SCOTTISH HOME PARENTERAL NUTRITION · Web viewPatients on Home Parenteral Nutrition Disclaimer: This document was prepared by the Scottish Nutrition Nurses Group and was up to date

Procedures for the management of Central Venous Access Devices (CVAD) forPatients on Home Parenteral Nutrition

Disclaimer: This document was prepared by the Scottish Nutrition Nurses Group and was up to date at the time of printing. It is the responsibility of the end user to ensure care when implementing.

Guidelines and Policies for central catheter managementStaff caring for the patient on HPN should have access to guidelines and policies to prevent

complications occurring with the central catheter. Evidence-based guidelines for preventing hospital-

acquired infections associated with the use of central venous access devices have been published by

(Pratt RJ et al 2007, O’Grady et al 2002).

The following procedures and protocols are available within this document:

Procedures/ Policies Page Number

Care of Exit site 10

Changing a connection device 11

Commencing Parenteral Nutrition via a external central catheter 12

Flushing the catheter 13

Commencing Parenteral Nutrition via a subcutaneous port 14

Flushing a catheter via subcutaneous port 15

Taking blood cultures 16

Complications 17

Fractured/ruptured catheter 23

Unblocking central venous access device 25

References 27

Managed Clinical Network members 29

Hand wash technique 36

Hand hygiene chart 37

Scottish HPN Managed Clinical Network ProtocolsRevised August 2010 - For revision August 2013

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Venous Access for Home Parenteral Nutrition

Definition

An intravascular catheter is defined as a ‘tubular device, single or multi lumen, designed to be partially or

totally inserted or implanted into the cardiovascular system for diagnostic and /or therapeutic purposes’.

Central venous access

Central catheters are used when permanent access is required for parenteral nutrition (PN). The routes

most commonly used for venous access are the subclavian vein or internal jugular vein. There is a vast

array of catheters available for the administration of PN.

The most frequently used catheters are:

External cuffed tunneled catheters: i.e. Broviac, Hickman

External tunneled catheter: i.e. Vygon Nutricath

Subcutaneous ports

Peripheral inserted central catheters

Single versus multi lumen catheters

Multi lumen central catheters can be used for a combination of HPN and other treatments such as,

chemotherapy or antibiotic therapy. It has previously been suggested that multi lumen catheters increase

the risk of catheter-related sepsis and should not be used for the administration of PN. Many authors

have refuted this. They report that there is no statistical difference in catheter-related sepsis, between

the uses of single or triple lumen catheters.

Unless there is a particular need for a multi lumen catheter, a single lumen catheter is generally

preferred for the patient on home parenteral nutrition. The workload associated with its use is less and is

generally preferred by the patient.

The choice of catheter is dependent on venous access available, duration of therapy and most

importantly patient preference. Table 1 lists the factors that should be taken into consideration when

determining the most suitable catheter for the patient.


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Table 1 – Factors in choosing a catheter for HPN

Short or long term use

Catheter material: i.e. silicone or Polyurethane

Multi or single lumen catheter, Cuffed or non-cuffed catheter

Implantable or external device

Patient preference/ body image, patients ability to care for central catheter

Ease of sterile dressing applications

Cost

Gauge of catheter and vein diameter. The narrowest catheter in the largest vein will provide better flow and reduce vein damage

Method of catheter removal

As the availability of these intravascular devices increases, so must the health professional's knowledge

base. It is essential that the nutrition team have knowledge of which device may be best suited for each

patient and be aware of which catheter has the fewest known complications.

There is a place for each catheter in the care of the patient with HPN; the choice will often be determined

by the patient and their needs. Table 2 lists the common advantages and disadvantages of each

catheter.

Catheter insertion

The central catheter should be inserted in an aseptic environment under the supervision of an

experienced clinician. There is strong evidence that using ultrasound guidance is a more effective

method of insertion (British Committee for Standards in Haematology, 2006). Potential complications

associated with the insertion of the catheter include:

Pneumothorax Venous air embolism

Arterial puncture Catheter misplacement

Cardiac tamponade Cardiac arrhythmias


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Table 2 Advantages and disadvantages of the commonly used catheters

Catheter type Advantages Disadvantages

External cuffed tunneled catheters: i.e. Broviac, Hickman

No external sutures requiredExternal portion of the catheter can be repaired without replacementNo discomfort when connecting PNCan be sterilised by antibiotic lock during periods of catheter sepsisCan remain in situ for several years

Requires an aseptic dressingProblems re body imageRequires surgical placement and removal

External tunneled catheter: i.e. Vygon Nutricath™

No discomfort when connecting PNCan be sterilised by antibiotic lock during periods of catheter sepsis

Requires an aseptic dressingProblems re body imageMay require sutures to anchor catheter to skin

Subcutaneous ports Freedom from dressingsReduces risk of exit site infectionsImproved patient toleranceAllows the patient to bathe and swim

Local discomfort and pain during use, possible skin ulcerationRequires operative placementCannot be sterilised by antibiotic lock if sepsis occursCatheter replacement required more frequently than external catheter

Peripheral inserted central catheters

Ease of insertionEase of removalReduced insertion associated complications

Requires suturingOcclusion /kinking problemsIncreased risk of catheter tip misplacement

A catheter placed in an optimal position, taking into consideration if patient is left or right handed, will

reduce potential complications. When inserting the catheter the clinician will consider the following

points:

The catheter tip should lie above the junction of the superior vena cava and right atrium

If a Dacron cuffed catheter is used, the cuff should be placed in the mid point of the tunnel away from

the exit site

A Chest X-Ray should be carried out to check the position of the catheter before PN is commenced

(unless inserted in radiology).


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Central venous access device care

Central venous access device-related infections account for 90% of nosocomial (hospital acquired)

bloodstream infections. Despite the profuse availability of evidence, there continues to be a significant

diversity in practice of health care professionals. It has been well documented that experienced staff and

educational programs can have a significant impact on the rate of catheter related problems. For this

reason it is essential that all staff caring for a patient with a central venous access device have access to

educational material and researched based protocols and procedures.

Hand washing

It is well documented that the most common cause of the spread of nosocomial infection is via the hands

of health care workers because of their inability to correctly wash their hands. Therefore, the first crucial

step in the reduction of catheter related sepsis is knowledge of the principles of hand washing and the

use of gloves. Any procedure connected with an intravenous catheter requires the health care worker to

wash with an antibacterial handwash. The purpose of a handwash is to remove dirt and to reduce the

load of bacteria on the skin of the hands. Washing with soap and water will remove the transient

bacterial flora, and washing with a cleansing agent will reduce the resident bacteria on hands. It should

be noted however, that resident bacteria will not be totally eliminated by hand washing.

