Central Venous Access Device Policy (Central Line Policy)

Policy No: OP41

Version: 3.0

Name of Policy: Central Venous Access Device Policy (Central Line Policy)

Effective From: 24/10/2013

Date Ratified 26/09/2013 Ratified Infection, Prevention and Control Committee Review Date 01/09/2015 Sponsor Director of Nursing, Midwifery and Quality Expiry Date 25/09/2016 Withdrawn Date

This policy supersedes all previous issues.

Version Control

Version Release Author/Reviewer Ratified Date Changes by/Authorised (Please identify page no.) by 1.0 01/12/2006 L Swanson Trust Policy 01/12/2006 Forum

2.0 29/10/2009 J Thompson IPCN Infection, 31/07/2009 Prevention and Control Committee

3.0 24/10/2013 C Griffiths IPCN Infection, 26/09/2013 Prevention and Control Committee

Central Venous Access Device Policy v3 2 Contents

Section Page

1. Introduction ...... 4 2. Policy scope ...... 4 3. Aim of policy ...... 4 4. Duties (Roles and responsibilities) ...... 4 5. Definitions ...... 5 6. Central Venous Access Device Policy (Central Line Policy) ...... 6 6.1 Principles of Care ...... 6 6.2 Setting ...... 6 6.3 Infection Prevention ...... 6 6.4 Use of Ultrasound Guidance ...... 6 6.5 Choice of line ...... 7 6.6 Total Parenteral Nutrition ...... 7 6.7 Critically ILL Patients ...... 7 6.8 Poor Access ...... 7 6.9 Bionectors ...... 8 6.10 Lumens not in use ...... 8 6.11 Flushing ...... 8 6.12 Documentation ...... 8 6.13 Types of CVADs ...... 8 6.14 Care of the insertion site ...... 9 7. Training ...... 9 8. Equality and diversity ...... 10 9. Monitoring compliance with the policy ...... 10 10. Consultation and review ...... 11 11. Implementation of policy (including raising awareness) ...... 11 12. References...... 11 13. Associated documentation (policies) ...... 11

Appendices Appendix 1 Types of Vascular Access Devices ...... 12 Appendix 2 The main veins used for Central Venous Access Device placement ...... 13 Appendix 3 Procedure for Administering Medication via a CVC ...... 14 Appendix 4 Procedure for using a double lumen Haemofiltration Catheter ...... 16 Appendix 5 Guidelines for Nursing staff on the Care and Management of Tunnelled Devices ... 17 Appendix 6 Guidelines for Nursing staff on the care and management of Hickman lines ...... 22 Appendix 7 Care Standard 25A Care of the patient with a Non Tunnelled ...... 26 Central Venous Access Device Appendix 8 Care Standard 25B Care of the patient with a Tunnelled Central ...... 27 Venous Access Device Appendix 9 Competency Based Assessment Document for a Registered ...... 28 Practitioner to access Central Venous Access Devices

Central Venous Access Device Policy v3 3 Central Venous Access Device Policy (Central Line Policy)

1 Introduction

Central venous catheters (CVC) are inserted for many reasons including haemodynamic monitoring, intravenous delivery of blood products and drugs, haemodialysis, total parenteral nutrition, cardiac pacemaker placement and management of perioperative fluids.

NICE have provided guidance on the methods used for placement of CVC. Their subsequent management has been mentioned in government documents such as Winning Ways and Saving Lives and is also been the subject of a review by EPIC.

High impact Intervention No 1 – Central Venous Catheter Care bundle found at website ‐ http://www.clean‐safe‐care.nhs.uk/index.php?pid=4 should also be use as part of normal practice for any area using and caring for central lines.

CVC’s are sited in a number of clinical areas within the Trust by clinicians from various specialties. This policy aims to aid all professionals in applying best practice within the setting of Gateshead Health NHS Foundation Trust.

This policy has been compiled by a multidisciplinary group in consultation with the Clinical Directors of each Division.

Paediatric practice is beyond the scope of this policy. Please refer to Consultant Paediatrician at RVI.

2 Policy scope

This policy applies to all clinical staff employed in the trust. Clinical staff must comply with the relevant local policy and guidelines and must be used in conjunction with: IC 4 Hand Hygiene Policy IC 2 Personal Protection Clothing in Clinical Practice Policy IC 9 Waste Disposal and Recycling Policy OP 41 Central Venous Policy

3 Aim of policy

This policy aims to aid all professionals in applying best practice for care of Central Access Devices within the setting of Gateshead Health Foundation Trust

4 Duties (Roles and responsibilities)

The Chief Executive has responsibility for ensuring the Trust has robust and effective Infection and Prevention Control Policies.

Central Venous Access Device Policy v3 4 Trust Board has a responsibility to ensure that the risk of infection to patients, staff and visitors is minimised to its lowest potential and therefore supports the full implementation of this policy.

The Directors of Infection Prevention and Control have executive responsibility for Infection Prevention Control and oversee Infection and Prevention Control activity via the Infection and Prevention Control Committee.

Consultant Microbiologist ‐ will give advice against this policy and follow up all positive blood cultures with clinical staff.

Head of Infection Prevention and Control ‐ will give advice against this policy and Ensure that all staff have access to this policy via the Trust Intranet and ensure that it is updated every two years or in line with current national guidance.

The Infection and Prevention Control Team – will give advice and support on management and policy interpretation.

The Infection Prevention and Control Committee ‐ is responsible for the ratification of Trust wide infection prevention and control policies, procedures, and guidance, providing advice ad support on the implementation of policies and monitoring the progress of the annual infection control programme.

Heads of Department ‐ Must ensure that appropriate training is available and that staff understand and comply with the Central Venous Access Device policy.

Managers – will ensure that all staff are aware of and follow this policy and are aware of their own roles and responsibilities to ensure safe practice.

All Trust staff ‐ have a responsibility to adhere to Trust policy and ensure that appropriate measures are taken to reduce risks associated with infection. All Trust staff have a responsibility to ensure they attend Central Line training, annual training in infection Prevention and Control and attend Central Line training updates thereafter.

5 Definitions

Central Venous Catheter (CVC)/Central line – termed CVAD (Central venous Access Devices). Device is used instead of “line”.

