Infection Prevention in Vascular Access & Subcutaneous

Infection Prevention in Vascular Access & Subcutaneous Infusion Devices Policy

Version 2.0 July 2018 1

Infection Prevention in Vascular Access & Subcutaneous

Infusion Devices

Target Audience

Who Should Read This Policy

All clinical staff

Disclaimer

BCPFT staff must have received specific training, have

completed the enclosed competency assessment & be

deemed as competent in the procedures BEFORE they

are able to care for patients with IV or SC infusions.

Alternatively patient’s requiring this type of treatment will require transfer to the nearest local Acute Hospital

for assessment & appropriate treatment.



Contents 1.0 Introduction 4

2.0 Scope of Policy 4

3.0 Risks of Cannula insertion 5

4.0 Objectives 5

5.0 Criteria for Practitioners Involved 5

6.0 General Principles 6

7.0 Patient Safety Incidents 14

8.0 Monitoring & compliance 14

9.0 Standards / key performance indicators 14

10.0 Equality Impact Assessment 15

11.0 Data Protection Act and Freedom of Information Act 15

12.0 Training 16

13.0 References 16

Appendices

1.0 Algorithms for IV fluid therapy in adults (NICE 2016) 17

2.0 Visual Infusion Phlebitis Score 21

3.0 Peripheral IV Cannula Record Chart - VIP Score 22

4.0 Care plan for the management of a patient with a Vascular Access Device 24

5.0 Inpatient Adult Peripheral Cannula Insertion Record 26

6.0 Saving Lives: Audit for VAD Insertion 27

7.0 Medical & Registered Nurse Competency Assessment Framework – Vascular Access

Devices 28



Explanation of terms used in this policy

Aseptic non-touch technique - Using practices and procedures to prevent contamination from pathogens,

applying strict rules to minimize the risk of infection. Bacteraemia - The presence of bacteria in the bloodstream

EC- European conformity (MHRA 2016a)

Embolism- Obstruction of a blood vessel by foreign matter e.g. blood clot, fat globule or air bubble

Erythema- Redness of the skin along a vein resulting from capillary congestion.

Extravasation - Accidental leakage of fluid from an IV infusion in the vein into the surrounding tissues

Haematoma- A localised collection of blood outside the blood vessels, caused by a break in a blood vessel.

Hypodermoclysis- The subcutaneous administration of fluids to the body in the form of saline or glucose solution

Induration- The hardening of a normally soft tissue due to inflammation or accumulation of blood.

Infection- The presence of microorganisms on/in the body that is causing an adverse effect or host- response

– the person is unwell and has signs and symptoms of an infection

Infiltration- Inadvertent administration of IV fluid into surrounding tissue

Lumen- Interior space of a tubular structure such as a blood vessel or cannula

Medical device- According to the Medical Devices Directive (MDD), a medical device is described as any instrument, apparatus, appliance, software, material or other article used alone or combined for humans to:

diagnose, prevent, monitor, treat or alleviate disease.

Phlebitis- Inflammation of a vein, pain, swelling, redness and tenderness are common symptoms.

Peripheral cannula- Is defined as one that is less than or equal to 3 inches (7.5cm) in length & is used for

short term therapy of 3-5 days and for bolus injections or short infusions.

Risk Assessment- A process used to identify any potential hazards and analyse what could happen, and to identify steps to be taken to reduce or minimise the risk.

Single use device- A single-use device is used on an individual patient during a single procedure and then discarded. It is not intended to be reprocessed and used again, even on the same patient.

Syncope- A faint or temporary loss of consciousness some people may faint during this procedure.

Thrombophlebitis- An inflammatory process that causes a blood clot to form and block a vein.

Vascular Access Device (VAD)- Vascular access device e.g. cannula, butterfly needles etc.

Vasoconstriction- Narrowing or diminution of the calibre of the blood vessels resulting in reduced blood flow

Visual Infusion Phlebitis (VIP) Score- The visual infusion phlebitis scale is used for assessment of the early

signs of phlebitis, along with prompt removal of peripheral intravenous cannulas.



1.0 Introduction

Many patients admitted to hospital or in receipt of health care in other settings, including their own homes, will become recipients of one or more infusion therapies at some stage which can have implications for patient care and safety. The priorities for a patient requiring therapy will depend upon an assessment of their clinical needs. Generally, Black Country Partnership Mental Health Trust patients will be recipients of short-term intravenous drugs or fluids and will require full nursing support for the duration of treatment. Patient assessment is not just about identifying the most suitable vein to site an IV cannula. It should also include consideration of the types of medication required and for how long, the volumes of fluids anticipated, this should then be matched against types of cannula, etc. Infusion therapy is now an integral part of the majority of nurses’ professional practice. It can range from caring for a patient with a subcutaneous or peripheral cannula in situ to nursing a patient requiring multiple parenteral drugs/infusions. Whatever the route, subcutaneous, peripheral or central, infusion therapy is not without risks. Patients have a right to receive a uniformly high standard of care, and nurses have a responsibility to deliver evidence based care. Research findings should be used to expand the evidence base of nursing knowledge in order to validate and improve practice, to advance professional accountability for the benefit of all patients.

2.0 Scope of Policy

The contents of this policy apply equally to medical staff as well as nursing staff. Subcutaneous or intravenous therapy is assessed as being necessary for the care of some patients within Black Country Partnership Foundation Trust. This may be carried out for the induction of anaesthetic, short-term fluid replacement, nutritional support or palliative care. These procedures are more commonly undertaken on our older adult units at Edward Street & Penn Hospitals. A significant complication of venous and arterial devices is infection, which may be localized or systemic, therefore knowledge of the relevant anatomy and physiology and skills in the insertion and subsequent care of these devices is vital. This policy applies only to peripheral venous cannula (PVC) and subcutaneous devices commonly known as Vascular Access Devices (VADs) and does not cover the insertion and management of central venous catheters (CVC). This policy also refers to devices that may be attached to VADs after insertion e.g. infusion sets and extension sets.

BCPFT staff must have received specific training, have completed the enclosed competency assessment & be deemed as competent in the



procedures BEFORE they are able to care for patients with IV or SC infusions.

Alternatively patient’s requiring this type of treatment will require transfer to the nearest local Acute Hospital for assessment & appropriate treatment.

This policy must be applied in any area within the Trust where VADs and associated equipment is used.

3.0 Risks of Cannula insertion

It must be recognised that intravenous cannulation is an invasive procedure. Observation must be carried out to monitor any risks associated with this procedure. These include localised infection, but also phlebitis, infiltration, extravasation and haematoma, all of which predispose the patient to an increased risk of local and systemic infection, bacteremia and therefore mortality.

The importance of using effective infection prevention and control measures are integral to all aspects of infusion therapy and associated devices.

4.0 Objectives

To ensure safe and effective subcutaneous and peripheral cannulation at all times.