There are several types of handwash available for use, each have different properties and advantages.

Choosing the appropriate agent will depend on several factors. APIC guidelines for hand washing and

hand cleansing in heath care settings (1995) describe three stages:

Characteristics that are desired (e.g. rapid destruction in flora, spectrum of activity)

Evidence of safety and efficacy

Staff acceptance

The practice of hand washing

The use of any handwash solution will prove to be ineffective if staff do not employ the correct hand

washing technique. Various studies have concluded that health care workers do not wash their hands

effectively, leaving many parts of the hands not exposed to soap, water or handwash. In practice the

most commonly missed areas are the fingertips, the thumb and the inside of the fingers.

The use of an alcohol hand rub/gel is known to be effective. It is a powerful cleansing agent that can be

applied quickly to hands that are not soiled. It will rapidly kill transient bacteria and a proportion of the

resident bacteria.


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The use of gloves

It is important that gloves are used in conjunction with hand washing and not in place of hand washing.

Many health care workers believe that gloves protect staff and patients from cross contamination, but in

reality this is not the case as hands can become easily contaminated under gloves when they are

unwittingly punctured or when they are removed. The lack of evidence regarding the benefits of using

sterile gloves has resulted in many teams developing procedures based on using a non-touch technique.

The care of the hub/the use of connection devicesSeveral studies have implicated contamination of the hub as the major source of catheter related sepsis

in catheters that remain in situ for more than two weeks. It is recommended that limited manipulations to

the catheter should occur, as each junction break brings additional risk of infection.

To reduce the risk of hub contamination:

Meticulous care must be taken when a break in the closed system occurs. Strict adherence to

policies and effective hand washing techniques are essential

If a multi lumen catheter is used, one lumen should be designated for the PN

A single lumen catheter should not be used for the administration of drug therapy or additional

intravenous fluids

The catheter should not be used for routine blood samples


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The use of closed luer lock connection devices with a membrane allows access to the catheter whilst

maintaining a closed system. (E.g. Bionector, Interlink, Smartsite).

The perceived benefit of this system is:

Reduction in nursing workload

Reduction in use of sterile equipment / reduce costs

Reduction in needle stick injuries

Reduction in catheter related sepsis

Reduction in air embolus

Connection devices are now widely used in clinical practice. Some health professionals are concerned

about the potential risk of contamination. Several studies have addressed this issue and conclude that

there is no evidence that their use is associated with increased risk of catheter related infection. When

using connection devices the greatest risk leading to contamination is an inability to disinfect the device

before puncture. The most effective method of disinfection is the use of a combination of antiseptic spray

and alcohol.

Anecdotal evidence suggests that using the closed system is much less cumbersome for nursing staff

and patients to use and thus compliance with procedures may be better. However, the use of the closed

systems does not diminish the need for careful catheter techniques, and the adherence of staff to

guidelines and educational programmes, remains the most vital aspect in the rate of catheter related

sepsis.

Changing connection devices

Routine connection device changes should occur as per manufacturer’s instructions. It will be necessary

to change earlier if blood products or lipid deposits are present, if damaged, contaminated or after

routine flushing.

Care of central venous access device exit site – Principles of careThe exit site forms an artificial break in the skin and is, with the tunnel, a potential source of infection. An

aseptic technique is therefore required when cleaning the exit site and changing the dressing. It has

been suggested that the use of an aseptic technique by a specially trained person has more effect on

reducing the rate of catheter related infection than the type of cleansing agent or dressing used.

There are several issues that require to be addressed when developing guidelines for care of the

catheter exit site. These are firstly the most appropriate cleansing solution secondly the most appropriate

dressing and thirdly how often the dressing should be changed.


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Cleansing Solutions

An alcoholic chlorhexidine gluconate solution (preferably gluconate in 70% isopropyl alcohol) should be

used to clean the catheter insertion site during dressing changes, and allowed to air dry (Pratt et al,

2007). An aqueous solution of chlorhexidine gluconate should be used if the manufacturer’s

recommendations prohibit the use of alcohol with their product (Pratt et al, 2007).

1. Dressings

The optimal dressing for the exit site remains controversial. The type of dressings frequently used

includes sterile gauze dressing and transparent occlusive dressing. Several studies have reported an

increased rate of infection associated with the use of transparent dressings. This is believed to be due to

an increase of moisture at the exit site. However, other studies have found no statistical difference in

rates of infection between transparent or gauze dressing. (It has been suggested than transparent

occlusive dressings are preferred by the patient, are cost effective, and can result in a reduction of

nursing time. The need for any type of dressing has also been studied. The frequency of exit site

infection is no greater when there was no dressing applied.

Dry dressing - Mepore™, Primapore™

Limitations associated with the use of this dressing, is the inability to visualise the exit site, and the need

for frequent manipulation of the dressing if the site needs to be checked. Their inability to provide a

bacterial and water barrier allows for the potential contamination from secretions or external moisture.

Transparent/ occlusive dressing – IV 3000™, Tegaderm™

The advantage of a transparent dressing is the ability to secure the catheter, to permit continuous

inspection of the site, to adhere well to dry skin, and to provide protection against external moisture

sources.

2. Dressing Changes

A Cochrane Review of gauze and tape versus transparent polyurethane dressings for CVAD concluded

that there was no evidence demonstrating any difference in the incidence of CR-related infections

between any of the dressing types compared in this review. Preferably, a sterile, transparent, semi-

permeable polyurethane dressing should be used to cover the catheter site. Transparent dressings


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should be changed every 7 days or sooner if they are no longer intact or moisture collects under the

dressing. (Pratt et al, 2007)

Recommendations for care of the exit site

1. The procedure should be carried out by an experienced member of staff

2. Cleansing solution is recommended to cleanse the exit site

3. The exit site should be cleansed with swabs working away from the catheter site, outward and

downward. The movement of the catheter should be limited to prevent unnecessary trauma.

4. Assessment of the exit site at dressing changes is important to detect any sign of redness,

inflammation or exudates. Any changes should be documented.

5. If the area is encrusted or appears infected take a culture swab from the exit site

6. Do not use occlusive dressing if exit site is moist or leaking

7. Occlusive dressing should be changed weekly or before if there is drainage from the exit site or the

dressing has becomes non-occlusive

8. The need for a gauze dressing should be assessed daily and changed when inspection of the

insertion site is necessary or when the dressing becomes damp, loosened or soiled. A gauze

dressing should be replaced by a transparent dressing as soon as possible. (Pratt et al, 2007)

9. Dressings used on tunneled or implanted catheter insertion sites should be replaced every 7 days

until the insertion site has healed, unless there is an indication to change them sooner. (Pratt et al,

2007).

