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Transcript of Picc Lines
CARE AND MANAGEMENT So what is a central catheter policy? Changing the Injection Cap Is it in? By Sarah Cannon, Nicole Fritts, Brian Kuske, and John McCall It's a policy to establish standard procedures for the placement, access, care and management of Central Line Catheters which support infection control principles and minimize the risk of infection. What type of catheter does this policy impact? What Does the Policy Look Like? The Policy Condensed 1. General Information
2. Central Line Placement - Assisting Physician/Practitioner
3. Central Line Flushing
4. Dressing Changes
5. Changing the Injection Cap
6. Extension Tubing Change
7. Drawing Blood
8. Vascular Access Port
9. Declotting Central Venous Catheters
10. Discontinuation and Culturing of Non-Tunneled Catheters
11. Repair of Central Line Catheters Port Cleaning and Flushing
Best Practice The Policy on "Scrub the Hub" What the Policy says. "Scrub-the-Hub" for at least 15 seconds using an alcohol swab" What the Literature says. Current peer reviewed literature by the Association for Vascular Access AVA describes recommendations for reducing CRBSI (catheter related blood stream infections):
"Cleanse the IV connector septum with 70% isopropal alcohol for a minimum of 15 seconds with a vigorous back and forth motion, allow to dry for up to 45 seconds."
(Nakae, Igarashi, & Tajimi, 2010) What the evidence is saying.... "A 2010 study at the Rady Children's hospital in San Diego, California concluded that a 15 second vigorous scrub with either alcohol alone, or chlorhexidine/alcohol was effective in preventing 99.99% of microorganisms from entering valves and ports"
(Hatler, Hebden, Kaler, & Zack, 2010) (Mahoney & King, 2011) CENTRAL LINE FLUSHING
AND LOCKING What the literature is saying..... Limitations of the study..... What the policy says... Limitations of the study..... Studies were completed on one type of valve, and at one hospital in California. The study was also limited to scrub technique and did not further investigate the use of port caps. What the evidence is saying.. In 2012, the Journal of Perinatal Medicine released a peer reviewed study which examined the patentcy of peripherally inserted venous catheters. The study concluded that "8 hour incremental flushes" using 0.9% saline, proved more effective at maintaining catheter life over the continuous infusion catheters using the same solution.
(Bernet, Brotschi, Feuz, & Perez, 2012) Equipment and Supplies needed:
* 10 mL pre-filled syringes with preservative free saline or heparin.
* Alcohol prep pads
* Gloves (sterile or non-sterile)
* Scrub the hub for 15 seconds.
* Flush line using push-pause method (brisk flush, followed by one second pause) once or twice during flush.
*Remove syringe and discard According to the peer reviewed JAVA (Journal of the Association for Vascular Access), current evidence strongly supports the push-pause method as an effective strategy in eliminating potential host sources and occlusions through fibrin build up (a potential host for contaminants). Furthermore, JAVA suggests a specific locking technique not noted in this protocol. They describe the method: twist and push while removing the syringe during the last 1.5 mL of syringe flush, to be an effective means of maintaining adequate pressure and reducing sediment buildup and future occlusion.
(Nakae et al., 2010) Implementation and their challenges.... The literature finds that there is ambiguity as to what is expected of the nursing staff regarding scrub-the-hub. For example, being told infection rates of "4.6/1000 line days" was not easily translated to bedside practice. The study shows how nurses want to understand how this protocol will affect them and their patient.
High patient to nurse ratios also present challenges in protocol adherence. By decreasing the nurse to patient ratio, practice guidelines are easily attained. Clinical role out..... Unfortunately, at the clinical location many of the nurses are misinformed regarding recommended time frames for "scrub-the-hub", as well as dry times. Questioning the technique, "10 seconds" has been the general response with confusion regarding mandated dry times.
Nurses are successfully practicing the vigorous scrub technique recommended in the protocol and have reported positively to the recommendations set forth by the education department. Relevance to Patient Care... Consistent and attentive focus on preparing the injection port for treatment is crucial in eliminating the transmission of organisms into the blood stream. Furthermore, the vigorous scrub method regardless of the material used has proven extremely effective at removing foreign matter from the port surface. Remember those ports come in contact with (gowns, skin, exudate, air particulate, etc). One limitation of the study was the investigation took place during two different time periods; one period being continuous infusion, the other being intermittent flushing. The limitation may have occurred due to fluctuations in staffing while in the neonatal care unit.
Another, limitation although minor was the limited age range of the clients studied. Arguably the neonates fall within the standard of care that translates to all patients. Meaning, these studies focused on the effectiveness of saline flushes and their patency, regardless of participants illness. Implementation and their challenges.... Research shows poor clinical compliance with evidence based practice guidelines that prevent catheter related infections and occlusions. In order to increase compliance the Infectious Diseases Society of America recommends a three level approach to implementation.