To ensure that infection control measures are observed through the insertion, management and removal of all vascular access devices.

To maintain the patency of the device.

To maintain the comfort and safety of the patients.

To maintain a closed infusion system to reduce the risk of contamination.

5.0 Criteria for Practitioners Involved

The Nursing and Midwifery Council (NMC) code of professional conduct The Code (NMC 2015) emphasises the need to base care on the best available evidence.

The Health Care Professional (HCP) responsible for the management (including device insertion and ongoing management) of infusion therapy should be competent in all clinical aspects of infusion care which they carry out and have the skills and knowledge pertinent to their role.

The HCP in addition should have validated clinical competence in accordance with the NMC’s Code (2015) or other relevant health professional Standards of conduct performance and ethics, in order to maintain their knowledge and skills.

The HCP will have undergone theoretical and practical training as part of a competency assessment (see Appendix 7)



Training for insertion and management may be undertaken during pre-registration period (i.e. Medical staff) or post registration courses (i.e. Nursing staff)

6.0 General Principles

Initial assessment should include whether or not infusion therapy is required and have other routes been considered and excluded. A number of broad principles apply to all aspects of the management of all infusions and associated devices. Specific guidance is given regarding each particular device but the following should be adhered to at all times.

Individuals who require VADs/infusion therapy should have the opportunity to make informed decisions about their care and treatment in partnership with the health professional looking after them. It may not be possible for some of our patients to understand or give verbal consent; this should be clearly documented in Medical/Nursing notes.

When the patient does not have capacity to make decisions, healthcare professionals should follow the DH guidelines and Trust policy on consent to treatment.

Infusion fluids must be prescribed by a doctor following an assessment of the patients fluid and electrolyte needs remembering the 5 Rs: Resuscitation, Routine maintenance, Replacement, Redistribution and Reassessment, and offer infusion therapy as part of a protocol (See NICE Algorithm for IV therapy in Appendix 1)

Infusion fluid therapy should only be used for patients whose needs cannot be met by oral or enteral routes, and must be reviewed daily and stopped as soon as possible.

Administration Sets (‘giving sets’)

Administration sets also known as ‘giving sets’ used for a continuous infusion MUST be changed every 96 hours unless indicated otherwise by the manufacturer, they become disconnected, or the integrity of the product or system has been compromised. Date/time labels must be applied to ensure administration sets are changed at the correct interval. Administration sets must be changed under aseptic conditions using standard precautions and following manufacturer’s recommendations. Used equipment must be discarded as clinical waste.

Administration sets used for intermittent infusion should be changed every 24 hours if remaining connected to a device or discarded after each use if disconnected. These should be changed using aseptic technique and observing standard precautions. Date/time labels must be applied to ensure administration sets are changed at the correct interval. Used equipment must be discarded as clinical waste.

Roller clamps should always be used to occlude the line when removing the administration set.

Manual flow control devices

The rate of infusions can be regulated by manual flow control devices to ensure timely delivery of the prescribed therapy e.g. resuscitation situations.



The healthcare professional should demonstrate knowledge and competency which has been assessed relative to the manual infusion device including indications for use, and regulating the flow to deliver the prescribed therapy.

The healthcare professional responsible for the care and management of the patient is accountable for the use of manual flow control infusion devices, if deemed competent in the use of manual flow infusion devices.

Electronic Infusion Devices

The use of an infusion pump to regulate the flow of IV or SC fluid is recommended – all Medical Devices used are standardized across the Trust and must be approved for use by the Medical Devices Committee and included on the medical devices asset register.

The healthcare professional should demonstrate knowledge and competency which has been assessed relative to electronic infusion device including indications for use, programming the device to deliver the prescribed therapy, mechanical operation, the use of lock-out safety devices, troubleshooting, monitoring and safe use. The healthcare professional is responsible for monitoring the patient and is accountable for the use of electronic flow control infusion devices. N.B. training and assessment of competency in the use of medical devices is provided by the Medical Device Nurse Trainer.

All infusion pumps must be configured correctly for their required application. (Configuring means selecting the appropriate mode for the intended use).

Administration sets should be compatible with the infusion pump and fitted with an anti-free flow device. The correct pump should be specified on the administration sets packaging.

Roller clamps should always be used to occlude the line when removing the administration set.

Infusion devices must be decontaminated after each use as per the manufacturer’s instructions.

Syringe pumps

Always ensure that the syringe is compatible with the syringe pump with attention to the positioning and securement of syringe barrel, syringe barrel clamp, syringe plunger clamp and syringe finger grips.

Use the prime or purge facility on the syringe pump to reduce mechanical backlash. NEVER prime or purge the line with the extension set still attached to the patient.

The healthcare professional is responsible for monitoring and documenting the infusion rate of the prescribed therapy.

The healthcare professional should demonstrate knowledge and competency which has been assessed relative to electronic infusion device including indications for use, programming the device to deliver the prescribed therapy. N.B. training and assessment of competency in the use of medical devices is provided by the Medical Device Nurse Trainer.



6.1 Preventing Infection – general principles

There is risk of infection when the device is inserted and while it remains in situ. The risks inherent in insertion of VADs include bypassing the skin, which is such an important barrier against microorganisms gaining entry to sterile sites such as the tissues and bloodstream, and leaving a foreign body in the patient for several days or longer which is likely to become colonised by microorganisms.

Skin organisms – colonisation of the external surfaces of the device by microorganisms from the patients skin around the insertion site. This can occur through contamination of the cannula tip at the time of insertion or migration of skin organisms at the insertion site into the cutaneous cannula tract after insertion

Contamination of the cannula hub with distal spread of the organisms down the intraluminal surface. This is largely thought to occur during handling of the connections at the cannula/line junctions.

Occasionally the cannula might become haematogenously seeded from another focus of infection.

Contamination of the fluid infuscate occurs on rare occasions.

6.1.1 Risk factors for VAD related blood stream infections

Prolonged hospitalisation before the VAD is inserted.

Prolonged placement of the device

Heavy microbial colonisation of the insertion site that contaminates the cannula during insertion and migrates along the cutaneous cannula track.

Heavy microbial colonisation of the cannula/hub, usually secondary to contamination from healthcare professional hands during care interventions.

Potential sources for indwelling device contamination:

6.1.2 Minimising the risk of blood stream infections from VADs

Adherence to the Trust Hand Hygiene policy and procedure including correct selection and use of PPE prior to all interventions and patient care episodes.



To minimise the risk to patients, VADs should only be used when absolutely necessary.

VADs must be removed as soon as they are no longer needed or alternative means are available to deliver appropriate care e.g. fluids/medication.

Prior to insertion suitable skin prep with rapid acting skin antiseptics e.g. 70% isopropyl alcohol with 0.5% chlorhexidine is recommended for procedures penetrating the skin (including subcutaneous infusions).

