Download Removal of a Surgical Closed Wound Drain

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.
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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.
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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
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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
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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
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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
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
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
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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
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 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
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
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
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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
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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
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APPENDIX 1
BellovacR - Low Pressure Wound Drain System
Instructions for use:
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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
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APPENDIX 3
ExudrainR - Low pressure Wound Drain System
Instructions for use:
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APPENDIX 4
PrivacR low wound drainage
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APPENDIX 5 - PrivacR Mini Draiage System
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