Are central lines driving you crazy?  Central Line Bundle Insertion Care & Maintenance TPN Flushes Blood Collection & Blood Culture Collection Preventing Infection Removal Needle-Free Valves

What you need to know when a central line is necessary…

Central Venous (Vascular) Access Devices: Insertion, Care and Maintenance, Blood Collection & Removal of [D-04], NPPM St . Luke’s University Health Network Annual 2014 Education for Nurses – updated 4/2014

Why? Significant policy & practice changes and reminders regarding central lines! Prevent infections! Best practice!

Central Venous (Vascular) Policy & Practice Expectations... Central Venous (Vascular) Access Devices Insertion Preventing Infection Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Flushes TPN Needle Free Valves

Insertion Policy & Practice Expectations An Informed Consent shall be obtained for the insertion of central lines, including PICCs, with the exception of emergency situations. Secure ”Central Line Insertion Form” (#16264NP) to serve as guide and provide documentation of the insertion procedure (new attachment to policy). Although this information should not be new to practice, the wording is new to the nursing policy. Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Insertion Policy & Practice Expectations Any line inserted emergently that was not placed under strict adherence to Central Line Bundle will be labeled, ”Emergent Line – insertion date: ____, time: ____.” Person inserting the line is responsible for labeling line accordingly. Typically the line should be removed within 24 hours of insertion. Central lines inserted into the femoral vein should be removed within 24 hours of insertion unless otherwise directed by the physician. 24 HOURS ONLY Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Policy & Practice Expectations Any member of the health care team present during a central line insertion, including the nurse, must the process if any aspect of the Central Line Bundle process is not complied with. f Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Policy & Practice Expectations Central line sites are assessed and site assessments are documented minimally upon first contact with the patient (e.g. at the beginning of shift, receipt of transfer, etc.) and with any changes or complications noted. Assess site for redness, swelling, warmth, tenderness, leaking, drainage, blood return, dressing integrity, etc. Promptly report any signs of infection or other complications, e.g. catheter occlusion, to the physician. Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Policy & Practice Expectations A physician’s order is needed to access a permanent venous access device, e.g. Port-a-Cath. To access a permacath requires a nephrologist’s order. Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Policy & Practice Expectations Dressings are to be changed: Every 7 days or when the integrity of the dressing is compromised, loose, or soiled. If gauze dressing is used, every 2 days or when the integrity of the dressing is compromised, loose or soiled. PICC – 24 hours post insertion, then every 7 days. Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Policy & Practice Expectations Please note… Dressing Change Procedure: 1. Perform hand hygiene. 2. Open dressing kit, maintaining sterility. 3. Don mask (self, and patient if unable to turn head to side away from catheter). 4. Put on non-sterile gloves. Remove old dressing in the same direction as the catheter was inserted and discard with gloves. Perform hand hygiene. Assess site for tenderness, redness, edema or drainage. Apply sterile gloves. Cleanse catheter insertion site with chlorhexidine following manufacturer's instructions for use. Allow to dry completely. Apply sterile dressing from kit. Apply label to dressing with time, date and initials. 12. Change needle-free valve(s) if no continuous or intermittent IV is infusing into lumen(s). Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

TPN Policy & Practice Expectations Reminders: Any central line (including PICCs) inserted for the purpose of TPN administration will have one lumen dedicated and labeled as follows: “TPN-do not inject/withdraw”. Labeling is to occur immediately post insertion and is the responsibility of the person inserting the central line. If a nurse is starting TPN for the first time on an existing central line that has not been previously labeled, the nurse must attach the label to the lumen selected for TPN administration. Insertion Preventing Infection Removal Central Line Bundle Blood Collection Care & Maintenance Flushes TPN Needle Free Valves

Policy & Practice Expectations Needle-free valves are to be changed: With each tubing change. With dressing changes when no continuous or intermittent IV is infusing into a lumen. Whenever the integrity of needle-free valve is compromised. When residual blood remains in the needle-free valve. Insertion Preventing Infection Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Needle Free Valves Flushes TPN

Policy & Practice Expectations Question: What does this mean? Needle-free valves are to be changed with dressing changes when no continuous or intermittent IV is infusing into a lumen. Answer: - If a lumen of a central line has a needle-free valve which is not being used for any IV infusion, the valve would not be changed because there would be no tubing changes... - Therefore, the needle-free valve must be changed with the dressing changes. Insertion Preventing Infection Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Needle Free Valves Flushes TPN