Standard precautions and aseptic non-touch technique must be used when inserting or handing VADs and associated equipment and uses sterile equipment ensuring checks that packing intact, products in-date etc.

Use of sterile occlusive cannula dressings ensuring the insertion site remains visible though the dressing.

Dressing changed as recommended e.g. if soiled or loosened (see section 7.6.1)

Daily use of the VIP score assessment tool and device replacement when clinically indicated.

If a VAD is inserted in an emergency, remove within 24 hours and insert a new device under appropriate conditions.

Replacement of administration sets every 96 hours when used for continuous infusion or after each use if used for intermittent infusion and disconnected from the device or every 24 hours if remains connected to the device (see section 7)

6.2 Peripheral Venous access

Veins that should be considered for peripheral cannulation are those found in the forearm or hands, generally IV’s are started at the most peripheral site that is available and appropriate for the situation. Where possible use the non-dominant forearm. Site selection should avoid areas of flexion although this may not always be possible.

The healthcare professional should have the necessary knowledge and competence to select the most appropriate site and device for the patient and the intended therapy.

6.3 Use of Subcutaneous (SC) Devices The administration of fluids by the subcutaneous route is a safe and reliable method of treating dehydration and symptoms of thirst in the elderly and palliative care patients. It is particularly useful in patients who have difficulty in taking fluids orally, such as those who have dysphagia, which results in decreased oral intake. Setting up a subcutaneous infusion is a relatively simple procedure and carries far less infection risk than an intravenous infusion. This method involves the insertion of a 21 or 23 gauge butterfly cannula under aseptic conditions into subcutaneous tissue. These may be inserted at an angle of 45 degrees and secured with a sterile transparent dressing. Only one device should be used for each insertion attempt for that particular device and patient (following failed insertion attempts discard equipment and select a new device)



Once the cannula is inserted it is attached to a giving set and connected to a bag of fluids (either 5% Dextrose or 0.9% Saline), commonly infused at a rate of 2 litres over a 24hr period. Small volumes of fluid/medication should be administered using a syringe driver. Prolonged use with large volumes of fluids in one site can result in localized pain and oedema. NB. This policy does not specifically refer to infusions for the purposes of palliative care.

6.3.1 SC Site Selection

The best sites for the continuous infusion of drugs or fluids are the lateral aspects of the upper arms and thighs but the most common site is the abdomen in the umbilical region. This is because these sites usually have adequate amounts of subcutaneous tissue. The skin should be cleansed and be gently pinched into a fold to elevate the subcutaneous tissue, which lifts the adipose tissue away from the muscle. Sites that should NOT be chosen are:

Limbs with pre-existing lymphedema - the absorption rate may be affected but the cannula breaches the integrity of the skin and increases the risk of infection to an already compromised limb.

Sites over bony areas. Skin which has received radiotherapy Sites near a joint, where movement could displace the cannula

6.4 Insertion of all Vascular Access or Subcutaneous (SC) Devices

Placement of any vascular access or subcutaneous device is a procedure that should only be undertaken by a Healthcare Professional (HCP) who have had appropriate training, has a comprehensive understanding of anatomy and physiology, vascular assessment and insertion techniques appropriate to the specific device, and has completed appropriate training and deemed competent to do so. In addition the HCP should have the necessary knowledge and competence to select the most appropriate site and device for the patient and the intended therapy (See competency requirements in Appendix 7).

Cannulation and venepuncture is an invasive procedure involving a breach of the skins integrity from the skin surface to the bloodstream.

Use of aseptic technique method and standard precautions in conjunction with product sterility are required to prevent infection.

Use of personal protective equipment is required based on assessment of risk of transmission of microorganisms and the risk of contamination of the healthcare worker. Gloves MUST be worn for invasive procedures.



Preparation The healthcare practitioner must wash hands prior to the procedure, select appropriate PPE and use an aseptic technique.

Preparing equipment

All equipment collected together

Integrity of packaging and expiry dates checked

All devices selected must have engineered sharps injury protection mechanisms; these mechanisms should be activated immediately after use and prior to disposal.

Hands must be decontaminated both before and after the insertion / removal and before all manipulations of a device. (See Hand Hygiene Policy)

Checking Identity of patient

Any allergies the patient has e.g. to tape, skin cleaning solutions, latex etc.

Positioning patient and preparing environment

Patient comfortably positioned

Good lighting and privacy

The healthcare practitioner must use hand sanitising gel prior to donning non-sterile procedure gloves.

Encouraging venous filling

There are various methods of dilating veins to assist selection of a suitable vein for cannulation and improve venous access: Apply tourniquet 4-5 finger widths above the planned puncture site – only venous

blood flow should be suppressed, to ensure a pulse id palpable distal to tourniquet. Place limb below level of the heart. Ask patient to open and close fist Light tapping of vein may seem helpful but can be painful and may cause a

haematoma therefore rubbing the skin is recommended. If vasoconstriction is a problem the application of a warm compress or the immersion

of the limb in warm water can promote venous distension.

Selecting a vein and preparing the site

Once a suitable vein has been selected the tourniquet should be removed and the site prepared.

Hair removal Removal of hair is only necessary if adhesion of the sterile dressing may be difficult

Before cleaning the site any excessive hair should be clipped with scissors, not shaved – this will help to enhance visualisation of the vein & eliminate undue discomfort when the dressing is removed. (Shaving increases the risks of infection)



Cleaning the skin Current guidelines recommend skin disinfection with an alcohol swab (2% Chlorhexidine in 70% isopropyl) or Chloroprep solution.

The application technique should be as per the manufacturer’s instructions allowing for appropriate cleaning (approx. 30 seconds) and drying time.

The solution should be allowed to air-dry completely before inserting the cannula. For the remainder of the procedure do not re-palpate the vein or touch surrounding cleaned skin after disinfection

Stabilising the vein Superficial veins tend to roll and need to be anchored to keep them stable. Veins are stabilised by using the non-dominant hand to apply traction to the side of the insertion site or below it.

Placing the cannula two-handed technique

NB: If a practitioner has had two unsuccessful attempts at insertion, another practitioner with more experience should assess the patient’s venous access. If reinsertion is attempted a NEW device MUST be used.

Using the dominant hand the HCP inserts the cannula with the bevel up so as to ensure smooth puncture of the vein

Skin traction is applied initially using the non-dominant hand. When the stylet is in the vein observe the first flashback, non-dominant hand releases skin traction and withdraws the stylet, observe second flashback then the dominant hand advances the cannula off the stylet.

The vein is occluded and the cannula is stabilised and the tourniquet is released and stylet removed.

If any bruising occurs while cannulation is being performed the tourniquet should be released at once, the device removed and pressure applied to prevent formation of a haematoma.