Procedure for dressing catheter exit site


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Equipment

Antiseptic Hand Wash (as per hospital policy)

Dressing pack

Alcohol hand rub Individual single use chlorhexidine 2% alcoholSterile Gloves Sterile dressingDisposal Bag Alcohol wipes

Procedure

1. Explain procedure to the patient

2. Level 1 / Social hand wash.

3. Clean surface of trolley or tray as per local policy.

4. Level 2 / antiseptic hand wash.

5. Open outer pack of sterile dressing pack, place on trolley. Apply alcohol rub and

open inside of dressing pack, touching corners only.

6. Place gloves and dressing on sterile field and pour cleansing solution into receiver.

7. Remove existing dressing from the exit site, taking care not to disturb the catheter.

8. Apply alcohol hand rub to hands and allow to dry. Apply sterile gloves.

9. Using a cleansing solution, clean the catheter exit site from inside outwards and

downwards, limit movement of the catheter.

10. Allow cleansing solution to dry for a minimum of 30 seconds, apply dressing.

11. Tape catheter to chest wall.

12. Dispose of waste according to hospital policy.

13. Document in nursing notes


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Procedure for changing closed luer lock connection devices

Equipment

Antiseptic Hand Wash (as per hospital policy) Individual single use impregnated wipeAlcohol hand rub Connection device Disposal Bag Sterile glovesSterile Sheet

Procedure

1. Explain procedure to the patient.

2. Social hand wash

3. Clean surface of trolley or tray

4. Wash hands using cleansing solution, dry with a paper towel.

5. Open sterile sheet touching corners only, place on trolley/tray.

6. Place alcohol wipes, connection device and sterile gloves on sterile field.

7. Apply alcohol hand rub to hands, allow to dry and put on sterile gloves.

8. Clean junctions of catheter and connection device with an alcohol wipe.

9. Place a sterile drape under the junction and clamp catheter.

10. Remove existing connection device and replace with new one. Clean junction with alcohol wipes.

11. Dispose of waste according to policy.

Change connection device according to instructions from the manufacturer

Change connection device earlier if contaminated with blood or deposits of PN

Document date and time of change in nursing notes


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Procedure for commencing PN

Equipment

Parenteral Nutrition Bag Administration set Antiseptic hand washAlcohol hand rubPre-filled saline syringe (10ml)

Disposal BagSterile sheetAlcohol wipes Sterile Gloves (if used)

Procedure


2. Social hand wash.

3. Hang the solution bag from the IV drip stand

4. Clean surface of trolley or tray


6. Open sterile sheet, alcohol hands and allow to dry, touch the corners only, and place on trolley/tray.

7. Place administration set, alcohol wipes and sterile gloves onto the sterile field.

8. Apply alcohol hand rub.

9. Open out the infusion set; do not touch either end of the set. Close the roller clamp.

10. Remove cap at end of the infusion set.

11. Clean the infusion port of the PN bag with an alcohol wipe, allow to dry.

12. Break the seal; do not touch the port after the seal is broken.

13. Insert the spike of the admin set into the port of the PN bag, using a gentle pushing/ twisting motion.

14. Prime the administration set as instructed.

15. Apply alcohol hand rub, allow to dry. (Put on sterile gloves if used).

16. Cleanse closed IV device with alcohol wipes, allow to dry.

17. Flush with saline.

18. Attach administration set to closed IV device.

19. Unclamp catheter, commence infusion via volumetric pump, and observe for

leakage.

20. Secure catheter with tape.

21. Dispose of waste according to Hospital policy.


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Procedure for completing PN / Flushing Catheter

Equipment

Antiseptic hand wash 2 pre-filled syringes**Alcohol hand rub Needles x 2 + 2 syringes if not using pre-filled syringesDisposal Bag Prescribed flushing solutionSterile Sheet Sodium chloride 0.9 % 10mlAlcohol wipes Sterile Gloves (if used)

Procedure


2. Social hand wash

3. Discontinue PN by switching off pump and disconnect.

4. Clean surface of trolley or tray as per policy.


6. Open sterile sheet, alcohol hands and allow to dry. Touch corners only, place on trolley/tray.

7. Place open alcohol wipes, /pre filled syringes onto sterile field. Apply alcohol hand rub to hands, allow

drying and put on sterile gloves.

8. Cleanse closed IV device / bung with alcohol wipes allow to dry for a minimum of 30 seconds

9. Inject flushing solution using a push pause technique, maintain positive pressure when removing

syringe.

10. If required, instill prescribed solution to lock the CVAD


12. Document.

* Do not use less than a 10ml syringe for flushing the catheter

** Pre-filled syringes with saline or heparin


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Procedure for commencing PN via a Subcutaneous Port

Equipment

Parenteral Nutrition Bag Disposal BagAdministration set Dressing packAntiseptic hand wash Alcohol wipes Alcohol hand rub Sterile GlovesAntiseptic solution Gauze DressingHuber needle Pre-filled syringes

Procedure

1. Social hand wash

2. Hang the solution bag from the IV drip stand.

3. Clean surface of trolley or tray as per Hospital policy.


5. Open sterile dressing pack, alcohol hands and allow to dry. Touch corners only arrange sterile pack

on trolley/tray.

6. Place open administration set, alcohol wipes, gauze dressing, needle, syringe and sterile gloves onto

the sterile field.

7. Pour antiseptic solution into receiver.

8. Apply alcohol hand rub, allow to dry.

9. Clean the infusion port of the PN bag with an alcohol wipe, allow to dry.

10. Break the seal; do not touch the port after the seal is broken.

11. Remove the cover from the administration set, do not touch the spike

12. Insert the spike of the IV tubing into the port of the PN bag, using a gentle pushing/ twisting motion.

13. Prime the administration set, place end of infusion set in an alcohol wipe.

14. Apply sterile gloves.

15. Attach pre-filled syringe sodium chloride 0.9%, prime Huber needle with solution.

16. Clean port site with cleanse solution, allow to dry.

17. Palpate port and hold between the index and middle finger of one hand. Pull the

skin tightly over the port to prevent slipping.

18. Push the needle firmly through the skin and port until it hits the bottom of the portal

chamber. Use a different part of the port for each insertion.

19. Flush the port with sodium chloride0.9%; confirm that fluid flows through the system.

20. Attach administration set to Huber needle.

21. Apply gauze dressing to secure Huber needle.


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22. Set pump, volume and rate and commence infusion.