ART team – Acute Response Team

IPCN – Infection Prevention and Control Nurse

TPN – Total Parenteral Nutrition

Central Venous Access Device Policy v3 5 6 Central Venous Access Device Policy (Central Line Policy)

6.1 Principles of care

Regardless of the type of CVAD used, the principles of care for the device remain the same. • To prevent infection. • To maintain a ‘closed' intravenous system with minimal connections to reduce the risk of contamination. • To prevent damage to the device and associated intravenous equipment. • To maintain a patent and correctly positioned device.

The clinician placing the line is responsible for ensuring that any contraindications have been addressed for example coagulopathy.

The procedure should be explained to the patient.

6.2 Setting

Tunnelled devices (Groshong or Hickman devices) for longer‐term access and devices for TPN should be sited in a Theatre environment.

There after for management, ie dressing changes a clean clinical area such a treatment room should be used whenever possible.

Open wards of critical care areas such as CCD, A&E and CCU are acceptable due to the nature of the patients treated.

The urgency of placement and the stability of the patient should be taken into account.

6.3 Infection Prevention

Groshong or Hickman lines for long‐term access and CVAD s for TPN should be sited and removed in a Theatre environment.

With reference to IC policy 18 MRSA policy, all in‐ patients should have MRSA screening of nose and throat unless femoral access when screening would be indicated nose, throat and groin, and thereafter on a once weekly basis for as long as the CVAD in situ.

Any plan for CVAD insertion, renewal or removal (where MRSA status positive) necessitates discussion with the microbiologist and IPCN review to ensure appropriate antimicrobials given prior. Octenisan body wash is indicated for all in patients. This is irrespective of their MRSA status.

6.4 Use of Ultrasound Guidance

Training in the use of ultrasound guidance is now routine in anaesthetic practice.

Central Venous Access Device Policy v3 6

NICE published guidance on this in 2002 and reviewed it in 2009 with no change to guidance from 2002. http://www.nice.org.uk/cat.asp?c=36752

The grade and training of the clinician inserting CVADs will vary between Divisions depending upon the level of expertise available. Anyone undertaking insertion should be competent to do so either as demonstrated by their training documents or experience.

6.5 Choice of Line

Renewal or insertion of further access must be risk assessed outside of the critical care setting. Decision to access more than 2 ports must be an exception and evidence to support this documented. Decisions made should take place in conjunction with microbiology and the IPC nursing team.

There is no strong evidence for the use of antimicrobial or silver bonded lines as routine for short term cannulation.

6.6 Total Parenteral Nutrition

If TPN is being administered prior to surgery, following a risk assessment a double lumen CVAD may be used. This has to be in conjunction with a risk assessment for a named patient only and not as routine practice.

Consideration must be given to patients with non tunnelled devices that require treatment for duration greater than seven days. A tunnelled device may be indicated and planned for by contacting radiology or the on call vascular team.

The lumen dedicated to TPN use should ideally be the smallest lumen on the device. It should be capped with a bionector and identified as the TPN lumen. Once TPN has been commenced the line should not be used for any other purpose.

Three way taps are not acceptable for TPN.

6.7 Critically ILL Patients

This encompasses patients in A&E, MAU, CCU, CCD, maternity and theatre.

The standard device for these patients is a quad lumen device with a port reserved for TPN.

Specifically designed devices for pacing should be available on CCU or catheter laboratory.

6.8 Poor Access

If a CVAD is being sited due to poor peripheral venous access (in a non perioperative situation ) a double lumen device should be used.

Central Venous Access Device Policy v3 7

Double lumen devices are to be held by A and E, theatres, MAU, CCD and CCU only.

6.9 Bionectors

TPN should be administered using a dedicated lumen (EPIC CVAD 37) with a dedicated Bionector in place.

Decontaminate the bionector before and after use with PDI Sani Cloth CHD 2% (chlorhexidine/alcohol)

The bionector must be replaced every 7 days.

Patients discharged from Critical Care with a CVAD in situ must have 3 way taps removed from the CVAD and replaced with bionectors prior to discharge. Advice may be sourced from the Acute Response Team. (ART)

6.10 Lumens not in use

Please note the guidance differs depending on the type of device see below.

For Non tunnelled Devices, CVADs lumens not requiring daily access should have a bionector and flushed daily, and consideration given for removal.

For Tunnelled devices, lumens not requiring daily access should have a bionector and replaced and flushed on a weekly basis.

6.11 Flushing

0.9% sodium chloride is advised for routine flushes unless the device is a Hickman CVAD. The policy for care and flushing of this CVAD is attached in Appendix 5.

6.12 Documentation

The procedure should be documented in the patient’s case notes. This will include the date, time and operators name, signature, grade and contact number, plus type of line inserted. Care standard 25a or 25b should be placed. Monitoring and record of the site should be done x 3 times per day and VIP scores recorded any signs of erythema should be reported, This should include referral to the link IPCN and /or microbiologist. All care documented and actioned. Any swabs taken from the site must be documented in the Care Standard evaluation.

6.13 Types of CVADs

Within Gateshead Health NHS Foundation Trust central lines are usually: • non tunnelled short term use/multi lumen (Acutely ill patients) • tunnelled, long term use (Groshong/Hickman)

Central Venous Access Device Policy v3 8

Please ensure you are aware of the type of line inserted prior to any care being given to the line.

Multi‐lumen Central Venous Catheters

Used predominantly within Critical Care, Theatres and A&E.

Used for : monitoring haemodynamic status (CVP); administration of inotropes/vaso‐active medication; administration of TPN (via a dedicated lumen); administration of medications which are irritant and are likely to cause phlebitis if administered via a peripheral vein.

Insertion sites

Neck (internal jugular vein), chest (sub clavian vein), or groin (femoral vein).

6.14 Care of the Insertion Site

As for other CVCs. Clean with 2% chlorhexidine / 70% isopropyl alcohol (EPIC CVAD 24), dress with transparent semi permeable dressing (EPIC CVAD 19) renewed every 7 days or more often if necessary (EPIC CVAD 20). A sterile gauze dressing may be indicated if there is bleeding from the insertion site or profuse perspiration. This will need changing if it becomes damp, soiled or displaced, or to inspect the site, and should be substituted with a transparent semi permeable dressing as soon as appropriate (EPIC CVAD 21 & 22).