Stabilising and dressing the cannula

The cannula should be secured using aseptic technique and in such a way that the cannulation site can be inspected visually and the flow of infusion fluid is not impeded. A sterile transparent semi-permeable membrane dressing and/or gauze should be applied – the entry site should remain visible.

Attach extension set/giving set or Luer plug

If giving IV fluids the primed giving set should be attached to the hub (an extension set is recommended to reduce mechanical phlebitis. If not immediate infusion is required a luer plug should be attached after flushing the cannula.

Injection and access caps/ports which are not integral to the device should be changed at established intervals according to the manufacturer’s instructions (record on care plan)

Injection and access caps/ports that are not integral to the device should be of closed Luer-Lok

TM design



Flushing the cannula

Once the cannula has been inserted and secured it should be flushed with 5mls 0.9% NaCL in a 10ml syringe. Excessive force should never be used when flushing as rupture of the vein could occur.

The cannula site should also be observed for evidence of infiltration.

PVC end caps are single use only and must be discarded after each use

Disposal of sharps Used sharps must be disposed of by the user, at the point of use, into a sharps container (conforming to UN 3291 and BS 7320). (See Waste Management Policy)

NB All non-disposable medical equipment used in associated with VADs must be cleaned daily when in use and following each patient use e.g. drip stands, splints and electronic infusion devices. Following insertion of a VAD all details must be documented (see Appendix 5)

6.5 Cannula sizes

Gauge Length Uses Considerations 24 gauge yellow hub (smallest)

19mm Neonates Paediatric Elderly

Suitable for extremely small veins slow flow rates

22 gauge blue hub

25mm Neonates Paediatric

Easy to insert Suitable for small or fragile veins Can be used for all IV fluids & medications Approximately 42ml/min

20 gauge pink hub

25mm Adolescents Adults Elderly

Most commonly used for all IV fluids & medications Approximately 67ml/min

18 gauge green hub

32mm Adults

Suitable for administration of viscous fluids or when high flow is required Approximately 133ml/min

16 gauge grey hub

32mm Adults

Suitable for administration of large quantities of IV fluids or when high flow is required

Painful insertion, requires a large vein Approximately 236ml/min

6.6 Monitoring the site

The condition of the site should be inspected and documented regularly (each shift),

for signs of complications such as infection or phlebitis and to also check that the cannula is still firmly secured and the dressing is clean and intact.

The VIP score should be used to assess the site (Appendix 2) Following the assessment findings must be recorded (Appendix 3) and the care plan

reviewed and evaluated at each shift. (Appendix 4)

6.6.1 Changing the dressing

The site should be kept clean and dry at all times. The dressing should only be changed if it becomes wet or soiled.



Aseptic technique should be used for dressing changes. Document on the care plan all interventions

6.6.2 Maintaining patency

Thrombi and fibrin deposits on intravascular devices may provide a site for microbial colonisation. Flushing with 0.9% Sodium Chloride (NaCL) solution should be performed before, between and after administration of medications or solutions by a competent healthcare professional who has be trained and assessed as competent to do so. Document all interventions on the care plan (Appendix 4) & record all use of flushes on the patient’s prescription sheet.

6.6.3 Removing a cannula Peripheral IV cannula should be removed and if necessary replaced after 72 – 96 hours. Removal should take place earlier if complications are suspected or the cannula is no longer required. Peripheral cannula only need to be re-sited when clinically indicated and not routinely.

The cannula should be removed carefully, slowly and steadily with the hub parallel to the skin.

Firm pressure should be maintained until bleeding stops and then a small sterile self-adhesive dressing applied.

The cannula should be inspected on removal to ensure that it is intact. Removal must be documented (Appendix 3 & 4)

7.0 Patient Safety Incidents

All patient safety incidents that have the potential to, or actually result in harm should be reported via DATIX to ensure that any necessary action can be taken to prevent similar incidents from occurring in the future and in order for learning to take place and be shared. Any adverse incident involving a medical device must be reported to the MHRA using the adverse incident reporting system/yellow card scheme. The Governance Assurance Team and Medical Engineering must be notified immediately and the medical device MUST be retained securely for inspection (this include any disposable single use equipment). Refer to Medical Devices Policy and associated procedures for more detailed information

8.0 Monitoring & compliance

Each Division is responsible for monitoring standards of clinical practice Exception reports will be presented to the relevant Division Management Board and the Quality & Safety Steering Group. The reports will include audit data from clinical areas, details of associated infection prevention and control issues. Any areas of non-compliance with this policy will be reported through the Nursing Board for dissemination of any lessons learnt.

9.0 Standards / key performance indicators



Key Performance Indicator Method of Assessment 1. Compliance with Hand Hygiene Inpatient Services audited monthly.

Community Services audited quarterly.

Saving Lives audit for VAD insertion (Appendix 6) should be undertaken each time a unit has a patient with a VAD

2. Compliance with Disposal of Sharps Waste Inpatient Services audited monthly.

Annual Audit Programme for all other areas.

3. In all cases of confirmed device associated bacteraemia the CCG is notified

The IPCT will notify The CCG of a confirmed case of HCAI within 24hrs (of the next working day). Feedback from CCG on receipt of Divisional quarterly reports.

4. Care of Medical Devices Inpatient services audited by the Matrons

5. Competency of healthcare professional in relation to this policy

All Ward Managers are responsible to ensure their staff are competent to perform procedures in relation to this document and where necessary ensure training is provided

Assessment part of individual performance reviews and 1-1’s with staff

10.0 Equality Impact Assessment

Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email [email protected]

11.0 Data Protection Act and Freedom of Information Act

Data Protection Act provides controls for the way information is handled and to gives legal rights to individuals in relation to the use of their data. It sets out strict rules for people who use or store data about individuals and gives rights to those people whose data has been collected. The law applies to all personal data held including electronic and manual records. The Information Commissioner’s Office has powers to enforce the Data Protection Act and can do this through the use of compulsory audits, warrants, notices and monetary penalties which can be up to €20million or 4% of the Trusts annual turnover for serious breaches of the Data Protection Act. In addition to this the Information Commissioner can limit or stop data processing activities where there has been a serious breach of the Act and there remains a risk to the data. The Freedom of Information Act provides public access to information held by public authorities. The main principle behind freedom of information legislation is that people have a right to know about the activities of public authorities, unless there is a good reason for them not to. The Freedom of Information Act applies to corporate data and personal data generally cannot be released under this Act.

mailto:[email protected]

http://simple.wikipedia.org/wiki/Information

http://simple.wiktionary.org/wiki/right



All staffs have a responsibility to ensure that they do not disclose information about the Trust’s activities; this includes information about service users in its care, staff members and corporate documentation to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies. The Information Governance Team provides a central point for release of information under Data Protection and Freedom of Information following formal requests for information; any queries about the disclosure of information can be forwarded to the Information Governance Team.