(O'Grady et al., 2011)
High nurse to patient ratios decrease compliance of q 8 hour catheter flushes.
(Bernet et al., 2012)
IV access teams prevent many floor nurses from practicing these protocols and committing them to memory.
(Hatler et al., 2010) Clinical Roll Out... In the clinical setting nurses feel prepared to flush central lines, but see limited numbers of patients coming to their unit with ports in place.
The push-pause technique has not been clearly demonstrated to many of the med-surg floor nurses as evidenced by a complete 10 mL saline flush by student nurses.
In the clinical setting the current patient to nurse ratio averages 5:1 and q 8 saline flushes on ports could be achieved with success, if implemented as a medication administration on the EMR. Relevance to Patient Care.... Routine flushing, the push-pause method, and appropriate techniques for locking ports can reduce the discomfort of changing a central line as well as reduce overall client costs with replacement of an occluded line.
The preventative care provided by the nurse when maintaining a patent port will also help assure that access is available in the event of an emergency, positively influencing client outcomes. QUESTIONS? References (Hatler et al., 2010) (Mahoney & King, 2011) Extension Tubing Change What the policy says: Equipment:
1. Luer-lock injection cap
2. Alcohol prep-pads x2
3. 10 mL syringe
4. Flushing solution
Change: Every 4 days and when contaminated or
not functioning properly
Wash hands with soap and water
Assure catheter clamp is closed Never remove injection cap when clamp is open
Unscrew the old cap and discard while holding hub of catheter
Avoid touching sterile end of catheter with your fingers
Do not lay catheter down
Cleanse catheter threads with prep pad
Remove protective cover from the new leur-lock injection cap
Attach new luer-lock injection cap to catheter by twisting into place What the research says: All evidenced based data suggests a time frame of 72 hours for IV extension tubing to remain in place safely in order to prevent CRBSI.
This policy does not give any recommendation of how long the extension tubing should stay in place. SWMC Policy vs Evidence Based Practice Guidelines All data and research is based on IV administration devices that are needleless. There is not enough information about administration systems that use needles to conclude how long a needle could be left in place safely.
“Little data exist regarding the length of time a needle used to access implanted ports can remain in place and the risk of CRBSI. While some centers have left them in place for several weeks without CRBSI, , this practice has not been adequately studied.”
(O'Grady et al., 2011) Limitations of study: Current, peer reviewed literature published in the Yearbook of Intensive Care and Emergency Medicine presents the following recommendations to reduce CRBSI in patients with central catheters:
Replacing venous tubing on central line catheters should be done every 72 hours.
This time frame has proved to be safe for the patient and cost effective.
Blood, blood products, and lipid emulsions pose a greater risk for infection and tubing used for administration of these products should be replace immediately or within 24 hours.
Aseptic technique should always be properly followed when performing tubing changes.
(Frasca, Dahyot-Fizelier, & Mimoz, 2010) What the literature says: (cont.) Nosocomial CRBSI can be prevented.
Nursing staff must be educated and be presented with accurate evidence based practice (EBP) guidelines to help prevent CRBSI.
According to EBP extension tubing can safely remain in place for 72 hours with the exception of administration of blood, blood products, and lipid emulsions which should be replaced within 24 hours.
Aseptic techniques must be followed in order to reduce the risk of CBRSI.
Proper communication between staff can aid in reducing the risk of infection, such as, labeling extension tubing with the time and date the tubing was placed, and initials of who placed the tubing. Relevance to Patient Care: “Catheter-related bloodstream infection remains the most serious complication of central venous access and a leading cause of nosocomial infection in the ICU.”
“The number of manipulations of the central venous line, especially when an aseptic technique is not respected, increases the risk of catheter-related bloodstream infection.”
(Frasca, Dahyot-Fizelier, & Mimoz, 2010) What the literature says: 3. Preparation:
a. Place patient in supine position when tolerated
b. Explain valsalva maneuver
c. Cleanse hands
d. Attach new leur-lock positive pressure injection cap to leur-lock extension set
e. Put on gloves
f. Prime the extension set with normal saline or heparin as per protocol
4. Assure line is clamped when appropriate
5. Instruct patient to turn head away from site and perform a valsalva maneuver (or occlude
catheter by folding it) while removing old leur-lock extension set
6. Remove old extension set from central line
7. Scrub the hub for at least 15 seconds with alcohol prep pad
8. Leur-lock the primed leur-lock extension set and leur-lock injection cap into place
9. Flush catheter per protocol
(Mahoney & King, 2011) What the policy says: (cont.) Extension Tubing Change:
a. Leur-lock positive pressure extension set with c-clamp
b. Leur-lock positive pressure injection cap
c. 10 mL syringe
d. Appropriate flush solution
2. Open-ended catheters must be clamped when disconnected to prevent air embolus or blood
a. Leur-lock positive pressure extension set will be considered a permanent part of the
catheter and not changed on a routine basis unless:
1) Leaking or damage to the extension occurs
2) The area of the tubing being clamped is permanently kinked
3) Solution precipitates (e.g. lipids, blood) visibly build up inside the tubing
KEYPOINT: A triple lumen pigtail with an existing extension set does not require an additional leur-lock extension set. What the policy says: Alexander, M., Corrigan, A., Gorski, L., Hankins, J., & Perucca, R. (2011). Infusion nursing: An evidenced based approach. St. Louis, MI: Saunders.