Condition of the insertion site should be observed and documented daily by nursing staff, and medical staff informed of any inflammation or discharge at site.

CVCs placed in neck or chest veins should have their position confirmed by x‐ray prior to use – also to exclude pneumothorax caused during insertion.

Line manipulation must be kept to a minimum and flushed daily when not in use. The flush should be recorded in the nursing record.

7 Training

This is a ward based learning clinical skill. Formal and practical training outside the clinical setting is available to both nursing and medical staff and is available through OD and

Central Venous Access Device Policy v3 9 training. All trust staff that carry out this procedure will need to be competency assessed prior to central venous blood sampling. Ward based learning (education and training) is available via IPCN/ PDT and the ART team.

8 Equality and diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the grounds of any protected characteristic (Equality Act 2010).

9 Process(s) for monitoring compliance with the policy

Surveillance will be carried out on a continual basis by the IPC nurses and any CVAD practice will be monitored and supported.

Any variance from best practice will be addressed with individual practitioners. This will be in conjunction with the practice development and ART team. Escalation to line managers will be initiated where additional education and support does not resolve poor practice issues.

Standard/process/ Monitoring and audit issue Method By Committee Frequency Ward Quality Dashboard Ward Manager IPC Committee Bi‐ monthly Measure Audits submission of designated weekly audits Nurse

Divisional Divisional safe Matron IPC Committee Bi‐monthly exception report care report for each divisions commitment to infection prevention and control

Blood culture IPCN Monitoring IPCN routine IPC surveillance Weekly contamination follow up meetings rates IPC Committee Bi‐monthly

MRSA admission Data reports IPCN MRSA IPC surveillance Weekly MRSA screening lead with IPCT meetings compliance Admin Support IPCC Committee Bi‐monthly SoTW PCT Practice & Monthly performance HCAI meetings

Central Venous Access Device Policy v3 10

10 Consultation and review

Members of Infection Prevention and Control Team (IPCT) and Infection Prevention and Control Committee (IPCC)

11 Policy implementation (including awareness raising)

All members of staff will be informed via e mail and individual team meetings when due for review.

12 References

Department of Health (2007). Saving lives: reducing infection, delivering clean and safe care. DoH, 2007. http://www.clean‐safecare

The Royal Marsden Hospital Manuel of Clinical Nursing Procedures Eighth Edition 2011

13 Associated documentation

The ‘Saving Lives’ programme to reduce healthcare‐associated infections includes guidance on taking blood cultures. This policy is based on that guidance and should be read and implemented in conjunction with the following infection, prevention and control policies:

IC 2 Personal Protective Equipment IC 4 Hand Hygiene IC 6 Isolation IC 7 Guidance for Clinical Healthcare Workers ‘Sharps’ Policy IC 18 MRSA

Central Venous Access Device Policy v3 11 Appendix 1

Vascular Access Devices ‐ Type of Material Features Common Insertion Recommended Device Site (Veins) Indwelling Life and Common Uses

Peripheral cannula Teflon Winged Cephalic 48‐96 hours for short‐ Vialon Non‐winged Basilic term access

Non‐ported Dorsal Ported Venous network

Midline catheter Silicone Single lumen Basilic Used for 1‐6 weeks or Polyurethane Dual lumen Median longer for short‐to Cubital intermediate‐term Cephalic access

Peripherally Polyurethane Dual lumen Antecubital fossa Used primarily for Inserted central Silicone Single lumen Basilic patients requiring catheter Valved Cephalic several weeks or Brachial months of intravenous access

Short‐term Polyurethane Heparin, antibiotic Jugular Intended for days to Percutaneous Silicone and antiseptic Subclavian weeks or intravenous central venous coatings, multiple Femoral access catheter (non‐ lumen tunnelled)

Skin‐ tunnelled Polyurethane Valved Jugular Indefinite. Used for Catheter Silicone Antimicrobial/silver Axillary long‐term cuff Subclavian intermittent, Multiple lumen Femoral continuous or daily intravenous access. May be appropriate for short‐term use if reliable access needed.

Implanted ports Catheter Dual ports Antecubital fossa Indefinite. Used for long‐term access. Peripheral ports Valved Subclavian Silicone Low profile Femoral CT compatible

Port

Titanium

Plastic

Central Venous Access Device Policy v3 12 Appendix 2

The main veins used for central venous access device placement

(a) Superficial veins of the forearm. (b) Superficial veins of the dorsal aspect of the hand. (Reproduced with permission from Becton Dickinson and Company.) (c) Veins of the thorax

Central Venous Access Device Policy v3 13 Appendix 3

Procedure for Administering Medication via a CVC

ACTION RATIONALE

1 Staff should wear a clean apron and wash To reduce the potential for the spread of hands thoroughly. infection.

2 An aseptic non‐touch technique should be To reduce the potential for the spread of followed throughout. infection.

3 Clean the injection bung / hub thoroughly To reduce the number of microbiological with 2% chlorhexidine / 70% isopropyl organisms that may be colonizing the alcohol (Sani‐cloth) (EPIC CVAD 33) injection bung.

4 With a 5 ml syringe, aspirate the lumen to This confirms the patency of the lumen and be used until 2‐3 ml blood withdrawn ensures there are no clots or residual medication in the lumen.

5 Administer the medication or commence the infusion as prescribed.

6 After use of the lumen: using a 10 ml Maintains patency syringe, aspirate until 2‐3 ml blood withdrawn, then flush and lock the line gently using 5 ml normal saline (EPIC CVAD 38).

On Critical Care

CVCs should not routinely be used to take blood samples. However they may be used in the absence of an arterial line in patients where phlebotomy is particularly difficult.

On Removal

All Tunnelled lines should be removed in theatre. Skin should be cleaned with Chloraprep solution prior. All CVC tips (4CM distal segment) should be placed in a sterile universal container and sent to Microbiology for culture and sensitivity.

Central Venous Access Device Policy v3 14 Continuous Veno‐Venous Haemofiltration (CVVH catheters)

Used within Critical Care to provide vascular access for Continuous Veno‐Venous Haemofiltration (CVVH).

Insertion sites: as for multi‐lumen CVCs

Care of the insertion site: as for multi‐lumen CVCs

Use of the CVVH catheter is only within the Critical Care Department.