12.0 Training

Please refer to the Trust’s Mandatory and Risk Management Training Needs Analysis for further details on training requirements, target audiences, and update frequencies. Intravenous therapy treatment MUST NOT commence until the staff involved have received appropriate specific training and deemed competent. Staff must also be competent in the use of all devices and consumables required. The appropriate Ward Manager/Matron will refer staff for training and the Division will secure funding if required. The Divisions will also fund the purchase of devices and infusion pumps. Only devices approved by the Medical Devices Committee may be ordered (See Medical Devices Policy).

13.0 References

1. Dougherty, L & Lister S (2015) the Royal Marsden Hospital Manual of Clinical Nursing Procedures, 9th Edition, Blackwell Science.

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

3. EPIC 3 (2017) Guidelines for Preventing Healthcare Associated Infections. NHS Improvement

4. Jackson, A. (1998) visual Infusion Phlebitis Score.

5. NICE, (2014) Quality statement 5: Vascular access devices. London, National Institute for Clinical Excellence

6. B Braun (2017) Braun Peripheral Cannulation & Venepuncture Training Programme© Workbook

7. BCPFT Medical Devices Policy and associated Standard Operating Procedures

8. BCPFT Infection Control Assurance Policy and associated Standard Operating Procedures

9. The Royal Marsden Hospital Manual of Clinical Nursing Procedures (9th Edition) 2015



Algorithms for IV fluid therapy in adults (NICE 2016)

Appendix 1 Appendix 1 Appendix 1

Using an ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach, assess whether the patient is hypovolaemic and needs fluid resuscitation

Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP<100mmHg;

heart rate >90bpm; capillary refill >2s or peripheries cold to touch; respiratory rate >20

breaths per minute; NEWS ≥5 45° passive leg raising suggests fluid responsiveness

Yes

See Algorithm 2:

Fluid Resuscitation No

Algorithm 1: Assessment

Assess the patient’s likely fluid & electrolyte needs

History: previous limited intake, thirst, abnormal loses, comorbidities

Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension

Clinical monitoring: NEWS, fluid balance charts, weight

Laboratory assessments: FBC, urea, electrolytes & creatinine

Can the patient meet their fluid and/or electrolyte needs orally or enterally?

Yes

Ensure nutrition & fluid needs are met

Does the patient have complex fluid or electrolyte replacement or abnormal distribution issues?

Look for existing deficits or excesses, ongoing abnormal losses, abnormal distribution or other complex issues.

No

No

See Algorithm 3: Routine Maintenance

Yes See Algorithm 4:

Replacement & Redistribution


Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP<100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to

touch; respiratory rate >20 breaths per minute; NEWS ≥5 45° passive leg raising suggests fluid responsiveness



Algorithm 2: Fluid Resuscitation

Yes

Initiate treatment

Identify cause and deficit and respond

Give a fluid bolus of 500ml of crystalloid (containing sodium in the range of 130-154 mmol/l) over less than 15

minutes.

Reassess the patient using the ABCDE approach Does the patient still need fluid resuscitation? Seek expert

help if unsure

Does the patient have

signs of shock?

Yes No

Assess the patient’s likely fluid & electrolyte needs

(see Algorithm 1 box 3)

Yes No

Seek expert help >2000 ml given?

Give a further fluid bolus of 250-500 ml of crystalloid

Yes

No


Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP<100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch;

respiratory rate >20 breaths per minute; NEWS ≥5 45°passive

leg raising suggests fluid responsiveness



Algorithm 2: Fluid Resuscitation

Yes No

Assess the patient’s likely fluid & electrolyte needs History: previous limited intake, thirst, abnormal losses,

comorbidities






No

Yes

No


Look for existing deficits or excesses, ongoing abnormal losses, abnormal distribution or other

complex issues

Yes See Algorithm 4: Replacement &

Redistribution

No

See Algorithm 3: Routine Maintenance

Give maintenance IV fluids

Normal daily fluid & electrolyte requirements: 25-30 ml/kg/d water

1 mmol/kg/day sodium, potassium*, chloride 50-100 g/day glucose (e.g. 5% contains 5 g/100ml)

Reassess and monitor the patient Stop IV fluids when no longer needed

Nasogastric fluids or enteral feeding are preferable when maintenance needs are

more than 3 days

*Weight-based potassium prescriptions

should be rounded to the nearest common

fluids available (for example, a 67kg person

should have fluids containing 20 mmol and 40

mmol of potassium in a 24 hour period).

Potassium should not be added to IV fluid

bags as this is dangerous


Assess volume status taking into account clinical examination, trends and context. Indicators that a patient may need fluid resuscitation include: systolic BP<100mmHg; heart rate >90bpm; capillary refill >2s or peripheries cold to touch;

respiratory rate >20 breaths per minute; NEWS ≥5 45°passive leg raising suggests fluid responsiveness



Assess the patient’s likely fluid & electrolyte needs History: previous limited intake, thirst, abnormal losses, comorbidities




No


No


Yes


Look for existing deficits or excesses, ongoing abnormal losses, abnormal distribution or other complex issues

No

Yes

Algorithm 4: Replacement & Redistribution

Existing fluid or electrolyte deficits or excesses. Check

for: Dehydration

Fluid overload Hyperkalaemia Hypokalaemia

Estimate deficits or excesses

Ongoing abnormal fluid or electrolyte losses. Check

ongoing losses and estimate amounts. Check for:

Vomiting & NG tube loss Biliary drainage loss High/low volume ileal

stoma loss Diarrhoea/excess

colostomy loss Ongoing blood loss e.g.

malaena Sweating/fever/dehydrati

on Urinary loss/polyuria

Redistribution and other complex issues, check for:

Gross oedema Severe sepsis

Renal/liver and/or cardiac impairment

Malnourished and refeeding issues

Seek expert help if necessary

and estimate requirements

Prescribe by adding to or subtracting from routine maintenance, adjusting for all other sources of fluid and electrolytes (oral, enteral and drug prescriptions)

Monitor and reassess fluid and biochemical status by clinical and laboratory monitoring



Visual Infusion Phlebitis Score

Appendix 2:



Peripheral IV Cannula Record Chart - VIP Score

Patient Label here Complete this record each shift & record each cannula inserted

Cannula: Cannula: Cannula: Cannula:

Gauge: Gauge: Gauge: Gauge:

Date of insertion: Date of insertion: Date of insertion: Date of insertion:

Insertion Site: Insertion Site: Insertion Site: Insertion Site:

Date of removal: Date of removal: Date of removal: Date of removal:

If the cannula is being accessed regularly for the administration of medication, IV fluids (at least every eight hours) no further flushing will be required. However in the event of infrequent access, the cannula should be inspected, assessed and flushed every eight hours with 5 mls 0.9% saline.

Date Time Cannula Site (detail position)

Reason for continuing please state clinical indication

Site inspection:

VIP score

Cannula Flushed with 0.9% NaCl

Problems please state (E.g. occlusion, positional, pulled out etc.)