Procedure for flushing Subcutaneous Port (if removing the needle)

Equipment

Antiseptic Hand Wash pre-filled syringe Sodium chloride 0.9 % 10mlAlcohol hand rub Alcohol wipesDisposal Bag Heparin solutionSterile Sheet Sterile gloves

Procedure

1. Social hand wash

2. Discontinue PN by switching off pump.

3. Clean surface of trolley or tray as per Hospital policy


5. Open sterile sheet, alcohol hands and allow to dry, touching corners only, place on trolley/tray.

6. Place alcohol wipes and pre-filled syringes on sterile field.

7. Remove gauze dressing from chest.

8. Apply alcohol hand rub to hands, allow to dry, apply sterile gloves.

9. Cleanse catheter hub and Huber needle with an alcohol wipe allow to dry and disconnect PN.

1. Inject sodium chloride using a push pause technique, maintain positive pressure when removing

syringe.

10. Inject Heparin solution using the same technique.

11. Cleanse exit site with an alcohol wipe, remove Huber needle from subcutaneous port, to avoid reflux

in the IV system, maintain positive pressure while simultaneously withdrawing the needle and

pressing down on the port with two fingers.

12. Dispose of waste according to policy.


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Procedure for central catheter blood cultures

Equipment

Antiseptic hand wash Sterile gloves 3 x 10ml syringesAlcohol hand rub 20ml syringe 4 x needlesDisposal Bag Set of blood culture bottles Prescribed flushing solutionSterile Sheet Connection device 10 mlSodium chloride 0.9%Alcohol wipes

Procedure1. Clean surface of trolley or tray as per Trust policy.2. Wash hands using a Chlorhexidine hand wash, dry with a paper towel.3. Open sterile sheet touching corners only, place on trolley / tray.4. Place alcohol wipes, connection device, syringes and needles onto sterile field.5. Clean vials with an alcohol wipe, and allow to dry. Open sodium chloride and heparin vial.6. Apply alcohol hand rub, allow to dry and put on sterile gloves.7. Connect needles to syringes, remove sheath, and draw up prescribed amount of solutions.8. Remove needles.9. Clean catheter junction site with an alcohol wipe and leave to dry.10. Put a sterile drape under the junction.11. Ensure catheter is clamped.12. Remove connection device, attach 10 ml syringe, unclamp catheter.13. Draw back 10ml of blood, clamp catheter then remove syringe.14. Attach 20-ml syringe; unclamp catheter, draw back 15 ml of blood using a 20-ml syringe.15. Clamp catheter and remove syringe.16. Flush catheter with 10 ml of sodium chloride 0.9%.17. Attach new connection.18. Inject Heparin solution into catheter.19. Clean top of culture bottles with an Alcohol wipe and allow to dry.20. Inject 7 ml of blood into each bottle using a separate needle for each culture bottle.


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21. Dispose of waste according to Trust policy.


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Complications

The network has prepared documents for the management of complications:

These include:

Protocol for the detection, prevention and treatment of central vein thrombosis.

Protocol for the management of catheter related sepsis.

Please contact your nutrition nurse specialist for a copy of the above.

InfectionDefinition of catheter related blood stream infection (CR, BSI) - “Clinical picture of spiking fever and

chills resulting from blood passage of micro organisms from an intra-vascular infusion system. Isolation

of the same organism from blood and catheter segments is considered definite proof”.

Definitions for CR, BSI Exit site infection – erythema, tenderness, induration or purulence within 2cm of the skin at the exit

site of the catheter

Tunnel infection- erythema, tenderness and induration in the tissues overlying the catheter and > 2cm

from the exit site

Catheter related bloodstream infection (CR, BSI) - isolation of the same organism from a semi-

quantitative or quantitative culture of the catheter segment and from the blood of a patient with

accompanying clinical symptoms of BSI and no other apparent source of infection

(Guidelines for prevention of intravascular device related infections: an overview 1996)

In practice, CR, BSI would be diagnosed by positive central blood cultures, clinical signs of septicaemia,

even in the absence of negative peripheral blood cultures.

The detection and treatment of CR, BSI This protocol should be available for all staff looking after patients on Home Parenteral Nutrition (HPN).

The decisions on whether to use antibiotics, to treat the sepsis or to immediately remove the catheter are

based on the:

type of micro-organism present

continuing need for the catheter

venous access of the patient


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future need for PN

the general condition of the patient

previous or recent CR,BSI (recent sepsis sensitivities)

If patient with a central venous access device presents with an acute febrile episode:

Assess: history and examination to exclude other infections

Blood cultures (from each lumen): 1 x peripheral

1 x central

see Protocol – minimum volume required 0.5ml/bottle

- Check with local microbiologist

Blood sample for FBC & CRP, U+E’s, LFT’s, ESR glucose + creatinine

Exit site swab if inflamed

Chest X-ray(if clinically indicated)

Urinalysis / urine culture

Other samples as directed by assessment

Then follow protocol for suspected CR, BSI (see over).


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Protocol for suspected CR, BSI


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If patient clinically stable and local exit site infection suspected, no tenderness at cuff of catheter, and patient apyrexial

If patient clinically stable If patient clinically

unstableIf patient severely, unwell, no other cause of sepsis suspected

Commence oral antibiotic therapy, clean exit site with antiseptic solution, continue PN, await result of swab

Await results of, cultures. Do not use catheter for PN or IV fluids

Insert Venflon, commence antibiotic therapy via catheter.* Do not use catheter for PN or IV fluids

Remove central catheter ***

If patient develops pyrexia or becomes clinically unwell stop PN while awaiting result of exit site swab

Consider the use of peripheral intravenous fluids or peripheral Parenteral Nutrition

If peripheral and catheter cultures negative If cultures from catheter or exit site swab

positive

Recommence PN. Monitor patient during first administration of PN. Record temperature 4 hrly

If patient becomes clinically unwell or pyrexial

Seek guidance from the microbiologist regarding most appropriate treatment

**Remove catheter if cultures positive with

staph aureus, or candida.

**If catheter infected with staph epidermis it may be possible to treat

After completion of antibiotic therapy, recommence PN, monitor patient during first administration of PN. Record temperature 4 hrly.

* Administering antibiotics via the central catheter is favoured. Treat with Vancomycin, and cefuroxime/or gentamycin.Guidance should be obtained from the microbiologist on call.** The decision when to remove a catheter is complex, there are several factors that need to be taken into account.The type of microorganism present, continuing need for the catheter, venous access of the patient and the general condition of the patient. It is generally not advisable to treat a staph aureus or candida sepsis however each patient must be considered individually.*** In paediatrics this may be the only IV access available.