Central Venous Access Device Policy v3 15 Appendix 4

Procedure for Using a Double Lumen Haemofiltration Catheter

ACTION RATIONALE

Staff should wear a clean apron and wash hands To reduce the potential for the spread of thoroughly. infection.

An aseptic non‐touch technique should be To reduce the potential for the spread of followed throughout. infection.

Clean the injection bung/hub thoroughly with To reduce the number of microbiological 2% chlorhexidine/70% isopropyl alcohol (Sani‐ organisms that may be colonizing the injection cloth) (EPIC CVAD 33) bung.

With a 10 ml syringe, aspirate the lumen to be This confirms the patency of the lumen, ensures used until 10 mls blood withdrawn, empty this there are no clots or residual locking dose of blood onto a clean piece of gauze and examine Heparin in the lumen, and allows for assessment for the presence of clots. Continue this until flow rate through the lumen aspirate is free from clots.

The lumen should then be flushed with 5‐10 ml Ensure patency and assess flow rates. normal saline

The cannula can then be attached to the extra corporeal circuit and treatment commence.

REPLACEMENT and REMOVAL of CVAD s.

CVAD s should not be replaced over a guide wire if infection is present or suspected.

NB ‐If a central line infection is suspected ie ‐ CSBSI (catheter suspected blood stream infection) and the device is the suspected source, it is essential that blood cultures are taken from both the device and peripherally . Both sets of cultures must be obtained at the same time and clearly indicated. The ICE request must reflect the suspicion of a CVAD CSBSI. This is to rule out the device as a source of sepsis. ie ‐ (CRBSI catheter related blood stream infection)

If the exit site is red, inflamed or oozing and an infection is suspected (observe for redness, leakage, inflammation) swab exit site for culture and sensitivity. If a CVAD infection is suspected, risk assessment must involve the senior medical team. Advice for this can also be sought from the Acute Response Team (ART) and from the link IPCN/ Microbiologist.

On removal, the tip of the device ( less than 4cm) should be taken using sterile scissors (tip of the old line) and sent to microbiology for culture and sensitivity.

All device tips should routinely be sent to Microbiology for culture and sensitivity.

Central Venous Access Device Policy v3 16 Appendix 5

Gateshead Health NHS Foundation Trust Guidelines for Nursing Staff on the Care and Management of Tunnelled Devices

The following guidelines are a reference material to professionals caring for central venous access devices within Gateshead Health NHS Foundation Trust. However, any professional performing these cares must first have been assessed and deemed competent within the Trust/Organisation. All practitioners must ensure they are aware of and working within their personal and professional accountability.

The term Central Venous Access Device (CVAD) or Central Venous Catheter (CVC) implies that the tip of the device is positioned in the lower third of the superior vena cava (SVC). For the purpose of this document CVC will include:

• Tunnelled catheters – generally inserted via the jugular vein, with the other end being tunnelled under the skin and exiting on the chest.

• Peripherally inserted catheters (PICC’s) – which are inserted through an antecubital vein or upper arm vein and threaded up to the SVC.

Groshong Catheters Groshong catheters can be single or double lumen. Double lumen Groshong lines have a red lumen for blood sampling and infusion of blood products, and a white lumen for infusion of other crystalloid products. They are soft, silicone tubes with radiopaque stripes and tips. They have winged connectors for injection cap placement. Groshong catheters have a valve. The Groshong valve remains closed at normal central venous pressure. The valve is designed to restrict blood backflow and air embolism when closed. The valve will remain closed between –7 and 80mm Hg. PICC lines have a Groshong valve.

Central Venous Access Device Policy v3 17 It is important to remember that only 10ml or larger syringes should be used for infusing with Groshong catheters. Infusion pressures should not exceed 25psi.

Maintaining Patency

The catheter should be flushed every 7 days when not in use. It should also be flushed after administration of medications, fluid/blood transfusion, TPN, blood aspiration or if blood is observed in the line.

Preventing Infection

The exit site should be dressed every 7 days if using a transparent dressing and skin area cleaned with chloraprep solution. This may need to be changed more regularly if loosened or if the patient is neutropenic. All patients should be prescribed Octenisan bodywash and have weekly MRSA screening performed.

Maintaining patency of a Groshong central venous catheter (single or double lumen)

Equipment required:

1 dressing pack 1 pair of sterile gloves 2 x 10ml luer lock syringes (4 if double lumen) 20mls 0.9% sodium chloride (40mls if double lumen) 1 needle free bung (2 if double lumen) ChloraPrep 3ml Solution 1 Sani cloth CHG 2% for cleansing line 1 x 21G needle (green for drawing up saline) 1 x 25G needle (orange for injecting through bung) (2 if double lumen) 1 apron 1 pair of non sterile gloves 1 sharps bin and a orange clinical waste bag transparent, occlusive dressing e.g. IV 3000

Central Venous Access Device Policy v3 18 Procedure:

ACTION RATIONALE 1 Explain and discuss the procedure with To gain the patient’s co‐operation and the patient. understanding as well as informed consent. 2 Apply apron and wash hands thoroughly. To reduce the potential for the spread of infection. 3 Clean trolley ‐ open the dressing pack and To provide a sterile working area. place equipment onto sterile field. 4 Remove old dressing with non‐sterile Safety of patient – line may need removed or gloves. Remove old dressing with non‐ antibiotic cover given. sterile gloves. Check exit site of line for any signs of infection. Redness, swelling, oozing. If present inform clinician. 5 Wash hands. Put on sterile gloves and To maintain a sterile working area. draw up 10ml of saline into the two syringes. 6 Place sterile drape under the CVC. To provide a sterile working area and prevent contaminating the CVC during the procedure. 7 Swab the injection bung with Sani cloth To reduce the number of microbiological on gauze and allow to dry. organisms that may be colonizing the injection bung. 8 Pre‐fill the new injection cap with saline. To establish a connection between the line and Remove the old injection cap and attach the syringe. a syringe. 9 Draw back approximately 3 ‐ 4 mls of Ensures line patent. blood. 10 Attach a pre‐filled syringe. 11 Using a push‐pause method (inject 1ml at To create turbulence in order to flush the a time), inject the contents of the syringe. catheter thoroughly. 12 Remove syringe and replace with new Withdrawing the needle under positive pressure needle free bung. Irrigate the catheter helps to prevent a vacuum occurring which may through the injection cap using the cause a small amount of blood to enter the tip second syringe and a 25G needle. Use a of the catheter. push‐pause method. Withdraw the needle as the last 0.5ml is being injected. If flushing a double lumen line, treat each lumen separately and repeat these steps for the second lumen. 13 Clean the exit site with ChloraPrep 3ml To reduce the number of microbiological solution organisms. 14 Apply new dressing. Dispose of To prevent contamination of others and equipment safely and in accordance with maintain safe practice. Occlusive dressing helps Trust policy. Document procedure. to prevent bacterial contamination.