Print name

Sign

Yes No

Score Visual Infusion Phlebitis (VIP) score

0 IV site appears healthy

1 ONE of the following evident: Slight pain near IV site OR slight redness near IV site

2 TWO of the following evident: Pain at IV site OR Erythema OR Swelling

3 ALL of the following evident: Pain along path of cannula AND Erythema AND Induration

4 ALL of the following evident and extensive: Pain along path of cannula AND Erythema AND Induration

5 ALL of the following evident and extensive: Pain along path of cannula AND Erythema AND Induration AND palpable venous cord AND Pyrexia

Appendix 3

Continue overleaf



Date Time Cannula Site (detail position)

Reason for continuing please state clinical indication

Site inspection: VIP score

Cannula Flushed with 0.9% NaCl

Problems please state (E.g. occlusion, positional, pulled out etc.)

Print name Sign

Yes No

POSITIVE Blood Culture (BC) results: Date blood culture taken

Cannula site Reason BC taken Results Action taken



Care plan for the management of a patient with a Vascular Access Device

Please print this care plan and keep it in patient’s nursing notes.

Patient Name: NHS No.:

Ward: Date/Time:

REASON FOR INFUSION Insert patient’s name - has been prescribed an infusion for the following reason/s:-

OBJECTIVES: (Expected outcome) To prevent discomfort To prevent any complications that may arise with the infusion / cannulation. To maintain fluid balance To allow intravenous drugs Other please state:

INTERVENTIONS: (Plan of nursing care) After the cannula has been inserted: -

Observe the area around the cannula for any swelling or inflammation. A phlebitis (VIP) score must be recorded at each shift and the cannula removed if the score is 2 or above

The cannula will be checked for patency at least daily and flushed with 0.9% Sodium Chloride if no infusion attached.

The cannula needs to remain secure with a dressing - change dressing if it becomes loose. In addition the dressing should remain clean and dry and should be renewed as necessary. Only sterile IV dressings should be used.

The cannula is dated on insertion and should be renewed or removed within a 48-72 hour period.

In some circumstances (e.g. if it is difficult to re-cannulate) and there is a need for continuing IV therapy the cannula can remain in place for more than 72 hours provided the phlebitis score does not exceed 2.

On removal of the cannula, the site should be cleaned and a dry sterile dressing applied. If the site appears red or inflamed a swab must be taken and the tip of the cannula sent to microbiology & blood culture’s obtained if the patient is pyrexial to check if there is any infection present.

Bandages should be removed each time the cannula is assessed or 8 hourly (which ever sooner) so that the site can be assessed correctly

Bandages should be avoided whenever possible – patient’s condition permitting

If the cannula site has become infected or a cannula related blood stream infection is suspected, inform Infection Control

Named Nurse: Signature: Date: Patient: Signature: Date: Relative: Signature: Date:

Appendix 4



*Evaluate this care plan on each shift & document findings overleaf Care plan evaluation for a patient with a Vascular Access Device

Patient Name: NHS No.:

Ward: Date/Time:

Date/time: Evaluation - include VIP score findings Nurse Signature



Inpatient Adult Peripheral Cannula Insertion Record

The practitioner inserting the peripheral cannula must complete the front of this form & the reverse must be completed by the Nurse caring for the patient as instructed

(Please mark boxes with X use black ink)

Please print this care plan on Blue Paper and keep it in patient’s notes

______________________________________________________________________________

1.0 Affix patient label: 1.1 Date Cannula inserted

2.0 Environment for Insertion

Ward/Department A&E

Community Other (specify) ECT

Specify ward where cannula inserted 2.0 Cannula Gauge:

Blue 22g Pink 20g Other (please specify) ………………………………………………..

3.1 Number of cannulation attempts : 3.1.2 Skin cleansed with …………………………….

Identify on the diagram site of cannula insertion

4.0 Surname of clinical practitioner inserting Cannula:

4.1 Signature of clinical practioner (nurse, doctor etc.)

4.2 Designation e.g. Nurse, House Manager, Doctor etc.

Surname: Reg No

Forename: Sex: D.O.B.

Address: Cons:

Ward/Dept.

Hosp:

Appendix 5

Standards of Practice Use an aseptic procedure trolley or sharps procedure tray for the cannulation procedure

Decontaminate hands prior to cannulating, remembering to use alcohol hand gel

Wear gloves and an apron

If possible place a sterile dressing towel underneath the arm, hand or area to be cannulated

Implement a non-touch aseptic technique and using Chloraprep to decontaminate the insertion site cannulate the patient

Post insertion apply an IV3000 peripheral cannula dressing to secure the device

Dispose of sharps at point of use into a sharps container & discard any clinical waste into a yellow clinical waste bin

Decontaminate hands post procedure

Cannulas inserted under non-aseptic conditions should ideally be removed within 24 hours of insertion, provided alternative IV access can be established if required



Saving Lives: Audit for VAD Insertion

Peripheral IV cannula care bundle review tool

Observation INSERTION ONGOING CARE

Date & Time Hand Hygiene

Gloves & apron etc.

Skin preparation

Dressing Documentation to record insertion

Hand hygiene

IV still clinically indicated

Site inspection

IV set replaced after 72hrs

Cannula replaced after 72 hours

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Date: Ward: Undertaken by:

Saving Lives: audit for VAD insertion To be used in all wards/departments caring for patients undergoing cannulation/infusion therapy. Monthly records to be sent to the Matron & Infection Prevention & Control Nurse for inclusion in the quarterly infection control reports. Each time a care element is undertaken, insert a tick in the relevant column. If the action is not performed leave it blank.

Do these for each patient action, ensuring you tick it only when an element of care is performed correctly for every patient with an IV cannula or infusion.

Appendix 6



Medical & Registered Nurse Competency Assessment Framework – Vascular Access Devices

Please note that a certificate of training is not evidence of competence. Before you are able to perform peripheral IV or SC cannula care without supervision you will need to carry out a number of assessments under the supervision of a competent practitioner. It is expected that all Registered Nurses will achieve a competency at Level 4 as a minimum.

Name:

Location:

Date commenced:

Date completed:

Assessor:

This framework describes the competencies that you will need to enable you to practice peripheral and subcutaneous therapy proficiently within the Black Country Partnership NHS Foundation Trust. Use this framework as a guide to enable you to appreciate the scope of practice you will require to allow you to practice competently and effectively. It provides a tool to enable you and others to assess your current level of practice and structure your development accordingly and acts a record of your professional development. The competency framework should be completed within 6 months of attending related training sessions. Assessment in practice must be by a Registered Nurse who can demonstrate competence at level 4 or

above. * Indicates procedure can only be undertaken by Medical Staff

Level of competency rating scale

Level Descriptor

0 Cannot perform this activity to participate in the clinical environment

1 Can perform this activity but not without constant supervision and assistance

2 Can perform this activity with basic understanding of theory and practice principles, but requires some supervision and assistance.