CONFIRMED LINE INFECTION

If line infection is confirmed, consideration must be given to catheter removal and antibiotic treatment.

Catheter removal was once thought essential in the treatment of line infection but in recent years

catheter salvage rates of around 50% have been reported using antibiotics. Attempts at catheter salvage

are certainly justified in stable patients with blood stream infections with Staph epidermidis. Tunnel

infections with obvious pus are unlikely to respond to antibiotics. Exit site infections may be successfully

treated. Blood stream infections with coagulase positive staphylococci, MRSA, gram negative bacteria,

and yeasts are more dangerous and serious consideration should be given to catheter removal.

However, as far as possible catheter salvage should be attempted. Discuss with the nutrition team

consultant or SR and microbiologist prior to line removal. In particular yeast infections carry a significant

risk of spread to the eye with potential for loss of sight (Nightingale 1995). Therefore catheters infected

with yeasts should virtually always be removed. For other infections the benefits of more certain

eradication of sepsis by catheter removal must be balance against the difficulty of venous access in that

patient.

Antibiotic treatment depends on the bacterial sensitivities. Vancomycin administered into the catheter is

the mainstay but the antibiotic used will depend on local bacteriological advice. It seems sensible to

infuse the antibiotics down the catheter but this must be done with sterile precautions, preferably with the

antibiotic made up in the pharmacy sterile unit. If a single daily dosage can be given the number of

catheter interventions is reduced. Thereafter the antibiotic can be left in the catheter before flushing at

the commencement of the next infusion.

Confirmed line infection: Complications Port abscess

Septic thrombosis

Endocarditis

Osteomyelitis

Consider line removal and treat, guided by sensitivities and advice from pharmacist and

microbiologist.

General comments1. Consider line cultures at end of treatment completion where line salvage attempted.

2. Nearly every patient will require peripheral access for continued fluid and nutritional needs.


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3. Consider advice from a microbiologist when planning a new line insertion. The interval before line

insertion is determined by the clinical case. Preferably, antibiotic treatment should be completed

before CVC insertion.

4. Consider screening fro MRSA and topical treatment in keeping with agreed local protocols.

5. When patients are slow to recover, consider complications and further investigation. Access to trans-

oesophageal echo-cardiograph may be helpful

6. Consider re-assessing patient line care technique.

Catheter occlusion There are many factors that may lead to occlusion of the central venous access device

Malposition of the catheter

A kink in the catheter

The formation of a fibrin sheath at the tip of the catheter can act as a one-way valve, allowing

saline to be flushed but preventing the withdrawal of blood into the catheter.

Fibrin deposits caused by the formation of a clot due to stagnate blood which has been left within

the lumen of the catheter

Lipid sludge caused by the formation of lipid deposits

Drug precipitation

Factors affecting the incidence intra luminal occlusion: Catheter material

The catheter flushing technique

Inappropriate use of heparin solution

The early detection and treatment of a partial blockage


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Flushing the catheter The patency of the CVAD should be checked prior to administration of feed. Central venous catheters

should be flushed with an anticoagulant when the device is not in regular use, unless advised otherwise

by the manufacturer (Pratt et al., 2007). It is usually recommended that pressure-activated valved

catheters and some positive pressure flush devices are flushed with 0.9% sodium chloride (Camp

Sorrell, 2004; INS, 2006; Pratt et al., 2007). The volume of the flush solution should be equal to at least

twice the volume of the catheter and add-on devices – usually 5–10 ml. The concentration of heparin

should be the lowest possible that will maintain patency – usually 10iu heparin in 1 ml 0.9% sodium

chloride (except with implanted ports which may require 100iu/ml heparin). Frequency of flushing should

be weekly for long term central venous access devices, unless occlusive problems indicate otherwise

(Kelly et al., 1992; Dougherty and Watson, 2008) or every 4 weeks for an implanted port (Camp Sorrell,

2004). Flushing with 0.9% sodium chloride solution to ensure and maintain patency should be performed

using a pulsated push-pause and positive pressure method. (NICE, 2003; INS, 2006).

Detection of an intra luminal occlusion:

1. Determine whether there is a mechanical cause for the blockage

2. Rule out a kink in the tubing or an external force causing obstruction

3. Arrange for a chest X-ray to be carried out to determine the position of the tip of the catheter.

4. Exclude the presence of a central venous thrombosis

5. If the catheter remains blocked, aspirate the catheter then flush with saline. Do not use extreme force

as forceful flushing can rupture the catheter and cause serious problems to the patient e.g. transitory

embolus. A syringe smaller than 10 ml should not be used due to the increased pressure that can be

exerted on the catheter

6. If the catheter remains occluded determine the most likely cause of occlusion, and consider

treatment options

Treatment options – see Protocol for the detection, prevention and treatment of central vein thrombosisFibrin deposits

Fibrin deposits may respond to the administration of urokinase (Wachs 1990). Obstructed catheters are

injected with 5,000 units of urokinase, left in situ for an hour, then aspiration of the solution and residual

clot attempted. If aspiration is unsuccessful, repeat attempts can be made. If this remains unsuccessful,


23

a urokinase infusion of 40,000 units can be infused over 6 hours. If occlusion is still present a further 6

hour infusion of 40,000 units can be prescribed.

Lipid Occlusions

The use of lipid 3 in 1 mixes can result in the presence of lipid deposits within the lumen of the catheter.

In an attempt to prevent this problem, some centres infuse the lipid infusion separately however the

practicality of this for the patient on home parenteral nutrition is much more difficult. The use of 70 %

ethanol solution can often clear the catheter (Pennington 1992). Replacing a saline flush with a 20 %

ethanol flush after lipid infusions may also prevent the problem of lipid occlusion.

Obstructed catheters are injected with 4 ml of a 70% solution of ethanol in sterile water. Ethanol is left in

the catheter for an hour then aspirated and flushed.

Drug Precipitation / Mineral deposits

Catheters can become blocked with drug precipitation or a build up of mineral deposits. These can

occasionally be reversed by the use of hydrochloric acid 0.1% in 3ml (Werlin et al 1995).

Ter Borg et al (1993) suggest that central venous access devices, which are unresponsive to treatment

with urokinase, ethanol, or hydrochloric acid, can be unblocked with a perfusion of 10 to 20 ml of 0.1

sodium hydroxide solution. They do point out however, that it is important to establish the safety of

catheter materials before attempting to administer a sodium hydroxide solution.

