CVAD Management Training

1. CVAD ManagementTraining Royal Children’s Hospital Melbourne, Australia

2. Contents Introduction Selecting the right technique Procedures • Changing smartsites • Changing dressings • Accessing infusaports Daily line review Summary

3. Preventing CVAD infections • In part one of this package we showed that CVAD infections can cause expense, harm and sometimes death • At RCH we are aiming to reduce our infection rate to below 1 per 1,000 line days in all areas of the hospital • What is the infection rate in your area? Is it below the target?

4. CVAD management Choosing the right technique

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

6. 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: This section demonstrates ‘sterile’ procedures using sterile pack and gloves

7. Smartsite change Smartsites should be changed every 6 days Sterile technique can be performed by 1 or 2 operators 1 operator technique can be performed if operator is competent and confident in performing the procedure on their own

8. Wipe trolley/bench thoroughly with alcohol • With clean hands, gather equipment

9. With clean hands, open equipment on trolley • Perform hand hygiene and put sterile gloves on

10. Draw saline with a needle • Prime the smartsite • Always discard used equipment away from sterile field

11. Clean connection thoroughly, 3cm on both sides of connection moving away from connection site • Then around the connection site

12. Allow to air dry for 20 seconds

13. 2 person procedure: the helper will clamp the catheter • 1 person procedure: operator to clamp the catheter • The operator to disconnect old smartsite and discard away from sterile field • If any substance visible on exposed lumen, clean using new gauze

14. Connect new smartsite

15. Unclamp the catheter: • 2 person procedure: helper to unclamp the catheter • 1 person procedure: operator to unclamp the catheter • Flush and withdraw to check for blood and flush again to clear the line using a pulsatile action (if disconnecting, use heparin and clamp with positive pressure) • Remove syringe and discard

16. Dressing change Dressings should be changed every 6 days Sterile technique can be performed by 1 or 2 operators 1 operator technique can be performed if operator is competent and confident in performing the procedure on their own

17. Remove dressing: • 2 people: the helper removes dressing with non sterile gloves • 1 person: remove dressing and discard from sterile field. Perform hand hygiene and don new sterile gloves

18. Clean site with 0.5% chlorhexidine and 70% alcohol in a circular motion, extending out around 5-10 cm diameter three times • allow to air dry

19. Clean down the lines away from the patient • Allow to air dry

20. Apply dressing either flat or as a sandwich • In some cases eg. allergy, an alternative dressing may be required, determined on an individual patient basis

21. Accessing an infusaport Ports need to be accessed using a sterile technique Port needles should be changed every 6 days This procedure can be traumatic and uncomfortable, so prepare patient carefully Apply local anaesthetic cream prior to procedure

22. Wipe trolley/bench thoroughly with alcohol • With clean hands, gather equipment

23. Open equipment on trolley • Choose needle gauge according to patient size • Perform hand hygiene and put sterile gloves on

24. Draw saline with a needle • Prime huber needle • Prepare set up before bringing patient into room as this decreases stress of patient

25. Remove emla or angel cream • Wash hands or alco-gel and don sterile gloves • Clean using chlorhex & alcohol, in a circular motion from centre of port ,extending out 5-10 cm diameter three times • Allow to air dry

26. Find the edges of the port • Hold edges between thumb and index finger

27. Press the needle through the skin using gentle, but steady pressure until the needle touches the bottom of the port

28. Gently flush port and withdraw to check for blood then flush again to clear line

29. Insert folded gauze under needle for support

30. Apply Steristrips to secure needle

31. Apply transparent dressing • Anchor line with tape and safety pin to clothing

32. Daily Line Review CVADs often remain in longer than required for treatment simply because removal has not been considered, or are kept ‘just in case’ The longer a CVAD remains insitu, the greater the infection risk

33. Daily Line Review • To prevent delays in removing unnecessary lines • Multidisciplinary team must review line daily • Questions to ask • How long has the line been in for? • Is central access necessary? • Are there alternative methods for access/treatment • CVADs no longer required for patient care should be removed immediately

34. Daily line review • Each day, the following should be documented on the CVAD observation chart MR114: • Number of days the line has been in for • Reason for access • Whether the line is still required

35. Adverse Events • Accidental disconnection • Immediately clamp catheter/line between leak and patient • Using aseptic technique, clean patient side connection • Withdraw air (if present) and check for blood return • Flush with normal saline • Prime new lines and continue infusion • Notify RMO to assess patient if required prior to continuing infusion • Blocked lines • Refer to Anticoagulation Therapy Guidelines

36. Adverse Events • Suspected infection • Observe every shift for early signs of infection (record on MR114) • Notify RMO to assess patient if required • Superficial infection • Swab site and smear glass slide for microscopy prior to placing swab in charcoal medium • Send specimens to bacteriology • Systemic infection • If temperature 38°C, take blood cultures from peripheral and central lines • Samples should be taken from all lumens and these clearly labeled

37. Documentation • MR114 (CVAD Observation Chart) • Insertion • Dressing • Adverse Events / Variances • MR52 (Medication Chart) • Heparin locks

38. Summary

39. 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

40. Summary • Use sterile technique for high risk procedures • Review CVAD’s daily, if they are not needed, remove without delay • If in doubt – ask a senior member of staff