ml of sodium chloride 0.9% flush to the needle free access device. Do not check for flash back of blood in the catheter or syringe (venous lines only), continue to flush the sodium chloride into the line using a push - pause flush technique. 5. Signs of catheter occlusion, whether partial or complete will require early action to restore patency of the device. 6. Do not force if resistance is met, as forcing may result in emboli or catheter rupture. 7. Prior to administration ensure that medication, dose and rate are second checked by an appropriate practitioner. 8. Administer the medicine/ prescription as recommended in the Trust IV Medication policy. Using a push-pause flush technique, flush the line between medicine administration and at the end of medicine administration with sodium chloride 0.9% and clamp under positive pressure. 9. Follow procedure and administration as per Medicine Prescription and Administration Record and manufacturer’s instructions. 10. Prime and attach new needle free access device (if required). Needle free devices must be changed within 7 days or 140 uses. 11. Flush the sodium chloride 0.9% into the line using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. Clamp the line under positive pressure. 12. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene referring to Trust Hand Hygiene Policy. 13. Record procedure and any variances in the patient’s clinical record.

13.5 Administration of a Continuous Infusion For Umbilical Venous / Umbilical Arterial Catheters / Long Lines

 Infusions within Neonatal Care should be delivered through an electronic infusion device as there is a need for accurate administration and prompt occlusion alarms. Increased resistance to flow (indicated by a change in pressure) could indicate migration of the catheter or another physiological obstruction to flow and should be immediately investigated. The pressures must be recorded hourly to facilitate this, measurable and sustained changes, sustained/ repeated occlusion alarms and indications of baby discomfort require a re-assessment of the baby and the infusion site, including VIP Score assessment. Raised VIP and continued concerns signal escalation to a medical practitioner.  The only fluid to be administered via UAC is heparinised saline (Hep Sal) as prescribed.  Blood products are only to be administered via a UVC or peripheral cannula.  When using a UVC or Long line it is recommended that a 0.22 micron filter is used on the Parenteral Nutrition bag and medication where indicated. Do not use with lipid. The 0.22 micron filter reduces

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the risk of contamination, retains endotoxins, protects against particulate matter, and air embolus. The filter should be changed every 96 hours.

 For Lipids a 1.2 micron filter is used -

1.2 Micron Filter for use with Lipids (blue filter)

0.22 Micron Filter for use with all TPN (as above but green)

 Administration sets to be changed as follows: - Parenteral Nutrition 24hour OR 48hour bags as advised from pharmacy - lipids changed every 24 hours - Clear fluids 48 hours if line is unbroken - Intravenous lines with additives should be changed 24 hourly. - Some medicines require the giving sets to be changed more frequently. - Lines should be labelled as per the line labelling policy for NICU

Equipment

 2% Chlorhexidine gluconate and 70% Isopropyl alcohol wipe  Intravenous infusion sets  Intravenous fluids as prescribed  Tray, apron, non-sterile gloves

 If the type of fluid / medication is to change also include:

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 10ml syringe with 3-5ml sodium chloride 0.9% to flush line before new infusion is attached. The volume of the flush solution should be equal to at least twice the volume of the catheter and add on devices (RCN 2010).

Procedure

1. Prepare the equipment as per ANTT and assemble on clean dressing trolley or tray. 2. Prepare the patient and examine catheter and patient for signs of infection/ damage, dislodgement or phlebitis. If any concerns inform clinician and document. 3. Undertake effective hand hygiene in accordance with the Trust Hand Hygiene Policy. 4. Prepare intravenous fluid as per prescription, keep key parts protected. 5. Make the line accessible, stop the infusion, clamp line, clamp the catheter (using correct method either ‘pinch clamp’ or 3 way tap ‘off to baby’) and remove infusion in situ if applicable, from needle free access device. 6. Using an ANTT clean the needle free device with 2% Chlorhexidine gluconate and 70% Isopropyl alcohol wipe. Allow to air dry for a minimum of 30 seconds. 7. Attach new infusion ensuring that medications must be infused through the needle free access device. 8. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Trust Hand Hygiene Policy 9. Record procedure and any variances in the patient's clinical record.

13.6 Disconnecting an Intravenous Infusion For Umbilical Venous / Umbilical Arterial Catheters / Long Lines

Never disconnect the heparinised saline infusion from the UAC for ‘UAC removal’, only disconnect if you are changing the heparinised saline due to expiry, as per ‘Administration of a Continuous Infusion’ guide above.

Equipment

 10ml syringes as required  Clean Tray, apron, non-sterile gloves  Blunt filter needle (for drawing up)  * Sodium chloride 0.9% as required (for flushing)  Needle free access device (if required)

* The volume of the flush solution should be equal to at least twice the volume of the catheter and add on devices (RCN 2010).

Procedure

1. Explain the procedure to the parent. 2. Prepare the equipment using ANTT and assemble on a clean dressing trolley or tray. 3. Use ANTT throughout the procedure 4. Clamp both the infusion line and catheter (using correct method either ‘pinch clamp’ or 3 way tap ‘off to baby’) and the ensuring needle free access device is left in situ, change to the second pair of gloves. 5. Disconnect the infusion.

