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8.9 GUIDELINE/PROCEDURE SUBJECT: Removal of a Surgical Closed Wound Drain in the Paediatric Patient DOCUMENT NUMBER: 8.9 DATE DEVELOPED: July 2012 DATES REVISED: NEW DATE APPROVED: November 2012 REVIEW DATE: November 2016 DISTRIBUTION: All Clinical Wards including PICU and NICU JHCH PERSON RESPONSIBLE FOR MONITORING AND REVIEW: CNC Paediatric Surgery JHCH COMMITTEE RESPONSIBLE FOR RATIFICATION AND REVIEW: 2016 JHCH Clinical Practice Guidelines Advisory Group (CPGAG) Kaleidoscope GNS Quality and Safety Committee KEYWORDS: aseptic no-touch technique (ANTT), Bellovac, children, drain, negative pressure, suction, wound Disclaimer: It should be noted that this document reflects what is currently regarded as a safe and appropriate approach to care. However, as in any clinical situation there may be factors that cannot be covered by a single set of guidelines, this document should be used as a guide, rather than as a complete authorative statement of procedures to be followed in respect of each individual presentation. It does not replace the need for the application of clinical judgment to each individual presentation. Surgical Drains 2012 Approved on: October 2012 Page 1 of 12 Sites where Clinical Procedure applies: All JHCH/JHH/RNC sites where a paediatric patient receives care Target audience: Medical and Nursing staff Description: Procedure- Removal of a Closed Surgical Wound drain. NB: This procedure does not apply to Intercostal Catheters. This Clinical Procedure applies to: 1. Adults 2. Children up to 16 years 3. Neonates – less than 29 days No Yes Yes Relevant or related Documents, Legislation, Australian Standards, Guidelines: NSW Health Policy Directive 2007-079 Correct patient, correct procedure, correct site http://www.health.nsw.gov.au/policies/pd/2007/pdf/PDF2007 079.pdf NSW Health Policy PD 2005-406 Consent to Medical Treatment http://www.health.nsw.gova.au/policies/PD/2005/pdf/PD2005 406pdf NSW Health Policy Directive PD 2007_036 Infection Control Policy http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007 036.pdf HNE Health Hand Hygiene by Healthcare Staff PCP http://intranet.hne.health.nsw.gov.au/data /assets/pdf file/0011/64973/PD2007 036 PCP 1 Hand Hygiene.pdf ______________________________________________________________________________ Clinical Procedure Summary: This clinical procedure is to be followed to ensure the safe and effective removal of a closed surgical wound drain in the paediatric patient. ABBREVIATIONS and GLOSSARY Abbreviation/Word ANTT ATSI Bellovac™/Privac™/Exudrain™ CSU Passive drains CALD EN Inlet Clamp MO PPE RN IIMS Definition Aseptic Non-touch Technique Aboriginal and Torres Strait Islander Product identification name; low pressure closed wound drain system Central Sterilising Unit Drain freely into the skin or dressing Culturally and Linguistically Diverse Enrolled Nurse Slide clamp on drain tubing Medical Officer Personal Protective Equipment Registered Nurse Incident Information Management System RISK STATEMENT: This local clinical guideline and procedure has been developed to provide instruction to the healthcare worker and to ensure that the risks of harm to the patient associated with surgical closed wound drains are identified and managed. Any unplanned event resulting in, or with the potential for, injury, damage or other loss to the patient as a result of this clinical procedure must be reported through the Incident Information Management System. This would include unintended patient injury or complication from treatment that results in disability, death or prolonged hospital stay and is caused by health care management. Open Disclosure procedures must be commenced to ensure the concerns of the patient are identified and managed in accordance with Ministry of Health Policy Directives. The Policy Directives and Guidelines for managing complaints and concerns about clinicians should be used in conjunction with other relevant NSW Health Policy Directives that govern the behavior and actions of all staff. Surgical Drains 2012 Approved on: October 2012 Page 2 of 12 BACKGROUND: Closed surgical wound drains: are inserted during surgery in the operating theatres are generally secured with a suture consist of a length of perforated stiff or supple material e.g. silastic, plastic or rubber exit the skin either through the primary operation incision site or through a separate small wound divert body fluids from the operated site through a tubing conduit into a sterile expandable chamber (bulb), which when compressed and