Central Venous Access Device Policy v3 19 Blood sampling from a Groshong central venous catheter (single or double lumen)

Equipment required:

Use equipment as for line flush. Also include the additional items listed below. 2 x 10ml syringes blood collection tubes

Procedure:

Follow the procedure for maintaining line patency through steps 1‐7.

Please note: When obtaining a blood sample from a double lumen line the sample should be taken from the RED lumen as outlined in the table below. The WHITE lumen just needs to be flushed as outlined above. The white lumen can be used for sampling if you are unable to use the red lumen.

ACTION RATIONALE 8 Pre‐fill the new injection cap with saline. To establish a connection between the line and Remove the old injection cap and attach the syringe. one of the empty syringes. 9 Pull back on the syringe plunger 1‐2ml To allow the valve to open. and pause for 2 seconds. Aspirate 5ml The saline in the blood may dilute the specimen blood and discard. and alter results. 10 Attach an empty syringe and aspirate To obtain specimen. the required amount of blood. 11 Remove syringe and attach a saline filled To establish a connection between the line and syringe. the syringe. 12 Using a push‐pause method (inject 1ml To create turbulence in order to flush the at a time), inject the contents of the catheter thoroughly. syringe. 13 Remove syringe and replace with new Withdrawing the needle under positive pressure needle free cap. Irrigate the catheter helps to prevent a vacuum occurring which may through the needle free bung using the cause a small amount of blood to enter the tip second syringe. Use a push‐pause of the catheter. method. Withdraw the needle as the last 0.5ml is being injected. 14 Place blood in collection tubes and label To ensure positive patient identification. correctly as per hospital policy. 15 Clean the exit site with ChloraPrep 3ml To reduce the number of microbiological solution. Allow to dry. organisms. 16 Apply new dressing. Dispose of To prevent contamination of others and equipment safely and in accordance maintain safe practice. Occlusive dressing helps with Trust policy. Document procedure. to prevent bacterial contamination.

Central Venous Access Device Policy v3 20 The following gives guidance on the management of possible line infections (intra/extra luminal or skin). All practitioners caring for these lines need to ensure they observe for any signs of infections and inform medical staff at each episode of care if concerned. BCSH Guidelines on the Management of CVAD Associated Infection

Category of Infection Non‐neutropenic Patient Neutropenic patient Exit site infection Remove catheter if no longer Remove catheter if no longer needed. needed. Treat empirically with *flucloxacillin Initial empirical therapy including glycopeptide

Treat for 10‐14 days or longer until infection resolved.

Modify according to isolates Remove catheter if evidence of progression or if blood cultures are positive for Staph. aureus, Pseudomonas spp, Mycobacterium spp., or fungi

Tunnel infection Remove catheter if no longer Remove catheter if no longer needed. needed Initial empirical therapy including Treat empirically with glycopeptide *flucloxacillin Treat for 10‐14 days or longer until *Unless patient known or resolution of soft tissue infection. suspected to be MRSA Modify according to isolates. positive. If tracking continues to spread remove catheter. Presumed catheter‐ Remove catheter if no longer Remove catheter if no longer needed. related bloodstream needed. infection Initial empirical antibiotic therapy. Treat empirically with Modify according to isolates. antibiotics targeted against isolates. Treat for at least 10‐14 days Remove catheter if cultures remain *Unless patient known or positive after 48 hours of therapy or if suspected to be MRSA proven catheter‐related infection with positive. Staph. aureus, Pseudomonas spp,, Mycobacterium spp., or fungi

* Unless known to be colonised with MRSA, when a glycopeptide should be used.

Central Venous Access Device Policy v3 21 Appendix 6

Gateshead Health NHS Foundation Trust Guidelines for nursing staff on the care and management of Hickman Lines

The following guidelines are a reference material to professionals caring for central venous access devices within Gateshead Health NHS Foundation Trust. However, any professional performing these cares must first have been assessed and deemed competent within the Trust/organisation. All practitioners must ensure they are aware of and working within their personal and professional accountability.

• Tunneled catheters – generally inserted via the jugular vein, with the other end being tunnelled under the skin and exiting on the chest.

• Peripherally inserted catheters (PICC’s) – which are inserted through an antecubital vein or upper arm vein and threaded up to the SVC.

Hickman Catheters A Hickman line is a narrow tube, made of silicone rubber or polyurethane. It can be single or double lumen. Double lumen Hickman lines have a red lumen for blood sampling and infusion of blood products, and a white lumen for infusion of other crystalloid products. These catheters have an open ended tip and therefore have a clamp on each lumen to prevent bleeding and air embolism.

Central Venous Access Device Policy v3 22 Maintaining patency of a Hickman central venous catheter (single or double lumen)

Equipment required:

*Clean trolley 1 dressing pack 1 pair of sterile gloves 1 x 10ml luer lock syringes (2 if double lumen) 3mls heparin sodium solution 10units/ml (6mls if double lumen) for weekly flush 1 needle free bung (2 if double lumen) ChloraPrep 3ml solution 1 Sani cloth to cleanse line(2 needed if double lumen line) 1 x 21G needle (green for drawing up heparin) 1 apron 1 pair of non sterile gloves 1 sharps bin and a orange clinical waste bag transparent, occlusive dressing e.g. IV 3000

Procedure

NB Flushing procedure for Hickman line

The patency of the device is a local agreement and according to Vygon (manufacturer).To maintain the patency of the Hickman device it is advised in action point 5 see below

1. Flush the catheter with 0.9% sodium chloride after each injection, perfusing or blood sampling. If several drugs injections are needed, carry out a careful flushing with saline between each one to avoid any precipitation or drugs interactions. 2. If the line is not being used regularly it needs to be flushed weekly with normal saline and locked after each flush with 3mls of 10units/ml Heparin (Heplock). This Heparin should be prescribed and ordered by pharmacy on a named patient basis.

