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. Choosing the right technique
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. 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 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

17. Due 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 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

19. 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

20. 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

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

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

23. 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

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. 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

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

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 position
Explain procedure to patient
Expose patient’s line and smart site
Allow sufficient open space around access point

29. 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

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

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

32. 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)

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

34. Dispose of equipment immediately after procedure
Dispose of gloves
Immediately 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. 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:

37. 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:

38. 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
IV Bags:

39. 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

40. 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

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 technique
Ensure new lines are capped and not touching anything

45. 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

46. Open Chlorhexidine swab and carefully remove from packet

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

48. Ensure giving set is primed appropriately

49. Disconnect cap from giving set

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

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

52. 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

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

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

55. 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

56. 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

57. 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

58. 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)

59. 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

60. Summary

61. 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

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