Fractured / Ruptured central catheters

Reasons for rupture

Rupture from an attempt to irrigate occluded catheter with a small syringe. Infusion pressures should

never exceed 25 psi. As smaller syringes generate more pressure than larger syringes, the catheter

should be never be flushed with a syringe smaller than 10 ml

Repeated clamping (wear and tear)

Contact with a sharp object (accidentally cut or pierced)


24

Rupture of the external part of the catheter is often easily detected as leakage of PN solution can be

seen. However internal fractures, which can cause infiltration of fluids into the surrounding tissues, may

not be easily recognized. Symptoms of pain and swelling around the catheter may alert staff to the

problem. A diagnosis can be made by the use of contrast studies (Verhage and Van Bommel 1999). If an

internal fracture is diagnosed the catheter should be removed immediately.

What to do if the event of an external catheter rupture

1. When damage occurs, the catheter should be immediately clamped or kinked to prevent the

possibility of air embolism, loss of blood or entry of microorganisms.

2. The catheter should be clamped between the catheter exit site and damaged area. The clamp must

remain in place during the repair procedure.

3. To repair the damaged external segment of the catheter it is recommended that there is at least 3cm

of undamaged catheter remaining beyond the skin exit site.

4. The catheter can be repaired on several different occasions, as long as there is sufficient length of

catheter externally.

It is important that the patient has access to the following:

A clamp to seal off the catheter in case of fracture or puncture

A repair kit and silicone gel which is within 'use by' date should be held in the designated area of the

hospital……………………………………………………………………………………

A supply of Urokinase and alcohol should be held in the parent ward of the hospital

Urokinase is available from pharmacy in 10000 unit ampoules of freeze dried powder

One ampoule mixed with 2ml water provides 5000 units / ml

This 1ml should then be diluted to 3ml with sodium chloride

The dosage is 5000units in 3ml

The paediatric dose is 5000 unit in 2 ml

The patient on HPN should be given written instructions on the first- aid management of an external

catheter rupture. Each patient should be supplied with a small clamp at home.

Repair of ruptured catheters


25

1. Contact nursing/medical member of multidisciplinary nutrition team

2. The appropriate repair kit should be available

3. The catheter repair is carried out under strict aseptic technique as per manufactures instructions

4. If necessary the catheter may be used after 4 hours, although the joint will not achieve full

mechanical strength for 48 hours. If possible the catheter should not be used for 48 hours,

decreasing further risk of rupture/fracture.

5. A prophylactic antibiotic may be of use if appropriate.


26

Procedure for unblocking central venous access device

Equipment

Cleansing Hand Wash 10ml syringes x 3Alcohol hand rub Needles x 3Disposal Bag Ampoule of Heparin saline solutionSterile Sheet Ampoule of Sodium chloride 0.9 % 10mlAlcohol wipes Alcohol or 70% Urokinase solution

Procedure

1. Explain to patient

2. Social hand wash

3. Clean surface of trolley or tray as per Hospital policy.

4. Wash hands using antiseptic hand wash, dry with a paper towel.

5. Open sterile sheet, alcohol hands and allow to dry. Arrange sterile sheet, touching corners only,

place on trolley/tray.

6. Place alcohol wipes, syringes, ampoules and needles onto sterile field.

7. Apply alcohol hand rub to hands, allow to dry, apply sterile gloves.

8. Attempt aspiration of the catheter.

9. Instill Urokinase / alcohol. Do not use extreme force

10. Leave the Urokinase / alcohol in situ for 2-4 hours. Aspirate back

11. Flush catheter with sodium chloride 10 ml using push pause technique then instill heparin solution

using push pause technique.

12. Dispose of waste according to Hospital policy.

* Do not use less than a 10ml syringe for flushing the catheter

Alcohol 70% in 4ml for lipid occlusion

Urokinase 5000iu for fibrin occlusions

AS PER MANUFACTURER’S INSTRUCTIONS


27

The following contacts can be used in an emergency for advice:

Name & position Telephone number


28

References

APIC Guidelines for hand washing and hand antisepsis in health care settings (1995) American Journal of Infection Control 23 (4) 251-69.

Appelgren P Ransjo U Bindslev L et al (1996) Surface heparinization of central venous access devices reduces microbial colonization in vitro and in vivo: results from a prospective randomized trial. Critical Care Medicine 24 (9) 1482-9.

Barzaghi A, Dell'Orto M, Rovelli A, et al (1995) Central venous access device clots: incidence, clinical significance and catheter care in patients with hematologic malignancies. Pediatric Hematology and Oncology 12(3) 243-50. Department of Health (2001). Guidelines for preventing infections associated with the insertion and maintenance of central venous access devices. Journal of Hospital Infection. 47 (suppl): S47-67. Kyle LA Turner BS (1999) Efficacy of saline vs. heparin in maintaining 24 gauge intermittent intravenous catheters in a rabbit model. Neonatal Netw 18 (6) 49-54. Le Duc K (1997) Efficacy of normal saline solution versus heparin solution for maintaining patency of peripheral intravenous catheters in children Journal of Emergency Nurse (4) 306-9.

Mudge B, Forcier D, Slattery MJ (1998) Patency of 24-gauge peripheral intermittent infusion devices: a comparison of heparin and saline flush solutions. Pediatric Nursing 24(2) 142-5. Pennington CR, Pithie AD (1987) Ethanol lock in the management of catheter occlusion Journal of Parenteral and Enteral Nutrition 11 (5) 507-8. Randolf AG Cook DJ Gonzales CA Andrew M (1998) Benefit of heparin in peripheral venous and arterial catheters: systematic review and meta-analysis of randomized trials British Medical Journal 316 (7136) 969-75. Sitges-Serra A, Pi-Serra T, Garces JM et al (1995). Pathogenesis and prevention of catheter related septicaemia. American Journal of Infection Control 23 (5) 310-16.

Taylor D Myers ST Monarch K 1996 Use of occlusive dressings on central venous access device sites in hospitalised children. Journal of Pediatric Nursing 11 (3) 169-74. ter Borg F, Timmer J, de Kam SS, Sauerwein HP (1993) Use of sodium hydroxide solution to clear partially occluded vascular access ports. Journal of Parenteral Enteral Nutrition 17(3):289-91.

Verhage AH van Bommel EFC (1999) Catheter fracture: an under recognised and serious condition Journal of Vascular Access Devices 4 (2) 33-4. Wachs T (1990) Urokinase administration in pediatric patients with occluded central venous access devices Journal of intravenous nursing 13 (2) 100-2. Weber DR (1991) is heparin really necessary in the lock, and if so how much? DICP (4) 399-407.