ACTION RATIONALE 1 Explain and discuss the procedure with the To gain the patient’s co‐operation and patient. understanding as well as informed consent. 2 Apply apron and wash hands thoroughly. To reduce the potential for the spread of infection. 3 Clean trolley. Open the dressing pack and To provide a sterile working area. place equipment onto sterile field. 4 Remove old dressing with non‐sterile gloves. Safety of patient – line may need removed or Check exit site of line for any signs of antibiotic cover given. infection. Redness, swelling, oozing. If present inform clinician. 5 Wash hands. Put on sterile gloves and draw To maintain a sterile working area. up normal saline into the syringe, in a separate syringe 3 mls of 10units/ml Heparin (Heplock).

Central Venous Access Device Policy v3 23

ACTION RATIONALE 6 Place sterile drape under the CVC. To provide a sterile working area and prevent contaminating the CVC during the procedure. 7 Swab the injection bung with Sane cloth and To reduce the number of microbiological allow to dry. organisms that may be colonizing the injection bung. 8 Ensuring the clamp is closed, remove the old injection cap and attach a syringe. 9 Draw back approximately 3 ‐ 4 mls of blood. Ensures line patent. Close clamp. 10 Ensuring clamp is closed attach the pre‐filled To establish a connection between the line syringe. Then open clamp. and the syringe and minimize the risk of air embolism. 11 Using a push‐pause method (inject 1ml at a To create turbulence in order to flush the time), inject the contents of the syringe. catheter thoroughly. Apply the clamp, whilst pushing, when last Applying the clamp whilst still injecting the 0.5 mls remain. heparin helps to prevent blood from backing up into the catheter. 12 Remove syringe and replace with new To keep lumen sterile. injection cap. If flushing a double lumen line, treat each lumen separately and repeat these steps for the second lumen. 13 Clean the exit site with ChloraPrep 3 ml To reduce the number of microbiological solution organisms. 14 Apply new dressing. Dispose of equipment To prevent contamination of others and safely and in accordance with Trust policy. maintain safe practice. Occlusive dressing Document procedure. helps to prevent bacterial contamination.

Blood sampling from a Hickman central venous catheter (single or double lumen)

Equipment required:

Use equipment as for line flush. Also include the additional items listed below. 2 x 10ml syringes (4 if double lumen) blood collection tubes

Procedure

Follow the procedure for maintaining line patency through steps 1‐7.

Central Venous Access Device Policy v3 24

BLOOD SAMPLING

ACTION RATIONALE 8 Ensuring the clamp is closed, remove the To establish a connection between the line and old injection cap and attach one of the the syringe and minimize the risk of air empty syringes. embolism. 9 Pull back the syringe plunger whilst The heparin solution in the blood may dilute the releasing the clamp. Aspirate 5ml of specimen and alter results. blood, re‐apply the clamp and discard the syringe. 10 Attach an empty 10 or 20ml syringe To obtain specimen. (depending on samples required) and aspirate, whilst opening the clamp, required amount of blood. 11 Re‐apply clamp, remove syringe and To establish a connection between the line and attach a pre‐filled syringe of 0.9% the syringe. sodium chloride solution. 12 Using a push‐pause method (inject 1ml To create turbulence in order to flush the at a time), inject the contents of the catheter thoroughly. syringe. Apply the clamp, whilst pushing, Applying the clamp whilst still injecting the when last 0.5 mls remain. heparin helps to prevent blood from backing up into the catheter. 13 Remove syringe and replace with new To keep lumen sterile. injection cap. 14 Place blood in collection tubes and label To ensure positive patient identification. correctly as per hospital policy. 15 Clean the exit site with ChloraPrep 3 ml To reduce the number of microbiological solution. Allow to dry. organisms. 16 Apply new dressing. Dispose of To prevent contamination of others and equipment safely and in accordance maintain safe practice. Occlusive dressing helps with Trust policy. Document procedure. to prevent bacterial contamination.

Central Venous Access Device Policy v3 25

Appendix 7

Gateshead Health NHS Foundation Trust

Care Standard 25A CARE OF THE PATIENT WITH A (NON‐TUNNELLED) CENTRAL LINE/CVAD Definition: A Central Venous Access Device (CVAD) is one where the catheter is threaded into the central vasculature. If this is inserted by direct skin puncture into a vein it is percutaneous e.g. non‐tunnelled. It can also be tunnelled under the skin (see Care Standard 26A). A central venous catheter tip will usually be in the superior vena cava or right atrium. The exception is when the device is placed in a femoral vein, when the tip lies in the inferior vena cava. Indications: To monitor central venous pressure in seriously ill patients. For the administration of large amounts of fluid or blood, e.g. in the case of shock or major surgery. For the administration of medications that are likely to cause phlebitis if administered through a peripheral vein. To provide venous access for Continuous Veno‐Venous Haemofiltration (CVVH). 1. Give the patient a full explanation regarding the procedure, nursing staff need to constantly reassure the patient throughout and after the procedure. 2. Prepare the equipment ready for the procedure and assist the medical staff with Aseptic Non‐Touch Technique. 3. On insertion of the CVAD, the patient needs to be in the Trendelenburg’s position (to prevent air embolism and increase venous return) 4. A check chest x‐ray is to be carried out to confirm the position of the line, which should not be used until confirmation of the correct position by doctor. 5. CVP readings are to be recorded hourly initially, then as the patients condition dictates (Critical care only) 6. An accurate fluid balance chart to be maintained, monitoring the patients’ fluid input and output. 7. The flush bag and the giving set are to be changed every 72hrs max, the flush bag is to be prescribed and checked as other intravenous fluids. If the fluid bag needs to be changed sooner, the flush set should be changed at the same time (Critical Care) 8. Lumens not in use are to be flushed daily with 5‐10ml normal saline using Aseptic Non‐Touch Technique. 9. Vital signs on the EWS chart (ward patients) should be assessed according to the patients risk assessment including record of 4 hourly temperatures. Inform medical staff if pyrexia develops. 10. The site should be observed at regular intervals for signs of infection; the site observed, and recorded on a daily basis, the doctor needs to be informed as soon as possible if signs of infection are noted. A swab from the venepuncture site needs to be sent to microbiology for culture and sensitivity. Duration should be risk assessed daily ( refer to OP41) 11. A transparent semi‐permeable dressing should be used to cover the site and should be changed every 7 days or earlier if indicated. 12. Intravenous drugs should be administered as per the Trust policy. The line should be flushed with 5ml 0.9% sodium chloride between each drug and on completion of administration. 13. Patients being discharged from Critical Care with a CVAD in situ should either have all 3‐way taps replaced with Bionectors and /or have the CVAD replaced as a double lumen device, one lumen of which may be dedicated for TPN with access identified. Luer lock syringes are preferred. 14. Removal of the CVAD should only be performed by a practitioner deemed competent, using Aseptic Non‐Touch Technique with the patient in a Trendelenberg position. Pressure should be applied at the puncture site for 3‐4 minutes to prevent bleeding and a sterile transparent dressing should then be applied. The CVAD tip needs to be sent to microbiology for culture after removal, as per Trust policy OP41. 15. Ensure that the patient’s privacy and dignity is maintained throughout both the procedure and their hospital stay. 16. Ensure that infection prevention and control standards are adhered to at all times, especially before and after any patient contact. 17. Involve the patient and relatives / carers in the decision making process around their care needs. 18. Ensure that the patient is aware of their condition/disease in order to promote independence and self‐ management. 19. Ensure you have considered making reasonable adjustments to meet the needs of patients with disabilities. References: The Royal Marsden Hospital Manual (2011) Epic 2: National evidence based guidelines for preventing healthcare‐ associated infections in NHS hospitals in England Gateshead Health NHSF Trust Operational Policy OP41 Central Venous Access Device /line policy Version number: 4 ‐ 2010

