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CVAD Management Training Royal Children’s Hospital Melbourne, Australia.

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Presentation on theme: "CVAD Management Training Royal Children’s Hospital Melbourne, Australia."— Presentation transcript:

1 CVAD Management Training Royal Children’s Hospital Melbourne, Australia

2 Contents Selecting the right technique Preparation Procedures: Administration of medicines Changing IV Bags / Syringes Changing IV lines Taking blood samples Summary

3 CVAD infections – the facts Why we need to be vigilant in CVAD care

4 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 % 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

5 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

6 CVAD management Choosing the right technique

7 Which technique should I use? Low risk procedures Non-touch: Administering medicines Flushing line Changing IV bags/ syringes Priming, connecting/ disconnecting IV lines to smartsite Taking bloods High risk procedures Sterile technique: Changing caps or Smartsites Changing CVAD dressings Accessing an infusaport

8 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

9 Non-touch technique Principles and practice of non-touch technique

10 Non-touch technique principles: key parts If key parts are contaminated by micro- organisms, 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: Needles Syringe tips IV line connections Smartsite tip

11 Examples of key parts

12 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

13 Important points: Sterile gloves and pack are not required for non- touch 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

14 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

15 Preparation for non-touch technique The preparation of non-touch technique in the ‘clean drawing up’ room, or at the bedside

16 Ensure workbench clean and free of clutterEnsure workbench clean and free of clutter With clean hands, gather tray, medications & equipmentWith clean hands, gather tray, medications & equipment If tray/surface is not clean, wipe thoroughly with alcoholIf tray/surface is not clean, wipe thoroughly with alcohol Use an appropriate size tray - taking bloods may require a larger tray than administering antibioticsUse an appropriate size tray - taking bloods may require a larger tray than administering antibiotics

17 Due to hand contamination from collecting equipment and touching cupboard handles etc, your aseptic hand clean should occur AFTER you have gathered everythingDue to hand contamination from collecting equipment and touching cupboard handles etc, your aseptic hand clean should occur AFTER you have gathered everything

18 Ensure hands and forearms are bare of jewellery, sleeves and wristwatchEnsure hands and forearms are bare of jewellery, sleeves and wristwatch Ensure lanyard not hanging over hands or key partsEnsure lanyard not hanging over hands or key parts Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Chlorhexidine 2% soap & water (30 seconds)Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Chlorhexidine 2% soap & water (30 seconds)Clean handsClean hands Ensure all surfaces of hands and wrists are cleanedEnsure all surfaces of hands and wrists are cleaned

19 Open equipment onto tray carefullyOpen equipment onto tray carefully Leave equipment in ‘clear packaging’ to assist with safe technique and decreased risk of contaminating key partsLeave equipment in ‘clear packaging’ to assist with safe technique and decreased risk of contaminating key parts Always leave vials & medications outside trayAlways leave vials & medications outside tray Remember: You are aiming for asepsis, not sterility

20 If wearing non sterile gloves, put them on at this stageIf 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 handlingGloves are worn for your own protection so be aware of the products you are handling

21 Connect all key parts using a non touch technique eg needles to syringesConnect all key parts using a non touch technique eg needles to syringes Touch non key points with confidenceTouch non key points with confidence

22 Prepare medications using non touch techniquePrepare medications using non touch technique Always use needles for ampoules and rubber capped bottlesAlways use needles for ampoules and rubber capped bottles

23 Use red caps on syringes when going to patientsUse red caps on syringes when going to patients Label syringes to ensure you know which is whichLabel syringes to ensure you know which is which After medications correctly checked by RNs, dispose of packaging, needles & vialsAfter medications correctly checked by RNs, dispose of packaging, needles & vials Remove gloves if not immediately performing procedure or if moving between roomsRemove gloves if not immediately performing procedure or if moving between rooms

24 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.

25 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:

26 Don’t break open packaging Things not to do:

27 Medication administration Administration of medicines using non-touch technique at the bed side

28 Enter patient’s room and place tray in a safe positionEnter patient’s room and place tray in a safe position Explain procedure to patientExplain procedure to patient Expose patient’s line and smart siteExpose patient’s line and smart site Allow sufficient open space around access pointAllow sufficient open space around access point

29 Ensure hands and forearms are bare of jewellery, sleeves and wristwatchEnsure hands and forearms are bare of jewellery, sleeves and wristwatch Ensure lanyard not hanging over hands or key partsEnsure lanyard not hanging over hands or key parts Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Chlorhexidine 2% soap & water (30 seconds)Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Chlorhexidine 2% soap & water (30 seconds)Clean handsClean hands Ensure all surfaces of hands and wrists are cleanedEnsure all surfaces of hands and wrists are cleaned

30 If wearing non-sterile gloves for personal protection, apply them at this stageIf wearing non-sterile gloves for personal protection, apply them at this stage Keep tray close to your access pointKeep tray close to your access point

31 Clean Smartsite vigorously with chlorhexidine & alcohol swabClean Smartsite vigorously with chlorhexidine & alcohol swab Allow to dry… at least 20 secondsAllow to dry… at least 20 seconds

32 Administer medications using non touch techniqueAdminister medications using non touch technique If infusion is not running, aspirate first to verify line is patentIf infusion is not running, aspirate first to verify line is patent It is not necessary to clean the hub between syringesIt 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)Flush line with normal saline using a pulsatile action (if disconnecting, use heparin and clamp with positive pressure)heparin

33 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 clinical guidelineclinical guideline

