Transcript thoroughly using ALCOHOL GEL (15 seconds)

CVAD Management
Training
Royal Children’s Hospital
Melbourne, Australia
Contents
Selecting the right technique
Preparation
Procedures:
• Administration of medicines
• Changing IV Bags / Syringes
• Changing IV lines
• Taking blood samples
Summary
CVAD infections – the facts
Why we need to be vigilant
in CVAD care
CVAD infections – the facts
• In Australia approximately 150,000 Healthcare
Associated Infections (HAI’s) contribute to 7,000
deaths each year
• CVAD-associated blood stream infections are
responsible for 20 - 40% of HAI in both
paediatric and adult patients
• Management cost estimates for a single line
infection are between A$10,000 and A$15,000
CVAD infections – the facts
• At RCH CVAD infection rates vary
between 3 and 13 per 1,000 line days
• Other hospitals have reduced their
infection rate to below 1 per 1,000 line
days by implementing improvements
to the quality of aseptic technique
• Some hospitals have remained at
zero infections for months, even years
at a time
CVAD management
Choosing the right
technique
Which technique should I use?
• Low risk procedures
• Non-touch:
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•
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Administering
medicines
Flushing line
Changing IV bags/
syringes
Priming, connecting/
disconnecting IV lines
to smartsite
Taking bloods
• High risk procedures
• Sterile technique:
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•
•
Changing caps or
Smartsites
Changing CVAD
dressings
Accessing an
infusaport
Or put another way:
• Non-touch procedures are used when
connecting to a smartsite or changing IV bags or
syringes
• Sterile procedures are used when the patient’s
lumen is open or the site of CVAD entry to the
skin is exposed
Note: All of the procedures contained in this section
are conducted using non-touch technique
Non-touch technique
Principles and
practice of non-touch
technique
Non-touch technique principles:
key parts
• If key parts are contaminated by microorganisms, the risk of infection is increased
• Key parts within IV therapy are parts of
equipment that come into direct contact with a
liquid infusion, for example:
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Needles
Syringe tips
IV line connections
Smartsite tip
Examples of key parts
Principles of non-touch technique:
• Use the correct hand cleaning technique
• Identify and protect the ‘key parts’ at all times
• Maintain a clean field
• Touch non ‘key parts’ with confidence
Important points:
• Sterile gloves and pack are not required for nontouch technique
• Non-sterile gloves should be worn for personal
protection when required for procedures such as:
•
Blood sampling, handling potentially harmful
medicines, hanging blood infusions
• If allergic/sensitive to chlorhexidine, use gloves
to protect hands from swab
• When preparing equipment, a large clean
surface is required eg. large silver trays,
procedure trolley
Important points:
• Needle free access ports (Smartsites) should be
used to maintain a closed system wherever
possible
• Use luer-lock syringes as a preference to ensure
a good connection with Smartsite
• Three way taps should be avoided wherever
possible to reduce internal surfaces of lines, and
number of connections
Preparation for non-touch
technique
The preparation of non-touch
technique in the ‘clean drawing up’
room, or at the bedside
•
•
•
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Ensure workbench clean and free of clutter
With clean hands, gather tray, medications & equipment
If tray/surface is not clean, wipe thoroughly with alcohol
Use an appropriate size tray - taking bloods may require a
larger tray than administering antibiotics
• Due to hand contamination from collecting equipment and
touching cupboard handles etc, your aseptic hand clean
should occur AFTER you have gathered everything
• Ensure hands and forearms are bare of jewellery, sleeves and
wristwatch
• Ensure lanyard not hanging over hands or key parts
• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or
Chlorhexidine 2% soap & water (30 seconds)
• Ensure all surfaces of hands and wrists are cleaned
• Open equipment onto tray carefully
• Leave equipment in ‘clear packaging’ to assist with safe
technique and decreased risk of contaminating key parts
• Always leave vials & medications outside tray
Remember: You are aiming for asepsis, not sterility
• If wearing non sterile gloves, put them on at this stage
• Gloves are worn for your own protection so be aware of the
products you are handling
• Connect all key parts using a non touch technique eg needles
to syringes
• Touch non key points with confidence
• Prepare medications using non touch technique
• Always use needles for ampoules and rubber capped bottles
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Use red caps on syringes when going to patients
Label syringes to ensure you know which is which
After medications correctly checked by RNs, dispose of
packaging, needles & vials
Remove gloves if not immediately performing procedure or if
moving between rooms
Things not to do:
• Don’t leave key parts or
needles unprotected or
exposed
• Don’t place vials in tray to
identify drugs- they often leak
around needles. Use stickers
instead.