Central Venous Access Device Policy v3 26 Appendix 8

Gateshead Health NHS Foundation Trust

Care Standard 25B CARE OF THE PATIENT WITH A TUNNELLED CENTRAL VENOUS ACCESS DEVICE

Definition: The term Central Venous Access Device (CVAD) indicates that the tip of the device is positioned in the lower third of the superior vena cava (SVC), these devices are known as tunneled catheters, they are generally inserted via the jugular vein, with the other end being tunneled under the skin and exiting on the chest. Tunneled CVAD s are known as Groshong and Hickman devices. Please refer to OP41 for flushing procedure.

Indications: To provide long term access for: ‐ a) Hydronation or electrolyte maintenance. b) Repeated administration of drugs, such as cytotoxic and antibiotic therapy. c) Repeated transfusion of blood or blood products. d) Repeated specimen collection.

1. The procedure must be carried out using a theatre setting by a Doctor deemed competent. 2. Give the patient a full explanation regarding the procedure, nursing staff need to constantly reassure the patient pre and post procedure. Routine bloods – FBC and coagulation screen are required prior to insertion. Confirm MRSA status. 3. Check chest x‐ray to be carried out to confirm position of the device unless inserted in radiology under guidance. Confirmation of correct position is decided by the doctor. 4. Strict EWS monitoring needs to be maintained in conjunction with an accurate fluid balance chart. 5. 4 hourly temperatures are to be recorded and the doctor needs to be informed if pyrexia occurs. 6. Insertion sites should be monitored closely,7 days after insertion remove insertion site sutures.21 days after insertion remove exit site sutures. A semi permeable dressing should be used to cover the sites. The dressing needs to be changed 24hrs post insertion at dressing check and subsequently every 7 days. 7. The site should be observed at regular intervals for signs of infection and medical staff informed as soon as possible if signs of infection noted, swab to be sent to microbiology for culture and sensitivity. Clinical suspicion of a CVAD infection necessitates two sets of blood cultures, one set peripheral and one set from the CVAD with ART and IPC support/surveillance, see OP41. 8. Line to be used only by health care professionals that are deemed competent. 9. Intra venous drugs should be administered as per the Trust policy. With intermittent administration of fluid/ medications, the device should be flushed with 5ml 0.9% sodium chloride between each drug and on completion of administration to maintain the patency of the device. 10. Removal of the tunnelled line should be carried out by health care professionals that are deemed competent in this area. A theatre setting is essential for this.(see OP421) 11. Ensure that the patient is prepared physically and psychologically for any investigatory procedures in line with hospital the guidelines. 12. Ensure that the patient’s privacy and dignity is maintained throughout both the procedure and their hospital stay. 13. Involve the patient and their relatives / carers in the decision making process around their care needs. 14. Ensure that the patient is aware of their condition / disease process in order to promote independence and self management. 15. Ensure that the infection prevention and control standards are adhered to at all times, especially before and after any patient contact. 16. Ensure you have considered making reasonable adjustments to meet the needs of patients with disabilities. 17. Patient to have weekly MRSA screens of nose, throat and any wounds whilst CVAD remains insitu.

References:

The Royal Marsden Hospital Manual of Clinical Nursing Procedures 2011. Epic 2: National evidence based guidelines for preventing healthcare‐associated infections in NHS hospitals in England. Gateshead Health NHSF Trust Operational Policy OP41 Central Venous line policy v3

Central Venous Access Device Policy v3 27 Appendix 9

COMPETENCY BASED ASSESSMENT FOR A REGISTERED PRACTITIONER TO access Central Venous Access Devices

Competence is a standardised requirement that a Health Care Professional needs to achieve in order to perform a specific task. It encompasses a combination of knowledge, practical and behavioural skills.

Prior to the completion of this Competency Based Assessment the Health Care Professional must have attended and have evidence of training courses identified as required for the successful completion of the assessment.