29

Werlin SL, Lausten T, Jessen S, Toy L, Norton A, Dallman L, Bender J, Sabilan L, Rutkowski D (1995) Treatment of central venous access device occlusions with ethanol and hydrochloric acid. Journal of Parenteral Enteral Nutrition 19 (5)416-8. Zevola DR Dioso J Moggio R (1997) Comparison of heparinized and non heparinized solutions for maintaining patency of arterial and pulmonary artery catheters American Journal of Critical Care 6 (1) 52-5.

Pratt RJ, Pellowe CM, Wilson JA, et al (2007) National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 65S, S1-S64.


30

Members of the Managed Clinical Network

Name Telephone E-mail AddressNutrition Support NursesDorothy Barber 01224 552946 [email protected] Aberdeen Royal Infirmary, ABERDEEN, AB25 2ZNLinda Davidson 0141 201 5243 [email protected] Victoria Infirmary, Langside Rd , GLASGOWMerrie Dwan 01224 553641 [email protected] Royal Aberdeen Children’s Hospital, ABERDEENLesley Faulds 01562 521133 [email protected] Crosshouse Hospital, KILMARNOCK, KA2 0BEJulie Fyall 01382 660111 [email protected] Ninewells Hospital, DUNDEE, DD1 9SYCraig Hurnauth 0141 201 6060 [email protected] Southern General Hospital, GLASGOWDawn Jordan 0141 211 4077 [email protected] Glasgow Royal Infirmary, Alexandra Parade, GLASGOWFiona MacKay 0141 211 4077 [email protected] Glasgow Royal Infirmary, Alexandra Parade, GLASGOWIsobel MacLeod 01412 321877 [email protected] Yorkhill Hospital, GlasgowChristina McGuckin 0141 201 9343 [email protected] Yorkhill Hospital, GLASGOWGill McHattie 0141 201 6060 [email protected] Southern General Hospital, GLASGOWKaren McIntyre 01382 740092 [email protected] Ward 28 Ninewells Hospital, DUNDEELorraine McVie 01315 373695 [email protected] Western General Hospital, EdinburghCarol Muir 0131 242 3635 [email protected] Royal Infirmary of Edinburgh, Little France, EDINBURGHCatherine Paxton 0131 537 1669 [email protected] Royal Hospital for Sick Children, EdinburghMay Shaw 01383 623623 m.shaw1@ nhs.net Queen Margaret Hospital, DUNFERMLINENancy Smith 0141 314 7117 [email protected] Royal Alexandra Hospital, Corsebar Rd, Paisley, PA2 9PNJan Tait 01382 740078 [email protected] Ninewells Hospital, DundeeKirsty Turnbull 01382 660111 [email protected] Ninewells Hospital, DUNDEE, DD1 9SYLynsey Watt 01412 111014 [email protected] Gartnavel General Hospital, Glasgow


31

mailto:[email protected]






ConsultantsRachel Edwards (clinical scientist)

01412 010350 [email protected] Yorkhill Hospital, Glasgow

Dan Lassman 07875836662 [email protected] Consultant GastroenterologistSabarinathan Loganathan

01224 558565 [email protected] Consultant Gastroenterologist, Aberdeen

Jonathan Manning 01896 826211 [email protected] Consultant Gastroenterologist, Melrose, BordersDavid Mitchell [email protected] Oliver 01786 434067 [email protected] SRIArindam Sengupta [email protected] DunfermlineSaha Subrata 01387 246246 [email protected] Dumfires&Galloway Royal Infirmary


PhysiciansAlistair McKinlay 01224 552312 [email protected] Consultant Gastroenterologist, Aberdeen Royal Infirmary

ABERDEEN, AB25 2ZNNigel Reynolds 01382 660111 [email protected] Consultant Gastroenterologist, Ninewells Hospital

DUNDEE, DD1 9SYAlan Shand 01315 371755 [email protected] Consultant Gastroenterologist, Western General Hospital,

EDINBURGHJohn Todd 01383 660111 [email protected] Consultant Gastroenterologist, , Ninewells Hospital

DUNDEE, DD1 9SYBrian Tregaskis 01397 702481 [email protected] Belford Hospital, NHS HighlandHazel Younger 01463 705442 [email protected] Raigmore Hospital, Inverness

32












SurgeonsRon Coggins 01463 706360 [email protected] Consultant Surgeon, Assynt House, NHS HighlandKen Fearon 0131 536 9009 [email protected] Consultant Surgeon, New Royal Infirmary, Little France,

EDINBURGHRuth McKee 0141 211 4286 [email protected] Consultant Colorectal Surgeon, Royal Infirmary

16 Alexandra Parade, GLASGOW G31 2ERFraser Munro 01315 360649 [email protected] Consultant Paediatric Surgeon, EdinburghSatheesh Yalamarthi [email protected] Consultant Surgeon, Dunfermline

BiochemistsAlison Avenell 01224 554336 [email protected] Clinical Biochemist, Aberdeen Royal Infirmary,

ABERDEEN, AB25 2ZNBernie Croall 01224 554620 [email protected] Clinical Biochemist, Aberdeen Royal Infirmary

ABERDEEN, AB25 2ZNAnne Cruikshank [email protected] Department of Biochemistry, Southern General Hospital

GLASGOW G51 4TFAndy Duncan 0141 211 4494 [email protected] Biochemist, Macewan Building, Royal Infirmary, 84 Castle

Street, GLASGOW G4 OSFPeter Galloway [email protected] Yorkhill Hospital, GlasgowMatty Lough 01292 610555 [email protected] Consultant Biochemist, Crosshouse Hospital,

KILMARNOCK, KA2 0BEArchie McConnell 0141 2014444 [email protected] Dept. Clinical Biochemistry, Inverclyde Royal Hospital,

Greenock, PA16 0XN.Denis O'Reilly 0141 211 4631 [email protected] Consultant Clinical Biochemist, McEwen Building, Royal

Infirmary, 84 Castle Street, GLASGOW G4 OSFBill Simpson 01224 554620 [email protected] Consultant Clinical Biochemist, Aberdeen Royal Infirmary

ABERDEEN, AB25 2ZNRajeev Srivastava 0141 201 4444 [email protected] Yorkhill Hospital, Glasgow

33








PharmacistsLynn Aitchison 01463 236189 [email protected] Senior Pharmacist, Assynt House, NHS HighlandNicola Cairns 01412 114265 [email protected] Senior Pharmacist, GRI, GlasgowGraham Conkie 0141 2010625 graham.conkie@ggc scot.nhs.uk Principal Pharmacist (Production), Pharmacy Production