Bernet, V., Brotschi, B., Fuez, I., & Perez, A. (2012). Intermittent flushing improves cannula patency compared to continuous infusion for peripherally inserted venous catheters in newborns: results from a prospective observational study. Journal of Perinatal Medicine, 40(3), 311 – 316. doi: 10.1515/jpm-2011-1000
Centers for Disease Control and Prevention (2011). Basic infection control and prevention plan for outpatient oncology settings. Retrieved from: http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/central-venous-catheters.html
Frasca, D., Dahyot-Fizelier, C., Mimoz, O. (2010). Prevention of central venous catheter-related infection in the intensive care unit. Critical Care, 14, 212. doi:10.1186/cc8853
Hatler, C., Hebden, J., Kaler, W., & Zack, J. (2010). Walk the walk to reduce catheter-related bloodstream infections using evidence-based practices, nurses can help prevent deadly infections linked to central venous catheters. American Nurse Today, 5(1), 26-31.
Mahoney, D., & King, C. (2011). Central catheters, care and management. Vascular Access Clinical Practice Committee (Publication No. 8720.746.7062.060). Retrieved from Peacehealth Southwest Washington Medical Center: Vancouver, Wa.
Nakae, H., Igarashi, T., & Tajimi, K. (2010). Catheter-related infections via temporary vascular Access Catheters: a randomized prospective study. Journal of the Association for Vascular Access, 12(2), 218-225. doi: 10.2309/java.12-4-8
O’Grady, N. P., Alexander, M., Burns, L. A., Dellinger, P., Garland, J., Heard, S. O., Lipsett, A., . . . Saint, S. (2011). Guidelines for the prevention of intravascular catheter-related infections. Infectious Diseases Society of America, 5, 1-32. doi: 10.1093/cid/cir257 Luer-lock caps prevent inadvertent disconnection and possible air embolism (Infusion Nurses Society, 2011). Injection caps should be changed every week, or when there are signs of blood, cracks, leaks, or other defects. Sterile technique should be utilized (CDC, 2011). Challenges to implementation: Limitations: Research focuses primarily on tubing changes, versus cap changes. Relevance to patient care: Safety, safety, safety. Nurses being accountable for proper handwashing and use of sterile technique
Proper education and training of staff
Appropriate equipment (manufacturers are cutting back on luer-slip connectors). Hospital policies vary, but if the integrity of the cap is compromised, it should be changed immediately (Infusion Nurses Society, 2011). Policy is appropriate given the research * Tunneled/Open ended catheter (i.e. Hickman)
* Valved Catheter (i.e. Groshing)
* Non-Tunneled Central Venous Catheter
* Implanted Ports (i.e. Portacath)
* Arterial Ports (Chemotherapy)
* Intraperitoneal Ports (Chemotherapy)
* Dialysis/Pheresis Catheters (Hemodialysis)
* Peripherally Inserted Central Catheters (PICC) How are central line policies relevant to patient care? What the Policy Says.... "Ensure x-ray has been ordered" What the literature is saying.... Historically, the chest x-ray has been the "gold standard" to confirm the tip of the catheter is in the correct location
The target location has changed to a much smaller area that may not be visible on a traditional x-ray
Anatomical landmarks vary from person to person
Soft tissue imaging is imprecise
Novel technology is required to ensure accurate and precise catheter tip placement What the evidence is saying.... Some practitioners believe there is not a significant distinction among tip locations. However, correct tip placement may prevent many adverse events including thrombosis, vascular tissue damage from caustic agents, and mechanical vascular damage.
What are the limitations of the study.... Challenges of implementation.... REMEMBERING!!! You are not the one who puts in the order
The nurse is not the member of the health care team who interprets the x-ray.
There is no consensus on ideal catheter tip positioning so interpretation of x-ray results may vary among practitioners (Hostetter et al., 2010).
The nurse must take it upon themselves to ensure the PCP or radiologist has reviewed the x-ray; this step is not included in the policy. Relevance to patient care.... Treatment efficacy
Reduces potential for litigation Provides access to systemic circulation necessary for treatments, medication administration, and diagnostic tests
Infection control and prevention
Patient safety, safety, safety How do you know if the line is in the right place? (Mahoney & King, 2011) (Hostetter, Nakasawa, Tompkins, & Hill, 2010) (Hostetter et al., 2010) (Hostetter et al., 2010) The studies reviewed do not all use the same standard for correct tip placement.
The authors rejected all current tip placement (Hostetter et al., 2010)