Flushes Policy & Practice Expectations Flush Protocol (attachment to policy) Updated: Highlights practice expectations in policy. Flush after blood draws standardized to 10 mL normal saline. Insertion Preventing Infection Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Flushes Needle Free Valves TPN

Policy & Practice Expectations Every effort should be made to utilize the same port each time a blood specimen is collected. All IVs infusing into all ports of central venous catheters must be stopped one minute prior to specimen collection. Vasoactive solutions should not be stopped. Blood samples should not be drawn from the lumen dedicated for TPN. Insertion Preventing Infection Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Flushes TPN Needle Free Valves

Policy & Practice Expectations In order to maintain a closed system, blood samples should be collected, without removing the needle-free valve, by using a vacutainer blood luer adapter and blood collection tubes OR syringe and blood transfer device. Insertion Preventing Infection Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Flushes TPN Needle Free Valves

Policy & Practice Expectations Blood Culture Collection: A central line should be used to obtain blood cultures only as a last resort, and use for this purpose requires a physician’s order. (Exception: It is acceptable to obtain a blood culture upon insertion of a new central line.) Prior to using a central line for drawing blood cultures, two (2) collectors should attempt a venipuncture on a patient. If a blood culture is drawn from a central line, this must be done under sterile conditions and the needle-free valve must be changed prior to draw. Further details are available in nursing and lab policies on MyNET. Insertion Preventing Infection Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Flushes TPN Needle Free Valves

Removal Policy & Practice Expectations A physician’s order is needed prior to removing a central line. Patient Care Units, based on patient population, will determine the types of catheters that validated RNs will be allowed to remove. The validation process must be specific to catheter type. The following temporary catheters may be removed by validated RNs: Introducer (e.g. Cordis) Multi-Lumen Small Bore Catheter (e.g. Triple Lumen) Multi-Lumen Large Bore Catheter (e.g. AVA) Temporary Dialysis Catheter (e.g. Medcomp, Quinton) PA Catheter (e.g. Swan Ganz) Venous Sheath PICC RNs may not remove the following catheters: Tunneled Dialysis Catheters (e.g. Permacath) Tunneled Catheters (e.g. Hickman, Groshong, Broviac, Tunneled Cuffed PICC) Implanted Catheters (e.g. Port-a-Cath) Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Removal Policy & Practice Expectations Should it be determined by the physician that the patient is to be discharged with a central venous catheter in place, a post-hospital plan for catheter care must be developed prior to discharge. Insertion Preventing Infection Removal Central Line Bundle Care & Maintenance Blood Collection & Blood Culture Collection Flushes TPN Needle Free Valves

Central Venous (Vascular) Policy & Practice Expectations... Please view these attachments online when policy is released in January… The protocols and guidelines are great resources for practice. Central Venous (Vascular) Access Devices Policy attachments now include: Flush protocols – adult Flush protocols – pediatrics Central line insertion form Procedure guidelines: Blood withdrawal from central venous catheters Obtaining blood cultures from central venous catheters Central line removal PICC line removal Insertion Preventing Infection Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Policy & Practice Expectations Ask daily, ”Does the patient really need a central line??” Remember to ALWAYS assess and reassess the patient for ability to insert peripheral access. Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Remember the central line bundles! Policy & Practice Expectations Remember the central line bundles! Hand hygiene! Aseptic technique! Insertion bundle Maintenance bundle Daily line necessity with prompt removal of unnecessary lines Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

Patient Education Reminders: Policy & Practice Expectations Patient Education Reminders: Use Krames On-Demand Always educate patients on central lines and preventing infection When education is provided use Teach Back method to validate learning Document education provided Preventing Infection Insertion Removal Central Line Bundle Blood Collection & Blood Culture Collection Care & Maintenance Flushes TPN Needle Free Valves

TARGET ZERO – CAUSE NO HARM HAND HYGIENE & ASEPTIC TECHNIQUE Know it, own it, do it! No Central Line Infections HAND HYGIENE & ASEPTIC TECHNIQUE EXCELLENT PRACTICE CENTRAL LINE BUNDLES

Policy changes go live date… January, 2014 – Stay tuned for P & P Memo Release

Don’t forget to take the test… Thank you! CL- CRZY