3 Can perform this activity with understanding of theory and practice principles without assistance and/or supervision

4 Can perform this activity with understanding of theory and practice principles without assistance and/or supervision at an appropriate pace and adhering to best practice guidelines

5 Can perform this activity with thorough understanding of theory and practice principles without assistance and/or supervision at an appropriate pace and adhering to best practice guidelines.

Additionally demonstrating initiative and adaptability to special problem situations.

6 Can perform this activity with thorough understanding of theory and practice principles, without assistance and/or supervision, at an appropriate pace, adhering to best practice guidelines.

Demonstrating initiative and adaptability to special problem situations and can lead others in performing this activity.

Appendix 7



Performance Criteria Assessment method

Level achieved

Date Assessor

1. Core Competencies: Demonstrates knowledge that underpins infusion therapy and peripheral/subcutaneous cannulation

1.1 Demonstrates knowledge of the BCPFT IV Vascular Access Devices & Infusions Policy

Questioning

1.2 Demonstrates knowledge of the BCPFT Hand Hygiene Policy

Questioning Observation

1.3 Demonstrates knowledge of the Aseptic Technique procedure


1.4 Demonstrates knowledge of the correct use of PPE

Questioning

1.5 Demonstrates knowledge of the principles of the Mental Capacity Act and Deprivation of Liberties Standards and essential requirements of obtaining informed consent

Questioning

1.6 Demonstrates knowledge of the accountability and responsibility of the Registered Nurse in relation to management of Vascular Access Devices

Questioning

1.7 Demonstrates relevance and attendance of Anaphylaxis and Basic Life Support training

Questioning

1.8 Demonstrates effective and appropriate communication with patient, carers, and medical staff

Questioning

1.9 Demonstrates knowledge and can differentiate between peripheral and subcutaneous infusions

Questioning

1.10 Demonstrates knowledge of anatomy and physiology that relates to peripheral IV and subcutaneous cannulation.

Questioning

1.11 Demonstrates knowledge of related terminology e.g. infusion, intravenous, extravasation, phlebitis etc. and its meaning

Questioning

1.12 Demonstrates knowledge of the patients present condition and medical history

Questioning

1.13 Demonstrates understanding of the relevance of risk assessment

Questioning

1.14 Demonstrates knowledge of the checking of prescribed infusion fluids, flushes at key points in the administration. E.g. prescription written correctly, correct identification of patient using NHS number & DOB, allergies, indications, contraindications, calculation etc.

Questioning



1.15 Demonstrates knowledge of the types of access devices, position in the body, recommended duration of use, device maintenance etc.

Questioning

1.16 Demonstrate knowledge and practice of the correct methods to monitor the administration of the fluids including documentation.


1.17 Demonstrate knowledge and practice of the correct methods to monitor the skin site of the device including the relevant documentation e.g. VIP score


1.18 Demonstrate knowledge and practice of correct methods and documentation to monitor the patient’s condition and responds appropriately to any change.


1.19 Demonstrates knowledge of the signs and symptoms of problems associated with infusion therapy and their management including; infiltration, extravasation, phlebitis, infection, fluid overload, embolism and breakage of the line etc.


1.20 Demonstrates knowledge and ability to develop care plans in relation to infusion therapy, anticipating any potential problems or issues and their consequences for the patient


2. Core Competencies Demonstrates safe practice in the administration of prescribed intravenous/ subcutaneous fluids

2.1 Demonstrates checking that the prescription is written correctly


2.2 Explains the importance of checking for allergy status


2.3 Demonstrates safe practice in relation to: Correct identification of the patient

using name, NHS Number and date of birth

IV/SC Fluid, dose, route, frequency & duration of infusion is accurate and appropriate

Ability to perform calculation for infusion rate

Check infusion fluids name, strength, expiry date, sterility, contamination etc.

Confirms rate and duration of administration

Calculates and records in the appropriate clinical record, the volume of fluids required to administer the prescribed dose.



Questioning Observation Questioning Observation Questioning Observation


2.4 Demonstrates preparation and administration using aseptic technique




including priming the infusion line and any extension set if required.

2.5 Demonstrates knowledge of when the cannula may require flushing


2.6 Demonstrates correct segregation and safe disposal of waste.


2.7 Demonstrates completion of all documentation correctly and in a timely logical sequence.


3. Specific Competencies: Peripheral Cannula Insertion (Medical Staff only to insert cannula) assisted by RN

3.1 Demonstrates safe knowledge and practice of the equipment and preparation required for Peripheral Cannulation including; patient preparation & comfort, selection of correct sized cannula and priming and use of extension & infusion set.


3.2 * Demonstrates safe knowledge and practice of insertion of a peripheral cannula Assessment of patient and medical

condition Assessment of appropriateness of a

peripheral cannula Awareness of possible unwanted

effects of a cannula Use of technical knowledge and

information gathering


Questioning Observation Questioning Observation Questioning Observation

3.3 * Demonstrates correct use of aseptic technique during the procedure of insertion of a peripheral cannula, identifying key parts and key sites.

Observation

3.4 * Demonstrates appropriate site selection Observation

3.5 * Demonstrates correct hand hygiene & use of PPE

Observation

3.6 * Demonstrates correct method for cleansing the skin prior to cannulation

Observation

3.7 * Demonstrates correct insertion technique of the peripheral cannula

Observation

3.8 * Demonstrates correct method of creating and maintaining a closed system

Observation

3.9 * Demonstrates correct selection and application of a peripheral cannula dressing

Observation

3.10 * Demonstrates the correct techniques in maintaining patency of the peripheral cannula including equipment for flush, amounts, intervals and techniques to maintain patency and positive pressure

Observation

3.11 Demonstrates correct documentation Observation



following insertion, using the peripheral cannula record chart to document date and time of cannula insertion and knows why this is important

3.12 *Demonstrates the correct administration of the recommended flush

Observation

3.13 Can initiate, regulate and evaluate peripheral infusion therapy

Observation

3.14 Can identify common intravenous solutions according to type of solution and indications for use

Questioning

4. Specific Competencies: Demonstrates practical skill in the on-going care and maintenance of patency of venous access devices

4.1 Demonstrates correct method of cleansing a needle free access device

Observation

4.2 *Demonstrates the correct administration of the recommended flush

Observation

4.3 Can describe the signs of phlebitis in vascular access devices (VADs)


4.4 Can correctly indicate when the cannula dressing should be changed and undertake the procedure


4.5 Demonstrates the ability to calculate infusion rates (Assessor to ask questions/give examples)


4.6 Demonstrates how to set up and use the IV infusion pump – state type used:

Observation

4.7 Can assess for signs of phlebitis and document using the VIP score and cannula record chart


4.8 Can assess and maintain accurate records of infusion sites at each shift using correct documentation

Observation

4.9 Can recognize complications of IV infusion therapy and take preventative nursing measures


5. Specific Competencies: Peripheral Cannula Removal

5.1 Can describe the reasons for the removal of a peripheral vascular device


5.2 Demonstrates correct use of aseptic technique during the procedure of removal of a peripheral cannula, identifying key parts