Things not to do:
• Don’t clutter tray with
unnecessary items
• Don’t ‘flick off’ key parts such
as needles or caps
Remember non touch
Things not to do:
• Don’t break open
packaging
Medication administration
Administration of medicines
using non-touch technique
at the bed side
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Enter patient’s room and place tray in a safe position
Explain procedure to patient
Expose patient’s line and smart site
Allow sufficient open space around access point
• Ensure hands and forearms are bare of jewellery, sleeves and
wristwatch
• Ensure lanyard not hanging over hands or key parts
• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or
Chlorhexidine 2% soap & water (30 seconds)
• Ensure all surfaces of hands and wrists are cleaned
• If wearing non-sterile gloves for personal protection, apply
them at this stage
• Keep tray close to your access point
• Clean Smartsite vigorously with chlorhexidine & alcohol swab
• Allow to dry… at least 20 seconds
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Administer medications using non touch technique
If infusion is not running, aspirate first to verify line is patent
It is not necessary to clean the hub between syringes
Flush line with normal saline using a pulsatile action (if
disconnecting, use heparin and clamp with positive pressure)
Safe injection of fluids
1) Syringes 10ml or more should be used to
administer a drug 'push' into the CVAD
2) If you must use a syringe <10ml, push very
slowly to avoid generating high pressures
3) If line accessed intermittently, aspirate first to
ensure catheter is patent before injecting fluid
4)If the catheter does not aspirate, consult more
senior staff, and see clinical guideline
• Dispose of equipment immediately after procedure
• Dispose of gloves
• Immediately clean hands with alcohol gel or by washing
Changing IV Bags and
Syringes
•This procedure can be
conducted using non-touch
technique
•Bags and syringes should be
changed every 24 hours
IV Bags:
• Remove new IV bag from outer wrapper and hang on stand
• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or
Chlorhexidine 2% soap & water (30 seconds)
• Don gloves if required for personal protection
IV Bags:
• Remove tab using non-touch technique
• Remove old solution from drip stand and tip upside down
• Remove giving set spike carefully
IV Bags:
• Without touching any key parts, insert spike into new bag
• Discard empty bag in trash or if containing liquid, retain for
subsequent draining and discard in pan room
• Perform hand hygiene immediately
Syringes:
• Stop infusion pump, clamp IV line and syringe
• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or
Chlorhexidine 2% soap & water (30 seconds)
• Remove syringe from pump
• Remove extension tubing from old syringe
• Clean smartsite at end of extension tubing vigorously with
swab and allow to dry for 20 seconds
• Without touching the key parts, remove cap from syringe and
attach extension tubing
• Note: certain medications may require a three way tap on the
end of syringe
• Perform hand hygiene immediately afterwards
Disconnecting/reconnecting lines
• Line disconnections should be kept to an
absolute minimum to reduce possible portals of
infection and risk of occlusion
• If line is connected via a smartsite, this can be
performed as a non-touch procedure
• Important: certain CVAD’s, such as neonatal
small bore (<5Fr) and right atrial (RA) lines
should not be disconnected at any time
Changing IV lines
• Priming and changing IV fluid
lines
• This can be conducted as a
non-touch procedure
Changing IV lines
• Replace IV lines every 3 days
• Replace lines if disconnected more than 6 hours
• If using blood products:
•
Replace lines at the end of infusion or 24-hour intervals
• If using Parenteral Nutrition:
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Replace tubing used to administer lipid emulsion
(including those combined with an amino acid and
glucose in a 3:1 admixture eg Baxter TPN) within 24
hours of commencing the infusion.
If nutrient and lipid are running via separate lines, only
the lipid needs to be changed at 24 hours
• Prime and set up new line using non touch aseptic technique
• Ensure new lines are capped and not touching anything
• Ensure forearms are bare of jewellery, sleeves and wristwatch
• Ensure lanyard not hanging over hands or key parts
• Clean hands thoroughly using ALCOHOL GEL (15 seconds) or
Chlorhexidine 2% soap & water (30 seconds)
• Ensure all surfaces of hands and wrists are cleaned
• Open Chlorhexidine swab and carefully remove from packet
• Clean access point and hub vigorously with swab using a
rotating motion using thumb for pressure
• Allow to air dry for 20 seconds
• Ensure giving set is primed appropriately
• Disconnect cap from giving set
• Connect new giving set to smartsite without touching key parts
Taking blood samples
How to take blood using
a non-touch technique
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Aim to collect all specimens at once to minimize access
With clean hands, gather equipment including a clean tray
Open and lay out equipment using non touch technique
As before, clinically wash or gel hands
• Explain procedure
• Place tray close to patient, expose line for easy access
• If entering a new area, re-clean hands & don non-sterile gloves
• Clean access point and hub vigorously with chlorhexidine and
alcohol swab
• Allow to dry for 20 seconds
• Note: if accessing a multi-lumen line, clamp other lumens
before withdrawing blood
• Infusions that should not be stopped, such as inotropes should
not be clamped
• Place 10 ml luer-lock syringe onto smartsite (if using slip
syringes, insert and give a quarter twist to lock in place)
• Gently and evenly pull blood through line into syringe
• If taking blood gases, aspirate directly into blood gas syringe
• 1st syringe may be used for blood cultures or discarded
• 5ml is a standard discard
• This blood can be re-infused in some patient groups, eg.
neonates
• 2nd syringe is used for blood specimen/s
• 3rd syringe is used for line flushing
• Flush using a pulsatile action (if disconnecting, use heparin
and clamp with positive pressure)
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Place blood into tubes carefully, filling EDTA tubes first
Collect and dispose of equipment safely
Remove gloves, clean hands with alcohol gel
Label, date, time and initial
Put in transport bag and sign card
Clean hands
Summary
Summary
• CVAD infections can be a source of harm and
sometimes death, but they can be prevented
• Disinfecting hands effectively before all line
interventions will reduce CVAD related sepsis
Summary
Follow the key principles of non-touch technique:
• Use the correct hand cleaning technique
• Identify and protect the ‘key parts’ at all times
• Maintain a clean field
• Touch non ‘key parts’ with confidence