clamped at its base creates low pressure suction. The bulb is then connected to a collection reservoir (drainage bag) contain drainage loss so the practitioner can quantify outflow and qualify drainage character reduce staff contact with patient’s body fluids promote tissue apposition Complications associated with closed drainage systems include: Hemorrhage from adjacent blood vessels Tissue erosion, irritation, inflammation, or breakdown Retrograde bacterial migration, potential bacterial colonisation, and sepsis Vacuum failure; drain holes/lumen blocked by tissue/ fibrin/ blood; kinked drain; suction pressure is impaired or disconnected Drainage tube migration/ loss or entrapment Indications for Drain Removal: Following a surgeon’s instructions and as per documentation in the child’s medical record Drain removal Rationale: Drainage volume has decreased sufficiently (cessation of drainage is not always achievable) Blocked drain, unable to be cleared, no longer serves the intended purpose Bulb suction is no longer creating a negative pressure vacuum Procedure Outcomes: Safe and effective extraction of the implanted drain Minimal distress, discomfort, or pain experienced by the child Alleviate/minimise the risk of complications arising from the removal of a closed surgical wound drain DRAIN REMOVAL PROCEDURE Aseptic Non-touch Technique is to be followed (NSW Health PD 2007_036) Hand hygiene (NSW Health PD 2010_058) Patient Preparation: Ensure that the patient, parents/ carers have received appropriate information to understand and provide informed consent (NSW Health PD 2005-406) Ensure that correct patient, correct procedure, correct site identification is completed prior to the procedure (NSW Health PD2007_079) The patient and family should be prepared for the procedure as per the JHCH Procedural Care clinical practice guideline 1.8. Access non pharmacological diversion, age appropriate i.e. e.g. enlist the services of MAP (Music, Art and Play) Assess if the family requires the support of an interpreter to facilitate understanding and informed consent Surgical Drains 2012 Approved on: October 2012 Page 3 of 12 Assess if there are any cultural sensitivities which need to be taken into account in view of the procedure. Seek advice from the CALD Liaison Officer or ATSI Liaison Officer if necessary Confirm allergy status with patient/ parent/ carer prior to the procedure and any preprocedure medications Offer /administer medication as per medication prescription orders Clinical Preparation: This is a potentially painful and threatening procedure requiring two clinicians. Consider the child’s analgesic and anxiolytic needs before proceeding Consider your level of experience before undertaking this procedure. Please seek assistance from experienced colleagues if not previously performed Ensure all relevant staff and equipment are available Locate and read the Surgeon/Medical Officer documentation in the patient’s medical record for details about the drain insertion, any shortening procedure used intra-operatively, and removal instructions Turn off the suction from the specified drain for a minimum of 30 minutes prior to drain removal, allowing the vacuum within the wound to dissipate Do NOT score, nick, or cut the tubing in an effort to release suction Prior to the commencement of the procedure, conduct an appropriate risk assessment of the environment to ensure the procedure can proceed safely Optimally, the procedure should be attended in the ward treatment room, preserving the child’s bed as a Safe Place as per the Procedural Care clinical practice guideline Confirm the planned activity/ procedure against documented medical orders with your assistant Verify correct patient identification by asking patient/ parent/carer to state child’s full name, and date of birth. Verify the answers against the child’s identification band/s together with the child’s medical record and Medical Record Number (MRN) Accompany the child and parent/carer to the treatment room after all required staff and equipment are assembled and you are ready to proceed Position the child in their chosen comfort position (this may be nursed in parent’s arms, or seated, or any position which allows access to the site but one which is comfortable for the child) and ensure access to the surgical site Maintain the child’s privacy/dignity at all times Continue to support and reassure the child, parent/carer in a manner sensitive to their needs Observe the child throughout the procedure for any behaviour which may signify pain or complications If problems