Unit, Western Infirmary, Dumbarton Road, GLASGOW G11 6NT

Utie Dediare 01224 553221 [email protected] Pharmacist, AberdeenJoanne Dunne 01419 515000 [email protected] Specialist clinical pharmacist, ClydebankSimon Fraser [email protected] Yorkhill Hospital, GlasgowDavid Hoole 01315 369009 [email protected] Clinical Pharmacist, EdinburghSteven Leadbetter 0141 2010625 [email protected] Senior Pharmacist, Aseptic Unit, Glasgow Royal

Infirmary,GLASGOW

Tommy McEwan 01382 660111 [email protected] Pharmacy Dept. Ninewells Hospital, DundeeVicki Welch [email protected] Nutritional Prescribing Advisor, GlasgowLorna Wilson 01412 019321 [email protected] Senior Pharmacist, Glasgow

DietitiansKimberley Brown 01412 012154 [email protected] Southern General Hospital, GlasgowElaine Buchanan 01412 019368 [email protected] Yorkhill Hospital, GlasgowEmma Hughes 01463 235189 [email protected] Renal dietitian, Assynt House, NHS HighlandJennifer Livingstone 01315 360311 [email protected] Senior Paediatric Dietitian, EdinburghJanice McKinlay 01224 552935 [email protected] Senior Dietician, Department & Nutrition & Dietetics,

Aberdeen Royal Infirmary, ABERDEEN AB25 2ZNLinda Murray 0141 211 4763 [email protected] Department of Nutrition & Dietetics, The Royal Infirmary

Alexandria Parade, GLASGOWRegina O’Connor [email protected] Paeds dietitian, Ninewells Hospital, DundeeEvelyn Ogilvie 07999980083 [email protected] Lead dietitian, InvernessKathryn Ralston 01382 660111 [email protected] Dietician, Ninewells Hospital, DUNDEE, DD1 9SY

Kathleen Ross [email protected] Dietitian, AberdeenElizabeth Stevenson 01343 567396 [email protected] Senior dietitian, ElginKerry Yuill 01315 369009 [email protected] Deaconess House, Edinburgh

34


















PaediatricsMike Bisset 01224 553035 [email protected] Royal Aberdeen Children’s HospitalDiana Flynn 0141 201 0313 [email protected] Yorkhill Hospital, Glasgow

Dagmar Kastner 01382 660111 [email protected] Ninewells Hospital, DundeeParaic McGrogan [email protected] Yorkhill, GlasgowDavid Wilson 0131 536 0661 [email protected] Consultant Paediatric Gastroenterologist, Royal Hospital

for Sick Children, EDINBURGH

35





Patient representativesSharon Bell [email protected] GlasgowRuth Grant [email protected] AberdeenMargaret McDonald

01382 819072 Dundee

Thelma Milne Aberdeen

Other staffWendy Cunningham

[email protected] Nurse, Queen Margaret Hospital, Dunfermline

Kevin Deans 01224 558565 [email protected] Specialist Registrar, Aberdeen

36





Name ___________________________

Date_____________________________

Practical assessment of procedures

ProceduresDate and Sign

Discuss Observe Practice under supervision

Competent

Preparation of feed and pump

Use of sterile field and non- touch technique

Social and antiseptic handwash

Commencing and disconnecting PN via central catheter

Commencing and disconnecting PN via peripheral catheter or venflon

Changing exit site dressing

Changing closed IV

Commence PN using subcutaneous port

Disconnecting PN using subcutaneous port

Completion of objectives

Signature of Assessor___________________________

Signature of Nurse_________________________

Date_________________

Scottish HPN Managed Clinical Network ProtocolsRevised July 2010 - For revision July 2013

37

Hand wash technique


38

Hand Hygiene Chart

Level of hand hygiene

Choice of agent Frequency (this list is not exhaustive)

Procedure Duration Comments

Routine / Social Liquid soap & water Between patients, before and after tasks that may contaminate hands:- Before preparing,

handling, eating food- After visiting the toilet- When hands are visibly

soiled

Follow Hand Hygiene Technique as per Appendix 4

10-15 seconds after contact with cleansing agent

Ensure hands are wet before applying soap

Alcohol based hand disinfectant

If hands have contact before of after a task, but are not visibly soiled

Follow Alcohol Hand Based Disinfectant Technique as per Appendix 3

20-30 seconds

Ensure hands are dry before commencing next task

Hygienic Liquid soap & water followed by alcohol based hand disinfectant

Follow Hand Hygiene Technique as per Appendix 4 and then Alcohol Hand Based Disinfectant Technique as per Appendix 3


Do not apply alcohol based hand disinfectant with antiseptic hand hygiene agent. Do not use when caring for a patient with an infection caused by a spore-producing organism, e.g. Clostridium Difficile

General Clinical Use: Chlorhexidine gluconate 4% skin cleanser e.g. Hydrex, Hibiscrub

Before aseptic procedures and after performing tasks that may contaminate hands:

- Before undertaking aseptic procedures

- Before leaving standard isolation rooms

- Before and after handling wounds, and

- Wet hands under running water

- Dispense 5mls of handwash solution into cupped hands

- Follow recommended handwash technique


Ensure hands are wet before applying handwash solution.

Residual activity following hand hygiene.


39

IV lines- During outbreaks of

infection- Before undertaking

operative and invasive procedures

- Rinse under running water

- Dry thoroughly with a disposable paper towel

Surgical In Theatre/Neonatal:

Chlor-hexidine gluconate 4% skin cleanser e.g. Hydrex

- Before undertaking operative and invasive procedures

- Wet hands under running water

- Dispense 5 mls of handwash solution into cupped hand

- Rub thoroughly over all surfaces of hands and forearms

- Dispense 5mls antiseptic handwash onto sterile nail brush, and scrub nails

- Rinse hands and forearms

- Dispense 5mls of antiseptic handwash and rub over all surfaces of hands and forearms again

- Rinse hands and forearms

- Dry thoroughly using sterile hand towel

Rub for 1 minute after contact with cleansing agent

Scrub for 1 minute (maximum)

Rub for 2-3 minutes

Repeat full procedure if any contact occurs with non-sterile surface

Do not scrub skin with nail brush

Rinse from tips of finders to elbows

Rinse from tips of fingers to elbows

OR

Povidone-iodine 7.5% (an alternative to chlorhexidine if skin reactions occur)


40


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Documents

SCOTTISH HOME PARENTERAL NUTRITION · Web viewPatients on Home Parenteral Nutrition Disclaimer: This document was prepared by the Scottish Nutrition Nurses Group and was up to date