Information required:

Identify relevant Directorate/s State additional training courses Attendance at half day theoretical session and completion of required associated workbook. State staff groups identified to Health Care Professionals undertake practice State clinical procedure protocol / The Health and Social Care Act (2008) policy / guideline linked to (if Hand Hygiene Policy (IC 04) applicable) Personal Protective Equipment Policy ( IC O2) Sharps Policy (IC 07) Standard of Practice No: 53 Aseptic Non‐Touch Control of infection (IC 03) Waste disposal Policy (IC 09) Incident reporting (RM 04) Consent to treatment (RM 22) Patient identification (RM 40) Marsden Manual of clinical Nursing procedures,8th edition (2011) State any related competencies Aseptic Non‐Touch Technique State who can assess this Registered Nurses at Band 5 and medics that have an competency appropriate learning and assessment qualification. The person assessing this competency must be competent in this field and have attended the required training to complete the assessment. Date of Ratification

Date of Review

Version Number (and date of first 1 ratification) Author(s) Sister Michelle Hughes ‐ Chemotherapy day Unit. Practice Development Team Janet Thompson

Central Venous Access Device Policy v3 28

Appendix 9 Competency Bases Assessment Document for a Registered Practitioner to access Central Venous Access Devices

Competency Date Staff Assessor Signature Signature

1. Teaching and Preparation

The Practitioner has received theoretical training and demonstration of technique as well as competency based assessment in own clinical area from a competent practitioner to access Central venous Access Devices. (CVAD s)

2. Legislation, policy and good practice

The Practitioner has demonstrated working knowledge of:

• Guidelines, policies and protocols/clinical procedures which affect practice in relation to CVAD s • Own responsibilities and accountability within the Trust Policy and the Nursing & Midwifery Council (NMC) and /or Health Professions Council (HPC) • The duty to report any acts or omissions in care that could be detrimental to self, other individuals or employer • Obtaining verbal consent before starting the procedure • Obtaining positive patient identification (PPI) • Health & Safety measures and safe practice in relation to the identified procedure.

Central Venous Access Device Policy v3 29

Competency Date Staff Assessor Signature Signature

3. Care and support

The Practitioner can demonstrate an awareness of:

• Maintaining the patient’s privacy and dignity relevant to CVAD s • Making an assessment of the patient’s communication needs with regard to equality and diversity in relation to the identified procedure. • Preparing individuals for the identified procedure, including how their personal beliefs and preferences may affect the preparation • What is likely to cause discomfort to individuals during and after the identified procedure and how such discomfort can be minimised

4. Background Knowledge

The Practitioner can demonstrate knowledge and understanding of:

• Anatomy and physiology in relation to CVAD s • Pharmacology of prescribed medications in relation to the identified competency. • Associated side effects and complications/adverse events and problems may occur and how to recognise them and what action(s) to take in relation to the identified competency. • Appropriate action/lines of referral with in agreed protocols in relation to the identified competency. • Criteria for patients not suitable for this procedure

Central Venous Access Device Policy v3 30

Competency Date Staff Assessor Signature Signature

5. Standard Control of Infection Measures

The Practitioner demonstrates knowledge and understanding of the principles and practice of preventing the transmission of infection with regard to:

• Correct hand hygiene technique before and after the delivery of care to the patient and at strategic points during the procedure as per Hand Hygiene Policy (IC4) • Appropriate use of personal protective equipment for the procedure as per Personal protective equipment Policy (IC2) • Good cleaning practices as per ( Cleaning and Disinfection Policy (IC15) • Adherence to the principles of ANTT. • Safe handling and disposal of equipment/waste in line with Sharps Policy (IC7) and Waste Disposal Policy (IC9) • The need to dispose of single use devices after ONE use • Management of any spillage of body fluids in line with Standard Precautions for the Prevention and Control of Infections Policy (IC3)

6. Preparation, Procedures and techniques

The Practitioner demonstrates a working knowledge of:

• Can identify individual CVAD s in order to determine correct procedure s for use and maintenance according to device type. • Can discuss the differences in structure and function of individual device type ie Non tunnelled acute, Tunnelled longer term devices such as Groshong, Hickman, Peripheral PICC.

Central Venous Access Device Policy v3 31

• Demonstrate cleaning and redressing. • Use the device safely for venous sampling demonstrating strict ANTT. • Taking venous blood cultures. • Closure following usage. • Use the device safely for administration of appropriate intravenous fluids or drugs. • Identify safe infusates for use within the clinical setting via specific CVAD s. • Can staff identify appropriate choice of dressing for use at the insertion site. • Identify and manage appropriately problems with the individual device and contact appropriate agencies. • To identify the presence of suspected infection at local insertion site or possible thrombus around the device or in limb which device is inserted. • The correct equipment and materials, preparation, set‐up, and operation of equipment and materials in relation to CVAD s • The practitioner can safely access CVAD s in clinical practice adhering to IPCC standards and policy.

7. Reporting, recording and documentation

The Practitioner can demonstrate a working knowledge of:

• The importance of immediately reporting any issues which are outside your own sphere of competence without delay to the relevant member of staff. • The correct information of the procedure that needs to be recorded and how it needs to be documented in the patient’s records. • The importance of documentation that is clear, legible and accurate

Central Venous Access Device Policy v3 32

8. Aftercare

The Practitioner can demonstrate a working knowledge of:

• Correct initial and on going care of the patient in relation to CVAD s • Identify/ discuss potential complications when carrying out CVAD care and identify who they should contact for advice and further assessment. • Show awareness of the procedure required if device needs to be removed and who the patient should be referred to for device removal. • Relevant guidelines / procedures and best practice in relation to CVAD s • Patient education/ support prior to/during and after CVAD access.

Staff name……………………………………………. Base ward……………………….. Assessor name…………………………………..

Central Venous Access Device Policy v3 33

Central Venous Access Device ‐ Confirmation form Successful completion of this assessment is a pre requisite to access CVADs

I certify that I have received and understand the training outlined above and understand my responsibility and accountability within Trust Policy and NMC. I am satisfied that I am able to access Central Venous Access Devices.

Registered Practitioner Signature…………………………… Date……………….. Print Name………………………………..

I am satisfied that…………………………………..(name) is able to access CVAD s, has attended a theoretical session and completed CVAD clinical support.

Assessors Signature……………………..Designation………………..… Date……………Print Name…………………………

I am satisfied that …………………………………..(name) can now access CVAD s.

This will be reviewed annually at appraisal

Ward / Department Manager ………………………...... Date……………….Print Name…………………………………

Next Actions

• The Practitioner will keep a copy within his or her PREP/KSF evidence file. However, this should not replace a reflective diary entry. • This Competency Based Assessment must be reviewed on a yearly basis by the Ward/Department manager and documented in the Practitioners Personal Professional Record.

Central Venous Access Device Policy v3 34