arise stop the activity, reassure the child, parent/carer and seek advice from a senior clinician/medical officer Required Documentation: Two clinicians should be present during drain removal to confirm drain is intact prior to being sent to pathology Documentation of drain/ tubing removal must also be recorded on the child’s Operation Report from the time of insertion and countersigned by both clinicians Details must confirm: date; time; ward location; proceduralist; assistant; tubing length; and tip integrity. If the tip is required to be sent to Pathology cut it with a sterile stitch cutter and document this in the operation report. Send the tip with a completed pathology request form Surgical Drains 2012 Approved on: October 2012 Page 4 of 12 Document the procedure in the patient’s medical record including information about pre, intra, and post procedural observations and pain scores, wound site, drainage exudate, actions taken, and patient outcomes Procedure Equipment: Clean dressing trolley Sterile dressing pack Sterile stitch cutter Sterile gloves Sodium Chloride 0.9% solution – 30mL sachet PPE: Protective eye wear, plastic apron if applicable, non-sterile gloves Protective sheet Sterile occlusive dressing Extra gauze swabs x2 (unopened) Alcohol hand gel Sharp disposal bin Contaminated waste disposal bin Closed Wound Drain Removal Procedure: Aseptic Non-touch Technique is to be used. Hand hygiene Moment 1 before touching the patient Assess level of patient readiness for the procedure including analgesic effect, diversional therapies in place, and ensure the patient/parent understands his/her role Maintain patient privacy Confirm the patient/parent’s permission to proceed Wipe the clean dressing trolley with large alcohol wipes or neutral detergent Hand hygiene Moment 2 pre-procedure. Wash hands with soap and water Prepare/assemble the equipment - check the sterility and expiry date of products Use the open dressing pack as the sterile field - place sterile equipment on it Take the dressing trolley to the patient’s side Adjust the height of the patient bed to avoid stooping Don non-sterile gloves, apron, and protective eyewear Place a protective sheet under patient at the area of the drain Maintain the child’s body temperature by covering appropriately Remove any securing dressings to expose drain exit site/wound Dispose of soiled dressing into contaminated waste repository Remove and dispose of non-sterile gloves Note the integrity of the skin around the drain. Record your observation in the child’s medical record. Inflammation or purulent discharge may warrant a swab be sent to pathology for culture/analysis. Discuss this with the attending surgeon or registrar prior to swabbing Note drainage quantity and character and record these observations in the child’s medical record at the conclusion of the procedure Surgical Drains 2012 Approved on: October 2012 Page 5 of 12 Hand hygiene Moments 3 post-procedure and 2 pre-ANTT procedure. Wash hands with antiseptic solution for 3 minutes as a clinical scrub. Don sterile gloves without contaminating them Using aseptic non-touch technique, cleanse the area at the drain exit site with sodium chloride 0.9% solution by swabbing once in an outward circular motion. Discard swab If the drain is secured by a suture and the suture is accessible, while securing the drain, grasp the suture knot with forceps and lift it clear of the patient’s skin. Cut the suture on one side close to the skin entry (exposed suture should not be pulled into the skin) with the stitch cutter by cutting away from yourself. Gently pull the suture through the skin with forceps and discard. Discard stitch cutter into sharps receptacle Fold the sterile gauze swabs to create an absorbent pad and hold it in position over the drain site. Position your non-dominant hand with opposing digits each side of the drain to support the skin surrounding the drain and stabilise the area with firm pressure (this hand is now no longer sterile) Warn the child to expect a pulling sensation as the drain is withdrawn. Reassure the child/parent that you will stop if it becomes painful A circular drain can be loosened by gently rotating the tubing to free it from tissue. With your dominant hand in sterile gloves firmly grasp the drain/tubing close to the patient’s skin and apply steady even tension to ease it free and onto the protective sheet If removal is difficult, do not apply force or cut the drainage tubing. Contact the patient’s surgeon or medical officer for advice Supple drains such as those made of silicone/ rubber can