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6. If ending the infusion (long line/ UVC only), then flush the line with sodium chloride 0.9% using 10ml syringe using a push-pause flush technique; this will create turbulence inside the catheter lumen aiding the removal of fibrin and medicine precipitation. Re-clamp the line under positive pressure ensuring needle free access device remains in situ. If the infusion contained medication infused over a period of time, it is recommended that the flush is infused at the same rate to ensure the remainder medication in the line is not given as a bolus. 7. If connecting a new infusion follow ‘Administration of a Continuous Infusion’ as above 8. Remove and dispose of waste equipment correctly. Undertake effective hand hygiene in accordance with the Trust Hand Hygiene Policy 9. Record procedure and any variances in the patient's clinical record. 10. Continue to observe the site as per policy.

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APPENDIX FOUR :

14.0 Risks Associated with CVADs

Partial Withdrawal Occlusion: This is usually caused by fibrin sheath formation and identified by absent or sluggish blood return whilst fluids can be infused. Fibrin sheaths can result in seeding of bacteria and drug extravasation and can be resolved of the instillation of a thrombolytic agent .  Seek medical advice.  Seek pharmacy advice.

Total Occlusion: This is when there is an inability to withdraw blood or infuse fluids or medications. This can be resolved by the instillation of a thrombolytic agent.  Seek medical advice  Seek pharmacy advice.

Infection: If the patient has clinical displays clinical signs of an infection, the CVAD should be considered as a possible source of an infection.  Blood cultures should be taken peripherally and from all lumens (Gorski et al, 2010).  Swabs from the exit point of the CVAD.  Microbiology advice should be considered and device removed if there is a strong suspicion of infection. The tip MUST be sent for C&S.

Thrombosis: A large proportion of patients who develop a thrombosis are never detected. However, if a patient develops pain in the axilla, shoulder or arm swelling of the face, neck, one limb or fingers, hand or arm or hand, distention of the local venous system, any skin temperature change or discolouration MUST be reported immediately to the medical clinician responsible for the patients care. An urgent Doppler or ultrasound or may be required to confirm diagnosis. Anticoagulation therapy may be required.

Catheter Migration: Monitoring of the CVAD should occur 8 hourly and documented upon the trust documentation chart. This also includes catheter length. The catheter will be secured into position however migration can still occur. Migration should be suspected if:  There are repeated and unresolved patency problems.  The patient complains of pain during flushing of the CVAD.  If the patients develops a thrombosis  The external length of the catheter increases

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If migration suspected the medical clinician responsible for the patients care must be informed immediately.

Haemorrhage: The patient should be monitored closely for any signs of haemorrhage and if suspected, the medical practitioner responsible for the patients care informed immediately and the patient urgently reviewed. (Doyle 2008, Thompson 2009)

Pneumothorax: Pneumothorax is a potentially life threatening complication associated with central venous catheter insertion and if suspected MUST be treated as a medical emergency. It is most common if the catheter is inserted via the subclavian vein. If the patient develops symptoms which include; dyspnoea, respiratory insufficiency / distress, tachycardia, hypotension, agitation, cough, pleuritic chest pain or shoulder tip pain.  The medical practitioner responsible for the patients care MUST be informed immediately.

Note: It is important to remember that an x-ray taken post insertion may not identify a slowly developing pneumothorax. A further chest x-ray will be required if the patient becomes symptomatic of a pneumothorax.

Air Embolism: Air embolism is a potentially fatal complication; it can be clinically silent and can occur at any time. Any signs of patient distress, respiratory insufficiency, dyspnoea, cyanosis and /or pain, this MUST be reported and responded to immediately. This may happen:  If there is a break in the closed system of the CVAD.  When changing a needle free device access device.  If the line become damaged during suture removal.  If there is air in the giving set.  During insertion and removal.

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15.0 APPENDIX FIVE:

Types / Common Insertion sites / Use and longevity of Central Venous Access devices - Adapted from Royal Marsden 2015

Type of Device Common Insertion sites Recommended Indwelling Life and (veins) Common Uses

Peripherally Inserted Antecubital fossa Used primarily for patients needing Central Catheter several weeks or months of intravenous Basilic access (PICC line) Brachial

Cephalic

Skin‐tunnelled catheter Jugular Check manufacturers recommendations Indefinite. Used for long‐term (e.g. Hickman Line) Axillary intermittent, continuous or daily intravenous access. May be appropriate Subclavian for short‐term use if reliable access needed Femoral

Implanted ports Usually implanted Check manufacturers recommendations subcutaneously into the chest Intermittent, continuous or daily (e.g. Port-a-caths) or arm, but can be placed on intravenous access – the port sited in a the lower chest wall/ abdomen subcutaneous skin pouch – the line is Peripheral ports or thigh depending on the sited into a large adjacent central vein Low profile patients’ needs They last much longer than CVADs can valve last between 5-10 years

Computed tomography compatible ONLY IF POWER INJECTABLE (check with manufacturer)

Midlines Inserted peripherally – the tip Check manufacturer’s does not go beyond the recommendations subclavian vein Used frequently for antibiotic therapy over 4-6 weeks Non – tunnelled Placed in the subclavian Check manufacturer’s percutaneous central (preferred route – lower risk of recommendations venous catheters infection) jugular, or femoral But usually 7-10 days for short term CVCs veins therapies Central Venous Pressure monitoring Emergency use for fluid replacement and absence of peripheral veins

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16.0 APPENDIX SIX: Quick guide to heparin flushes / Parenteral Access Devices https://pharmacy.sfh-tr.nhs.uk/formulary/Ch2/heparinflush.htm

http://pharmacy.sfh-tr.nhs.uk/formulary/misc/centrallines.htm

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