34 Dispose of equipment immediately after procedureDispose of equipment immediately after procedure Dispose of glovesDispose of gloves Immediately clean hands with alcohol gel or by washingImmediately clean hands with alcohol gel or by washing

35 Changing IV Bags and Syringes This procedure can be conducted using non-touch technique Bags and syringes should be changed every 24 hours

36 Remove new IV bag from outer wrapper and hang on standRemove 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)Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Chlorhexidine 2% soap & water (30 seconds)Clean handsClean hands Don gloves if required for personal protectionDon gloves if required for personal protection IV Bags:

37 Remove tab using non-touch techniqueRemove tab using non-touch technique Remove old solution from drip stand and tip upside downRemove old solution from drip stand and tip upside down Remove giving set spike carefullyRemove giving set spike carefully IV Bags:

38 Without touching any key parts, insert spike into new bagWithout 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 roomDiscard empty bag in trash or if containing liquid, retain for subsequent draining and discard in pan room Perform hand hygiene immediatelyPerform hand hygiene immediately IV Bags:

39 Stop infusion pump, clamp IV line and syringeStop infusion pump, clamp IV line and syringe Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Chlorhexidine 2% soap & water (30 seconds)Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Chlorhexidine 2% soap & water (30 seconds)Clean handsClean hands Remove syringe from pumpRemove syringe from pump Remove extension tubing from old syringeRemove extension tubing from old syringe Syringes:

40 Clean smartsite at end of extension tubing vigorously with swab and allow to dry for 20 secondsClean 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 tubingWithout 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 syringeNote: certain medications may require a three way tap on the end of syringe Perform hand hygiene immediately afterwardsPerform hand hygiene immediately afterwards

41 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

42 Changing IV lines Priming and changing IV fluid lines This can be conducted as a non-touch procedure

43 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: 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

44 Prime and set up new line using non touch aseptic techniquePrime and set up new line using non touch aseptic technique Ensure new lines are capped and not touching anythingEnsure new lines are capped and not touching anything

45 Ensure forearms are bare of jewellery, sleeves and wristwatchEnsure forearms are bare of jewellery, sleeves and wristwatch Ensure lanyard not hanging over hands or key partsEnsure lanyard not hanging over hands or key parts Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Chlorhexidine 2% soap & water (30 seconds)Clean hands thoroughly using ALCOHOL GEL (15 seconds) or Chlorhexidine 2% soap & water (30 seconds)Clean handsClean hands Ensure all surfaces of hands and wrists are cleanedEnsure all surfaces of hands and wrists are cleaned

46 Open Chlorhexidine swab and carefully remove from packetOpen Chlorhexidine swab and carefully remove from packet

47 Clean access point and hub vigorously with swab using a rotating motion using thumb for pressureClean access point and hub vigorously with swab using a rotating motion using thumb for pressure Allow to air dry for 20 secondsAllow to air dry for 20 seconds

48 Ensure giving set is primed appropriatelyEnsure giving set is primed appropriately

49 Disconnect cap from giving setDisconnect cap from giving set

50 Connect new giving set to smartsite without touching key partsConnect new giving set to smartsite without touching key parts

51 Taking blood samples How to take blood using a non-touch technique

52 Aim to collect all specimens at once to minimize accessAim to collect all specimens at once to minimize access With clean hands, gather equipment including a clean trayWith clean hands, gather equipment including a clean tray Open and lay out equipment using non touch techniqueOpen and lay out equipment using non touch technique As before, clinically wash or gel handsAs before, clinically wash or gel hands

53 Explain procedureExplain procedure Place tray close to patient, expose line for easy accessPlace tray close to patient, expose line for easy access If entering a new area, re-clean hands & don non-sterile glovesIf entering a new area, re-clean hands & don non-sterile gloves

54 Clean access point and hub vigorously with chlorhexidine and alcohol swabClean access point and hub vigorously with chlorhexidine and alcohol swab Allow to dry for 20 secondsAllow to dry for 20 seconds

55 Note: if accessing a multi-lumen line, clamp other lumens before withdrawing bloodNote: if accessing a multi-lumen line, clamp other lumens before withdrawing blood Infusions that should not be stopped, such as inotropes should not be clampedInfusions that should not be stopped, such as inotropes should not be clamped

56 Place 10 ml luer-lock syringe onto smartsite (if using slip syringes, insert and give a quarter twist to lock in place)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 syringeGently and evenly pull blood through line into syringe If taking blood gases, aspirate directly into blood gas syringeIf taking blood gases, aspirate directly into blood gas syringe

57 1st syringe may be used for blood cultures or discarded1st syringe may be used for blood cultures or discardedblood culturesblood cultures 5ml is a standard discard5ml is a standard discard This blood can be re-infused in some patient groups, eg. neonatesThis blood can be re-infused in some patient groups, eg. neonates

58 2nd syringe is used for blood specimen/s2nd syringe is used for blood specimen/s 3rd syringe is used for line flushing3rd syringe is used for line flushing Flush using a pulsatile action (if disconnecting, use heparin and clamp with positive pressure)Flush using a pulsatile action (if disconnecting, use heparin and clamp with positive pressure)heparin

59 Place blood into tubes carefully, filling EDTA tubes firstPlace blood into tubes carefully, filling EDTA tubes first Collect and dispose of equipment safelyCollect and dispose of equipment safely Remove gloves, clean hands with alcohol gelRemove gloves, clean hands with alcohol gel Label, date, time and initialLabel, date, time and initial Put in transport bag and sign cardPut in transport bag and sign card Clean handsClean hands

60 Summary

61 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

62 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


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