potentially stretch for some distance and then break free On removal inspect the entire drain. The drain edge should not appear jagged or torn, if it does this may indicate breakage Hand hygiene Moment 3 post-ANTT procedure In the presence of any abnormalities do not discard the removed drain. Report your concerns to the nurse unit manager/team leader and the child’s surgeon to determine the need for further investigation and management. Complete an IIMS notification for the adverse event Ensure that the family are offered open disclosure of the adverse event and its management. Fully document the adverse event (including the IIMS incident number) and the procedure in the child’s medical record Document the removal of the drain on the child’s Operation Report (HSMR23) and have this entry confirmed and countersigned by your assistant. Also document this on the child’s care plan If removal is without complication continue: Cleanse drain site with sodium chloride 0.9% solution Maintain pressure over the drain site with the gauze pad until the bleeding and/or drainage is controlled Dress the wound with a sterile dressing to maintain asepsis and to promote healing If the tip of the drain is required for microbiological investigation, it should be cut off with sterile scissors and placed in a sterile specimen container Ensure that the child is comfortable and returned to his/her bed safely by your assistant. Assess and address any pain Surgical Drains 2012 Approved on: October 2012 Page 6 of 12 Dispose of all equipment and contaminated waste appropriately (disposable equipment and supplies to yellow contaminated waste bins, and reusable equipment is to be rinsed and sent to CSU) Wipe trolley with large alcohol wipe or neutral detergent Remove apron and discard into contaminated waste bin Hand hygiene Moment 3 post-ANTT procedure. Wash hands thoroughly Settle the patient back into his/her bed and assess pain Hand hygiene Moment 4 after touching patient Staff need to monitor the insertion site and report any signs of infection or haematoma to the medical officer Record vital sign observations as per orders - report anomalies immediately to Surgeon Provide wound care instruction to family on discharge. Provide information to patient/ parent/carer on management of the drainage site wound. This should include when to seek nursing/medical advice in the event of pain, discomfort, inflammation, skin breakdown, swelling, exudate, or odour Leave the patient comfortable and safe and within reach of the nurse assist buzzer Hand hygiene Moment 5 after touching patient environment APPENDICES Appendix 1: BellovacR – Low pressure Wound Drain System – Instructions for use Appendix 2: BellovacR Catheter Specification Chart Appendix 3: ExudrainR – Low pressure Wound Drain System – Instructions for use. Appendix 4: PrivacR low wound drainage Appendix 5: PrivacR mini wound drainage REFERENCES Joanna Briggs Institute Acute Care Practice Manual - Wound Drain: Removal Last update 2005 GNAH Procedure_Surgical Drain Management HNELHD Adult CP 11-03 27 July 2011 Removal of Handivac/Bellovac Drain SWP_Calvary Mater_2009 Privac low wound drainage: http://www.nationalsurgical.com.au/ Walker J (2007) Patient preparation for safe removal of surgical drains. Nursing Standard.21, (49) pg 39-41 Aug. 15. Paediatric Surgical Nursing, Chapter11. Pg.320-321 Care and Management of Patients with tubes. American Pediatric Surgical Nursing.Association. Pub.2007 JHCH Procedural Care Clinical Practice Guideline 1.8 AUTHOR: K.Sullivan CNC Paediatric Surgery JHCH REVIEWED BY: Paediatric Surgeons JHCH, Paediatric Nurse Educator JHCH, JHCH Operation’s Manager, ICU CNE, NICU, CNC APPROVED BY: JHCH Clinical Practice Advisory Group and KGN Quality and Safety Committee – 29th October 2012 Surgical Drains 2012 Approved on: October 2012 Page 7 of 12 APPENDIX 1 BellovacR - Low Pressure Wound Drain System Instructions for use: Surgical Drains 2012 Approved on: October 2012 Page 8 of 12 APPENDIX 2 BellovacR Catheter Specification Chart Size Perforation Length Total Catheter Length Graduation Mark Distance from Last Drainage Hole FG 10 14cm 75cm 5cm FG 14 14cm 75cm 5cm FG 18 18cm 75cm 5cm Surgical Drains 2012 Approved on: October 2012 Page 9 of 12 APPENDIX 3 ExudrainR - Low pressure Wound Drain System Instructions for use: Surgical Drains 2012 Approved on: October 2012 Page 10 of 12 APPENDIX 4 PrivacR low wound drainage Surgical Drains 2012 Approved on: October 2012 Page 11 of 12 APPENDIX 5 - PrivacR Mini Draiage System Surgical Drains 2012 Approved on: October 2012 Page 12 of 12