CVAD Management Training

1. CVAD ManagementTraining 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 7,000deaths 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

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. 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 Which technique should I use?

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 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 useneedles 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

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

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

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