Observation

5.3 Demonstrates appropriate equipment preparation

Observation

5.4 Demonstrates the correct removal techniques of the peripheral cannula

Observation

5.5. Demonstrates correct selection and application of an appropriate dressing


5.6 Demonstrates correct segregation and disposal of waste

Observation

5.7 Demonstrates correct patient education regarding care of the site

Observation

5.8 Demonstrates correct documentation following removal of cannula

Observation

6.Specific Competencies: Subcutaneous Infusion Devices insertion and care (*Medical Staff only to insert cannula) assisted by RN

6.1 Demonstrates knowledge of common sub-cut infusion sites




6.2 Demonstrates knowledge of the purpose of hypodermoclysis (SC infusion)


6.3 Demonstrates safe knowledge and practice of the equipment and preparation required for subcutaneous cannula insertion including; patient preparation & comfort, selection of correct sized cannula and priming and use of extension & infusion set.


6.4 Demonstrates safe knowledge and practice of insertion of a subcutaneous cannula following the manufacturer’s instructions: Assessment of patient and medical

condition Assessment of appropriateness of a

sub cut cannula Awareness of possible unwanted

effects of a cannula Use of technical knowledge and

information gathering


6.5 * Demonstrates correct use of aseptic technique during the procedure of insertion of a sub cut butterfly cannula, identifying key parts and key sites.


6.6 * Demonstrates appropriate site selection The smallest gauge and shortest length necessary should be selected


6.7 Documents date and time of cannula insertions and knows why this is important.


6.8 * Demonstrates correct hand hygiene & use of PPE


6.9 * Demonstrates correct method for cleansing the skin prior to insertion

Observation

6.10 * Demonstrates correct insertion technique of the sub cut cannula

Observation

6.11 * Demonstrates correct method of creating and maintaining a closed system

Observation

6.12 * Demonstrates correct selection and application of a sub cut cannula dressing – a sterile transparent dressing should be used to cover the administration site

Observation

6.13 * Demonstrates the correct techniques in maintaining patency of the sub cut cannula including equipment for flush, amounts, intervals and techniques to maintain patency and positive pressure

Observation

6.14 Demonstrates correct documentation following insertion, using the cannula record chart to document date and time of cannula insertion and knows why this is important

Observation

6.15 Demonstrates how to set up and prime an infusion line and extension sets

Observation

6.16 Can initiate, regulate and evaluate Observation



sub cut infusion therapy

6.17 Can identify common fluid solutions according to type of solution and indications for use


6.17 Can correctly indicate when the cannula dressing should be changed and undertake the procedure under aseptic technique


6.18 Demonstrates the ability to calculate infusion rates (Assessor to ask questions/give examples)


6.19 Demonstrates how to set up and use the sub cut infusion pump/syringe driver – state type used:


6.20 Can identify and describe complications of hypodermoclysis (sub-cut infusion) and clinical manifestation and document findings


6.21 Can assess and maintain accurate records of infusion sites at each shift using correct documentation


6.22 Knows how to escalate concerns in relation to VADs to an appropriate member of staff


7. Specific Competencies: Sub Cut Cannula Removal

7.1 Can describe the reasons for the removal of a sub cut infusion device


7.2 Demonstrates correct use of aseptic technique during the procedure of removal of a sub cut infusion device, identifying key parts

Observation

7.3 Demonstrates appropriate equipment preparation

Observation

7.4 Demonstrates the correct removal techniques of the sub cut cannula

Observation

7.5. Demonstrates correct selection and application of an appropriate dressing


7.6 Demonstrates correct segregation and disposal of waste

Observation

7.7 Demonstrates correct patient education regarding care of the site

Observation

7.8 Demonstrates correct documentation following removal of device

Observation

I can confirm that I have attended initial training in relation to the care and management of vascular devices on: ……………………………………… and that I am confident and competent in the administration of intravenous and subcutaneous infusions and the care and maintenance of the vascular access devices, namely:

Competency Verification date

Assessor’s Signature

1. Demonstrates knowledge that underpins infusion therapy and peripheral/subcutaneous cannulation

2. Demonstrates safe practice in the administration of prescribed intravenous/ subcutaneous fluids

3. Peripheral Cannula Insertion (Medical Staff only to insert



cannula) assisted by RN

4. Demonstrates practical skill in the on-going care and maintenance of patency of venous access devices

5. Peripheral Cannula Removal

6. Subcutaneous Infusion Devices insertion and care (*Medical Staff only to insert cannula) assisted by RN

7. Sub Cut Cannula Removal

Nurse

Assessor Name & Status

Date completed

Comments



Policy Details

* For more information on the consultation process, implementation plan, equality impact assessment,

or archiving arrangements, please contact Corporate Governance

Title of Policy Infection Prevention in Vascular Access & Subcutaneous Infusion Devices Policy

Unique Identifier for this policy BCPFT-COI-POL-07

State if policy is New or Revised Revised

Previous Policy Title where applicable IV Infusions Policy

Policy Category Clinical, HR, H&S, Infection Control etc.

Clinical (Formerly Infection Control)

Executive Director whose portfolio this policy comes under

Executive Director of Nursing, AHPs and Governance

Policy Lead/Author Job titles only

Infection Prevention and Control Team

Committee/Group responsible for the approval of this policy

Nursing Board

Month/year consultation process completed *

August 2018

Month/year policy approved October 2018

Month/year policy ratified and issued November 2018

Next review date October 2021

Implementation Plan completed * Yes

Equality Impact Assessment completed * Yes

Previous version(s) archived * Yes

Disclosure status ‘B’ can be disclosed to patients and the public

Key Words for this policy

Aseptic non-touch technique, Bacteraemia, European conformity- EC (MHRA 2016a), Embolism, Erythema, Extravasation, Haematom, Hypodermoclysis, Induration, Infection, Infiltration, Lumen, Medical device, Phlebitis, Peripheral cannula, Risk Assessment, Single use device, Syncope, Thrombophlebitis, Vascular Access Device (VAD), Vasoconstriction, Visual Infusion Phlebitis (VIP) Score



Review and Amendment History

Version Date Details of Change

V2.0 Jul 2018

Complete review and updating with name change from ‘Infection Prevention and Control Assurance - IV Infusions’ to ‘Preventing Infections in Vascular Access & Subcutaneous Infusion Devices’ Policy.

V1.0 Jan2015 Reformatted to meet new trust policy template